Gastrointestinal bleeding

Dr. Székely Hajnal

2nd Department of InternalMedicine

2015/16-I

Incidence

1-2% of all hospital admissions

One of the most common dg. of new

ICU admits

5-12% mortality

40% for recurrent bleeders

85% stop spontaneously

massive bleeding - urgent intervention

5-10% need operative intervention after

endoscopic interventions

DefinitionsUpper GI source - (proximal to DJ flexure)esophagus, stomach, or proximal duodenum

–Non-variceal bleeding

–Variceal bleeding

Mid-intestinal bleed – distal duodenum to ileocecal valve

Lower intestinal bleed – colon / rectum

Stool color and origin/pace of bleeding85% of all GI hemorrhage is upper

– Hematemesis, coffee ground vomit, melena

– UGI origin (can be SB, prox. colon origin if slow pace)

Degradation of hemoglobin to hematin by acid

Bowel bacteria and digestive enzymes contribute

– Hematochezia

– Spectrum: bright red blood, dark red, maroon

– colonic origin (UGI if brisk pace/large volume – 10%)

Guaiac positive stool

– Occult blood in stool - not informative of localization

– slow pace, low volume bleeding

Iron def. anaemia- very slow pace of bleeding

History and physical examination

History

Localizing symptoms

History of prior GIB

NSAID/aspirin/anticoag.

Liver disease

Vascular disease

Aortic valv. disease,

chronic renal failure

malignancy

Radiation exposure

Family history of GIB

Physical exam.

Vital signs, orthostatics

Gen. appearance, mental

status

Abdominal tenderness

Skin, oral examination

Stigmata of liver disease

Rectal examination

NG Tube findings (upper

vs. lower g.i. source)

Urine output

Aim : source - cause, severity, precipitating factors.

Initial Assessment

severity + degree of hypovolemic shock

Class I Class II Class III Class IV

Blood loss

(mL)

750 750-1500 1500-2000 >2000

Blood

volume

loss (%)

< 15% 15-30% 30-40% >40%

Heart rate <100 >100 >120 >140

SBP No change Orthostatic

change

Reduced Very low,

supine

Urine

output

(mL/hr)

>30 20-30 10-20 <10

Mental Alert Anxious Aggressive Confused/

Upper GI bleeding- UGIBCrampy abdominal pain, hyperact. bowel sound

Large caliber NGT (?)

useful: severe hematochezia - UGIB vs. LGIB

– Red blood – high risk endoscopic lesion

– Coffee grounds – less severe/inactive bleeding

Neg. aspirate – 15-20% of patients with UGIB.

Can be used for lavage prior to endoscopy

Upper endoscopy indications –dg., progn., therapeutic.

Should be completed in 24hrs for HD stable patients

Risk factors –poor outcome UGIB

Age over 60y

Shock

Malignancy

Variceal bleeding

Onset in hospital

Comorbid illness

Active bleeding

Recurrent bleeding

Severe coagulopathy

High risk: >5; mort:10-41%, rebl:24-40%

interm.:3-5; mort.:3-10%, rebl:11-24%

low:0-2; mort.:0-0.2%, rebl.:4-5%.

Takes priority over determining the

diagnosis/cause

ABC (main focus is ‘C’)

Takes priority over

determining the

diagnosis/cause

IV PPI: 80 mg bolus, 8 mg/hr drip for 72 h

– Rationale: suppress acid (pH>6), facilitate clot

formation and stabilization

– Duration: at least until EGD, then based on

findings

– Decreases need for endoscopic therapy

Octreotide - Used in variceal bleeding

Reduces the risk of continued non-varic. UGIB

NOT as primary th.- in patients with peristent

bleeding despite PPI, poor surgical patients

Pre-endoscopic Pharmacotherapy

Diagnostic, prognostic, therapeurtic

Goal- treat the bleeding, prevent recurrent bleeding

UGIB- sources

Peptic ulcer disease – DU+GU 50%

Varices – 10-20%

Gastritis – 10-25%

Mallory-weiss – 8-10%

Esophagitis – 3-5%

Malignancy – 3%

Dieulafoy’s lesion – 1-3%

Watermelon stomach – 1-2%

Peptic ulcer hemorrhage

20% of PUD patients bleed at least once

H. pylori 40-50%, NSAID’s 40-50%

Other (Z-E syndrome)

Stress ulcer

Medical management

Anti-ulcer medication

H. pylori treatment

Stop NSAIDs

Follow up EGD for gastric ulcer in 6 weeks

Minor Stigmata

Flat pigmented spot Clean base

Low rebleeding risk – no endoscopic therapy needed

Low rebleeding risk – no endoscopic therapy needed

Adherent Clot

Role of endoscopic

therapy -

controversial

Clot removal usually

attempted after inj.

