Approach To

gastrointestinalBleeding

With special reference to obscure bleeding

DR.AKASH SENGUPTA22.02.2017, MALDA MEDICAL COLLEGE

Significance Newer diagnostic modalities

New therapeutic interventions

Mortality still high

Better understanding needed

Potential to bring down mortality

Changing trends in incidence

Over last 20 years-Rampant use of NSAIDs and SSRIs

Advent of newer PPIs

•Overall, the incidence of hospitalization for acute gastrointestinal bleeding has fallen by a modest 4% between years 1998 and 2006.*

*Ref:Sabiston,20th edition, page 1139

Cause of gastrointestinal bleeding

1. Upper GI bleed

2. Lower GI bleed

3. Obscure GI bleed

Emergency !! Resuscitation – First priority

Attempts made at diagnosis – when patient stable

Run parallel – when possible Better revive the

patient before you have to diagnose him

in AUTOPSY

Massive haemorrhage

Resuscitation

1. Securing airway

2. Maintaining Breathing

3. Maintenance of circulation:

Crystalloids

Colloids

Blood & blood products

4. Disability

5. Proper exposure

Ascites

Spider angioma

Caput medusae Palmer erythema

Must not forget!Nasogastric tube insertion

Catheterisation

Empirical treatment: Blind attempt

at arresting the bleed1. Proton pump inhibitors –

Omeprazole, Pantoprazole, Rabeprazole etc.

2. Stopping NSAIDs or SSRIs

3. Antifibrinolytics- Tranexamic acid

DIAGNOSTIC APPROACHDifferentiate between upper and lower GI

bleeding

Further investigation- find out the exact cause and location

Treatment according to cause

How to understand ? 1. Chief complaints

2. History

3. Physical examination

Patient presentation Directly due to the bleed-

1. Haematemesis

2. Haematochezia

3. Malena

As a Consequence of the blood loss

Signs of shock Respiratory distress due to aspiration

As symptoms of underlying disease

Pain Vomiting

In case of scanty blood loss

Only symptoms of anemia

•Detailed account of pain and vomiting

•Age

•Bowel habit & other personal histories

•History of medication and prior surgery

•History of past illnesses

IMPORTANT POINTS IN HISTORY

Physical examination1. General survey

2. Examination of the oral cavity, nasopharynx and oropharynx

3. Abdominal examination

4. Looking for signs (stigmata) of chronic liver disease- such as jaundice, ascites, palmer erythema, caput medusa etc.

UPPER GI BLEED

History and physical examination strongly suggests

Oesophagogastrodudenoscopy (preferably within first 24 hours)

Diagnostic

Treatment

Non-diagnostic

Slow haemorrhage

RBC scan

Massive haemorrhage

AngiographyOperation

Time is of paramount importance

Common causes of upper GI bleed

Esophagogastroduodeoscopy Merits-

-Highly accurate

-helps in risk stratification

-Identify the underlying disease

-Therapeutic interventions

-Taking biopsy specimen

Duodenal ulcer

Gasric ulcer

Oesophagial varices

Hemoclip applied to bleeding varix

Band ligation of ulcer

Therapeutic interventions

Fix the leak after you’ve found it

Risk stratification by EGD

Rockall classification

Forrest classification

When in doubt,

perform EGD to exclude Upper GI

bleed

When history and physical examination strongly suggests

Lower GI bleeding

Extent of bleeding

Slow haemorrhage

colonoscopy

Massive haemorrhage

angiography

Diagnostic

Non-diagnostic

•RBC scan•Capsule endoscopy•CT angiography•Meckel’s scan

Lower gastrointestinal haemorrhage-

•Multiple sources (40% cases)

•Longer list of D/D

•More difficult to diagnose

•Intermittent

•commonly ceases spontaneously

•Less extensive

•lower mortality rates

Causes of lower GI haemorrhageLower Gastrointestinal

bleeding: causes

Colonoscopy - minimal to moderate bleeding-within 24 hours, can be quite accurate-Can identify :active bleeding site, clot adherent to mucosa,diverticula, Polyps, cancers, and inflammatory causes; -therapeutic intervention-collection of biopsy sample

-Ineffective in massive haemorrhage-Risk of complications are high-Needs expertise for performance

Colonoscopic view

Crohn’s disease

Colorectal carcinoma

Colonic diverticula

RBC scanning

Alternative investigations Radionuclide (RBC) scanning:Can be used in massive haemorrhageAble to identify bleeding at a rate of 0.1mL/min90% sensitivePredicts outcome of angiographyInaccurate

CT angiographySensitivity and specificity similar to radionuclide scanningMore accurate in localizing the bleeding

CT angiograhy

Mesenteric artery angiography

Can only be used in ongoing haemorrhageCan diagnose bleeding at a rate of 0.5-1.0mL/minBest for diagnosing angiodysplasia and actively bleeding diverticulaCan be used therapeutically- vasopressors and embolization High risk of complications

Selective mesenteric

Mesenteric artery angiography

Obscure GI bleedingObscure GI hemorrhage is defined as bleeding that persists or recurs after an initial negative evaluation with EGD and colonoscopy.*

1. Obscure-overt bleeding: EGD and colonoscopy fail to localize the site but visible bleeding present.

2. Obscure-occult bleeding: characterized by iron deficiency anemia or guaiac-positive stools without visible bleeding.

*Sabiston, 20th edition, page 1155

Significance of obscure GI bleeding:

•Accounts for 1% of gastrointestinal haemorrhage

•Frustrating for both patient and doctors

•25% cases remain undiagnosed (mostly lower GI origin)

•High rate of rebleeding (33-50% within 3-5 years)

•Repeated blood transfusion needed

Causes of obscure GI haemorrhage

DIAGNOSTIC APPROACHRepeated endoscopy:Repeat esophagoduodenoscopy and colonoscopy

Identifies the lesion in 35% cases (most cases distal to ligament of Treitz)

Conventional imaging:RBC scanning, angiographyProvocative testsSmall bowel enteroclysis (largely abandoned now)Computed tomographic enterographyMeckel’s diverticulum scanning (especially in young patients)

Meckel’s scan

Small bowel enteroclysis

Small bowel enteroscopy& sonde pull endoscopy, double balloon endoscopy

Push endoscopy uses paediatric colonoscope;Can reach up to 50-70 cm beyond ligament of Treitz; Success rate 40%

Double balloon endoscopy is successful in 85% cases of occult bleeding (performed within 1 month);if done within 72 hours, more successful than capsule endoscopyTherapeutic intervention, biopsy possible

NEWER DIAGNOSTIC APPROACHESVideo Capsule Endoscopy •Well tolerated•Has a high success rate of 90% •Best for haemodynamically stable patients having ongoing GI bleed•Time consuming•Warrants continuous presence of a doctor•Contraindicated in intestinal obstruction and motility disorders

Intraoperative endoscopy

•In patients with transfusion-dependent occult-obscure bleeding •Paediatric colonoscope used•Introduced through mouth/anus/entereotomy •Whole bowel can be run •Obscure bleeding sources identified•Therapeutic intervention

Colonic polyp

Small intestinal ulcer

Key points:- Resuscitation first, and resuscitate fast

EGD within 24 hours: in upper GI bleed

Colonoscopy: in moderate lower GI bleed

Treat underlying disease: prevent rebleed

Newer modalities attempted only after EGD and colonoscopy fail repeatedly.