GI Hemorrhage

8/3/2019 GI Hemorrhage

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GI Hemorrhage

April 29, 2012

David Hughes


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Incidence

1-2% of all hospital admissions Most common diagnosis of new ICU admits

5-12% mortality 40% for recurrent bleeders

85% stop sponateously

Those with massive bleeding need urgent intervention Only 5-10% need operative intervention after

endoscopic interventions


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Etiology

85% are due to: Peptic ulcer disease

Variceal hemorrhage

Colonic diverticulosis

Angiodysplasia


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Chain of events

1. Recognize severity

2. Establish access for resusitation3. Resusitate

4. Identify source

5. Intervention


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Question #1

JB a 30 y/o with hematemesis presents with

orthostatic hypotension, clammy hands, butwithout tachycardia. How much blood hashe lost?

a) >40%

b) 20-40%c) 10-20%

d)


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Question #1

JB a 30 y/o with hematemesis presents with

orthostatic hypotension, clammy hands, butwithout tachycardia. How much blood hashe lost?

b) 20-40%


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Upper GI hemorrhage

How do you know its upper? 85% of all GI hemorrhage is upper

Hematemesis diagnostic Dont forget about nasal bleeding as possible source

Melena Degradation of hemoglobin to hematin by acid

Bowel bacteria and digestive enzymes also contribute

Hematochezia 10% of patients with very rapid UGI source


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http://www.pathology.vcu.edu/education/gi/images/2.1e-a.jpg


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Gastric varices


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Gastric varices

EsophagealVarices


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Gastric varicesBleeding ulcers

EsophagealVarices


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Gastritis


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Gastritis Dieulafoys lesion


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Mallory-weiss


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http://www.hardisty.ca/images/fair_watermelon3.jpg


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Watermelon stomach


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Upper GI hemorrhage

Etiology Peptic ulcer disease - 50%

Varices 10-20%

Gastritis 10-25%

Mallory-weiss 8-10%

Esophagitis 3-5%

Malignancy 3% Dieulafoys lesion 1-3%

Watermelon stomach 1-2%


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Upper GI hemorrhage

Crampy abdominal pain common

Large caliber NGT Coffee grounds or gross blood

No blood

Can be used for lavage prior to endoscopy

Upper endoscopy indications

Melena or hematochezia with hypotension Hematemesis

NGT with guiac positive fluid

Should be completed in 24hrs for stable patients


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Peptic ulcer hemorrhage

Peptic ulcer disease 20% of patients bleed at least once

Most lethal complication

Vessel is usually


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Predictors of mortality Renal disease 29%

Acute renal failure 63%

Liver disease 25%

Jaundice 42%

Pulmonary disease 23%

Respiratory failure 57% Cardiac disease 13%

Congestive heart failure 28%


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Medical management Anti-ulcer medication

H. pylori treatment

Stop NSAIDs

Follow up EGD for gastric ulcer in 6 weeks


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Endoscopic interventions Thermal coagulation

Injected agents

Success rate

95% initailly

80% will not rebleed

Repeat treatment after 1st

rebleed salvages 50% Increased risk of mortality


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Surgical intervention

Only 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


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Anti-secretory surgery?? Indicated for NSAID pts who need to continued meds

H. pylori ulcer disease controversial

Only 0.2% of pts every require surgery for bleeding ulcer

Surgery pts had lower than average H. pylori positivity

Oversewing and antibiotics still leave 50% at high risk forrebleeding

Bottom line: still recommended but without definitiveevidence


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Doudenal ulcer Expose ulcer with duodenotomy or

duodenopyloromyotomy

Direct suture ligation, four quadrent ligation, ligation ofgastroduodenal artery

Anti-secretory procedure

Truncal, parietal cell vagotomy

If unstable can use meds


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Gastric ulcer 10% are maliganant

30% will rebleed with simple ligation

Need Resection

Distal gastrectomy with Bilroth I or II

Subtotal gastrectomy for 10% high on lesser curve


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Somatostatin or vasopressin w/wo NTG


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Shunt procedures

Sugiura procedure

TIPS


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Other sources of UGI hemorrhage Mucosal lesions

Gastritis, ischemia, stress ulceration Key is prevention with acid supression Surgery often requires resection and Roux-en-Y due to multiple bleeding sites

>50% mortality with surgery Mallory-Weiss

10% will have significant bleeding 90% stop spontaneously Surgery rare, but gastrotomy with oversewing effective

Dieulafoys Wedge rxn after endoscopic marking

Aortoenteric fistula 1% of AAA repair patients Herald bleed preceeds exsangunation by hours to days Endoscopy and if negative CT scan and if negative angiography Surgery graft removal and extraanatomic bypass


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LGI hemorrhage

Sites Colon 95-97%

Small bowel 3-5%

Only 15% of massive GI bleeding

Finding the site

Intermittent bleeding common Up to 42% have multiple sites


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Bleeding

diverticulosis


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Bleeding

diverticulosis

Colonic angiodysplasia


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LGI hemorrhage

Etiology Diverticulosis 40-55%

Right sided lesions > left 90% stop spontaneously 10% rebleed in 1st year and 25% at 4 years

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 chrons patients Radiation, infectious, AIDS rarely

Vascular Hemorrhoids

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

Others


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LGI hemorrhage

Evaluation Same for UGI bleed

If unstable with hematochezia need EGD 1st

After stable

Rectal

Anoscopy for hemorrhoids


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LGI hemorrhage diagnostics

Colonoscopy Within 12 hours in stable patients without large amounts

of bleeding

Selective viseral angiography Need >0.5 ml/min bleeding

40-75% sensitive if bleeding at time of exam

Tagged RBC scan Can detect bleeding at 0.1 ml/min

85% sensitive if bleeding at time of exam

Not accurate in defining left vs right colon


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Meckels Diverticulum

Cecal angiodysplasiawith extravasation

Small bowel ulcerationdue to NSAIDS


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LGI hemorrhage treatment

Endoscopy Great for angiodysplasia and polypectomy sites

Angiographic Selective embolization for poor surgical candidates

Can lead to ischemic sites requiring later resection

Surgery Ongoing hemorrhage, >6 units or ongoing transfusion

requirement

Site selection

Blind segmental will rebleed in 75%

Based on TRBC scan will rebleed in 35%


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GI hemorrhage from unknown source

Only 2-5% are not upper or lower

Average patient 26 month duration of intermittent bleeding 1-20 diagnostic tests

Average of 20 units transfused


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Localization of GIHOUS

CT scan Tumors, inflammation, diverticuli

Enteroclysis Ulcerations, inflammation

Only 10-20% yeild (SBFT is 0-6%)

Meckels scan Initial test for patients


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Etiology of GIHOUS Arteriovenous malformation 40 Small bowel leiomyoma 11 Small bowel adenocarcinoma 7

Small bowel lymphoma 6 Crohns disease 6 Watermelon stomach 4 Meckels diverticulum 4 Small bowel leiomyosarcoma 3 Metastatic colon carcinoma to small bowel 3 Small bowel varices 3 Small bowel melanoma 3 Others 10

Szold A, Katz L, Lewis B: Surgical approach to occult gastrointestinal bleeding. Am J Surg 163:9093, 1992.


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Treatment

Surgery Without localization only for acute exsanguinating

hemorrhage

Intraoperative endoscopy

Segmental resection

Documents

GI Hemorrhage