Underlying lesion

can then be

assessed, treated if

necessary

Endoscopic th.

High risk stigmata of recent hemorrh.

Inj+thermal coag. endoclip

Post-endoscopy management

low risk ulcers – prompt feeding, oral PPI th.

ulcers requiring endoscopic th.-PPI iv (72 h.)

Determine H. pylori status

Discharge patients on PPI

duration dictated by

etiology and

need for NSAIDs/aspirin

CV disease on low dose aspirin:

restart as soon as

bleeding has resolved

Peptic ulcer hemorrhage

Surgical intervention- 10% of patients

– Indications

–Failure of endoscopy

–Significant rebleeding after 1st endoscopy

–Ongoing transfusion requirement

–Need for >6 units over 24 hours

–Earlier for elderly, multiple co-morbidities

E.g. Under-running of ulcer (bleeding DU),

wedge excision of bleeding lesion (e.g. GU),

partial/total gastrectomy (malignancy)

Mallory Weiss tears -5% UGIB

Mucosal /submuc.

lacerations at the GEJ

History of recent

nonbloody vomiting +

excessive retching,

followed by haematemesis after alcohol intake

Endos: – tear at the GEJ

80-90% stops spontaneusly

Rebleeding – endos. electro-coagulation,

Angiographic embol. or surgical oversewing

Endos. hemostasis

Rebleeding-tatoo

Surgery – wedge resection

Rows or stripes of ectatic mucosal blood vessels

from the pylorus towards the antrum

Cause?

Older women,

end-stage renal disease

liver cirrhosis, scleroderma

Linear / diffuse angiomas

Endos. th.- APC

Surgery-antrectomy

Watermelon stomach -GAVE

Upper GI malignancy

1% of severe, 3% of any UGIB

Bening (leiomyoma, stromal tu)

Malignant – primary or sec.

Large, ulcerated masses

Endos. hemostasis –temporal controll

Angiogr.+embilozation – severe UGIB

External beam radiation- palliative

hemostasis in cases of advanced disease

surgery

Variceal Bleeding

Hep. ven. press. gradient > 12 mmHg

in 1/3 of patients with cirrhosis

1/3 initial bleeding episodes are fatal

1/3 will rebleed within 6 weeks (48-72)

Only 1/3 will survive 1 year or more

Mortality:15-50%-each episod

70-80% in cont. bleeding

1/3 causes of death due to liver cirrhosis

Suspect in patients with history of chronic liver

disease/cirrhosis or stigmata on clinical exam.

Liver cirrhosis - portal hypertension - porto-

systemic anastamosis

Sites of porto-systemic anastamosis include:

Oesophagus

Umbilicus

Retroperitoneal

Rectal

+ clotting derrangement - worsens bleeding

Altered liver eznymes, bi., poor synth. function

Variceal Bleeding

closely related to severity of underlying chronic

liver disease (Childs-Pugh grading)

Mortality 32% Child A, 46% Child B, 79% Child C

Variceal Bleeding -prognosis

leed

Vasoconstrictor th.

Antibiotics

Resuscitation

ICU level care

Endoscopy

ALternative / rescue th.

Beta blockade

asoconstrictor therapy

Goal: Reduce splanchnic blood flow

Terlipressin – only agent that improvescontrol of bleeding and survival

Vasopressin

Somatostatin

Octreotide (somatostatin analogue)

Efficacy is controversial;

Standard dose: 50 mcg bolus, then 50 mcg/hr drip for 3-5 days

Beta-blockers- prevent rebleeding

Management – variceal bleeding

ntibiotics

Bacterial infection - in up to 66% of variceal bleed

Negative impact on hemostasis (endogenous heparinoids)

Prophylactic AB reduces the incidence of bacterial infection, early rebleeding

– Ceftriaxone 1 g IV QD x 5-7 days

– Alt: Norfloxacin 400 mg po BID

esuscitation

Promptly but with caution

Goal = maintain HD stability, Hgb ~7-8,

CVP 4-8 mmHg

Avoid excessively rapid overexpansion

of volume; may increase portal

pressure, greater bleeding

ndoscopyas soon as possible

after resuscitation

(within 12 hours)

Endotracheal intubation

frequently needed

Band ligation is

preferred method

Acute hemostasis:

80-85%

Fewer complications

↓rebleeding, mortality

Endoscopic injection sclerotherapy

1-3 ml scler. agent

Effective

More complic.,

rebleed.,

more sessions,

higher mortality rate

ternative/Rescue therapies

Sengstaken-Blakemore Tube

Very effective immediate, temporary control

(85-98%)

Up to 60% - rebleed. after ballon deflation

High complication rate (30%)– aspiration, migration, necrosis + perforation of esophagus

bridge to TIPS within 24 h.

Airway protection strongly recommended

eta blockade

↓risk for recurrent variceal hemorrhage

nonselective beta blocker (splanchnic

vasoconstriction, decrease cardiac output)

titrate up to maximum tolerated dose

(HR 50-60 / min.)

– Start as inpatient, once acute bleeding has

resolved and patient shows hemodynamic

stability

Lower GI Bleeding - LGIB

arising from the colorectum /anus

20% of GIB, 15% of massive GIB

first consider possibility of UGIB (10-15%)

Intermittent

Less severe

Up to 42% -

multiple sites

Mean age:63-77y.

80% stops spont.

Mort::2-4%.

Differential Diagnosis – LGIB

Diverticulosis

Angiectasias

Hemorrhoids

Colitis (IBD, Infectious, Ischemic)

Neoplasm

Post-polypectomy bleed (up to 2 weeks)

Dieulafoy’s lesion

Most common diagnosis

Most common diagnosis

LGIB - etiologyDiverticulosis – 40-55%

– Right sided lesions > left

– 10% rebleed in 1st year and 25% at 4 years

– 90% stop spontaneously

Angiodysplasia – 3-20%– Most common cause of SB bleeding in >50 y/o

– >50% are in right colon

Neoplasia– Typically bleed slowly

Inflammatory conditions– 15% of UC patients, 1% of chron’s patients

– Radiation, infectious, AIDS rarely

Vascular

Hemorrhoids– >50% have hemorrhoids, but only 2% of bleeding attributed to them

Others meckel’s, polyps, solitary rectal ulcer, Dieulafoy’s lesion of the colon, portal colopathy, NSAIDs, intussusception, or bleeding following colonoscopic

biopsy or polypectomy.

Colon Rectum Anus

Diverticular Disease Polyps Haemorrhoids

Polyps Malignancy Fissure

Malignancy Proctitis Malignancy

Colitis

Angiodysplasia

LGIB - etiology

LGIB - diagnosticsEvaluation

Same for UGIB bleed; If unstable – first EGD

After stable – Rectal exam., anoscopy for hemorrhoids

ColonoscopyWithin 12 hours- in stable patients without massive bleeding

Selective visceral angiographyNeed >0.5 ml/min bleeding

40-75% sensitive if bleeding at time of exam

Tagged RBC scanCan detect bleeding at 0.1 ml/min

85% sensitive if bleeding at time of exam

Not accurate in defining left vs right colon

LGIB – Risk StratificationPredictors of severe* LGIB:

HR>100 SBP<115 Syncope nontender abdominal examination bleeding during first 4 hours of evaluation aspirin use >2 active comorbid conditions

HR>100 SBP<115 Syncope nontender abdominal examination bleeding during first 4 hours of evaluation aspirin use >2 active comorbid conditions

0 factors: ~6% risk

1-3 factors: ~40%

>3 factors: ~80%

0 factors: ~6% risk

1-3 factors: ~40%

>3 factors: ~80%

* Defined as continued bleeding within first 24 hours (transfusion of 2+ Units, decline in HCT of 20+%) and/or recurrent bleeding after 24 hours of stability

Urgent Colonoscopy

Within 6-12 h.

rapid “purge” prep., colonoscopy performed

within 1 hour after clearance

bowel prep. + sedation - may affect the

unstable patient

Def. bleeding source identified more frequently

endoscopic th. - in 10-40% of patients

Evidence - colonoscopy should be performed

within 12-24 hours in stable patients

unclear if affects major clinical outcomes

Radiographic StudiesTagged RBC scan

Noninvasive, highly

sensitive (0.05-0.1 ml/min)

Ability to localize bleeding

source correctly only

~66%

More accurate when

positive within 2 hours

(95-100%)

Lacks th. capability

Coordinate with IR so that positive scan is followed closely by angiography

Coordinate with IR so that positive scan is followed closely by angiography

AngiographyDetects bl. rates of

0.5-1 ml/min

Th. capability – embolization

with microcoils, polyvinyl

alcohol, gelfoam

Complications: bowel

infarction, renal failure,

hematomas, thromboses,

dissection

Recommended for patients with brisk bleeding who cannot be stabilized or prepped for colonoscopy

(or had colonoscopy with failure to localize/treat bleeding site)

Recommended for patients with brisk bleeding who cannot be stabilized or prepped for colonoscopy

(or had colonoscopy with failure to localize/treat bleeding site)

Multi-Detector CT (CT angio)

Readily available

Can detect bl. rate of 0.5 ml/min

Can localize site of bleeding

(must be active) and provide info

on etiology

Useful in the actively bleeding

but hemodynamically stable

patient

Role of Surgery

Reserved for patients with life-threatening

bleed who failed other options

General indications: hypotension/shock

despite resuscitation, >6 U PRBCs

transfused

Preoperative localization of bleeding source

important

Emergency resuscitation - as described

Pharmacological– Stop NSAIDS/anti-platelets/anti-coagulants if safe

Endoscopic– OGD (15% have upper GI source!)

– Colonoscopy – dg. + th. (injection, diathermy, clipping)

Angiographic– Selective embolization for poor surgical candidates

– Can lead to ischemic sites requiring later resection

Surgery– Ongoing hemorrhage, >6 units or ongoing transfusion

requirement

LGIB - treatment

RadiologicalCT angiogram – diagnostic only (non-invasive)

Determines site and cause of bleeding

Mesenteric Angiogram – diagnostic and therepeutic

(but invasive)

Determines site of bleeding and allows embolisation of

bleeding vessel

Can result in colonic ischaemia

Nuclear Scintigraphy – technetium labelled red blood

cells: diagnostic only

Determines site of bleeding only (not cause)

LGIB - treatment

Surgical – Last resort in management as very

difficult to determine bleeding point at

laparotomy

Segmental colectomy – where site of bleeding is

known

Subtotal colectomy – site of bleeding unclear

Beware of small bowel bleeding – always

embarassing when bleeding continues after

large bowel removed!

LGIB - treatment

Algorithm: Evaluation of Patient with

Hematochezia

HematocheziaHematochezia

Assess activity of bleed

Assess activity of bleed

NG lavageNG lavagePrep for

ColonoscopyPrep for

Colonoscopy

PositivePositive

EGDEGD

NegativeNegative

active inactive

Risk for UGIB

Hemodynamically stable?

Hemodynamically stable?

No risk for UGIB

negativeTreat lesionTreat lesion

positive

Algorithm: Evaluation of Patient with

Hematochezia

Active Lower GIBActive Lower GIB

Hemodynamically stable?

Hemodynamically stable?

Angiography(+/- Tagged RBC

scan) /Surgery if life-

threatening

Angiography(+/- Tagged RBC

scan) /Surgery if life-

threatening

Consider “urgent colonoscopy” vs.

traditional approach

Consider “urgent colonoscopy” vs.

traditional approach

YesNo

Small intestinal bleeding-sources

Angioectasia 20–55%

Tumor 10–20%

Crohn’s disease 2–10%

NSAID enteropathy 5%

Coeliak dis. 2–5%

Meckel diverticulum 2–5%

Dieulafoy lesion 1–2%

Ectopic varices 1–2%

Portal hypert. enteropathy 1–2%

Irradiation enteritis <1%

Aliment Pharmacol Ther 2011; 34:416–423K. Liu* & A. J. Kaffes, Mussetto A et al. Dig Liv Dis. 45 (2013) 124– 128.

Small bowel endoscopy