Bleeding: oropharynx => Anus

Acute: rapid loss of blood even shock

Chronic: anemia, fatigue

Maybe the first symptom of GI disease

Self limited or need for intervention

Hematemesis , coffee-ground

Melena (50 – 60 cc)

Hemato chezia

Occult blood in stool (10 cc)

Upper G I Bleeding

Lower G I Bleeding

Obscure G I Bleeding

UPPER GI BLEEDING

Causes of Upper GI BleedingPUD 40%Oesophagitis 10%Varices 5%Mallory – Weiss Syndrome (longitudinal tear

in the mucosa of the GE junction) 5%Erosive Disease 6%Neoplasm 4%Other 6%No Obvious Cause 24%

Massive Upper GI Bleeding

Acute Bleeding Proximal to the ligament of treitz

Requires blood transfusion

Massive Upper GI Bleeding

PUD

Gastritis

Mallory weiss Syndrome

Esophagogastric Varices

Massive Upper GI Bleeding ( Less Common Causes)

Neoplasm (malignant – benign)AngiodysplasiaDieulafoy’s Lesion (Congenital arteriovenous

malformation)Arterioenteric Fistula (Aortic Graft-Repair of

visceral artery aneurysm)

History P. U. D-Heart burn – reflux

Drugs (NSAID- stroid- anticoagulant)

Alcohol

Cirrhosis

Peptic ulcer disease Bleeding may be the first symptom

DU: GU = 4 : 1

Upper GI Bleeding

Most common complication of PUD

Most peptic ulcer related death

Typically Present with melena and/or hematemesis

ManagementResuscitation

- Large-bore IV access (2 IV line)- Foley catheterization- NGT + irrigation with normal saline (room

temperature)

Continuous IV PPI

Managment

Lab test- CBC, Hb, HCT, Platelet- BUN - Cr – Na – K- PT, PTT- L.F.T- ABG+ E.C.G

Upper GI Bleeding due to peptic ulcer

Acid suppression + NPO

- ¾ will stop

- ¼ will continue to bleed or will rebleed

All mortalities & operations occur in this group

Risk StratificationMagnitude of the Hemorrhage - Shock

- Hematemesis - Transfusion > 4 units in 24 h - Hypotension - Tachycardia - Oliguria - Low Hct - Pallor - Altered Mentation

Risk StratificationComorbidities - Lung - Liver - Kidney - Heart

AgeAnticoagulated or immunosuppressed

Risk StratificationEndoscopic Findings

- Bleeding from varices

- Active bleeding or Visible vessel

High Risk Patients (25%)Type & Crossmatch

Admit to ICU

Consult Surgeon

Consult gastroenterologist

Start continuous infusion of PPI

High Risk Group (25%)Endoscopy within 12 hours after correction

of coagulopathy (Diagnosis the cause – Assess the need for hemostatic therapy)

Endoscpic hemostasis

Arteriography (occasionally)

Operation

Endoscopic Therapy

Injection with epinephrine

Electrocautery

Clip (exposed vessel)

Indications of Operation

Massive Bleeding unresponsive to Endoscopic Therapy

Transfusion requirement of > 4-6 UnitPersistent bleeding or rebleeding after one or

more endoscopic therapyLack of availability of a therapeutic endoscopistLack of availability of blood for transfusionRepeat hospitalization for bleeding ulcer Concurrent indication: Perforation – Obstruction

Indications of Early Elective Operation After initially successful endoscopic treatment

Elderly PatientsMultiple comorbidity(don’t tolerate another episode of Hemorrhage)

Deep ulcer overlying a large vessel :posterior duodenal bulb(Gastroduodenal Artery) or lesser gastric curve (left gastric artery)

LOWER GI BLEEDING

Symptoms

Unexplained Iron – Deficiency Anemia (Occult Blood)

HematocheziaDark or Clot Rectal BleedingMassive Shock

Causes

HemorrhoidsFissureSRUIBDMalignancyPolyps

Causes- Angiodysplasia

Usually in cecum & R.T Side colon

- Non congenital or Neoplastic but Degenerative

- No relation with other skin & visceral vascular lesions

- with age- Usually small < 5 mm

Causes- Angiodysplasia

Colonoscopy or Angiography for diagnosis

80 % self limited

50 % Recurrence during 3 years

Treatment options: laser, electrocoagulation ,surgery

Causes - Diverticulosis

Left sided colon

Cause of > 50% massive lower GI Bleeding

CausesMeckel’s Diverticulum

Infectious Colitis

A-V malformation

Ischemic colitis

Mesenteric Thrombosis

HistoryWeight loss

Abdominal Pain / Cramp

Recent Bowel Habit Change

+ Ve Family hx of colorectal CA

Drug History

ManagementResuscitation (2 IV Line)Correction of coagulopathy, thrombocytopeniaLab test- CBC, Hb, HCT, Platelet- BUN - Cr – Na – K- PT, PTT- L.F.T- ABG+ E.C.G

Identify the SourceNGT:

- Return of Bile => Source of Bleeding is distal to the ligament of treitz

- Blood => Upper GI Bleeding

Proctoscopy + DRERectal Tumors

Hemorrhoids

SRU

Proctitis

Rectal Polyps

Varices

ColonoscopyStable Patients

Rapid Bowel Prep 4-6 h

Therapeutic - Cautery - Injection of Epinephrine

99 mTC RBC ScintigraphyMassive Bleeding Responsive to conservative

treatment (Stable Patients)

Extremely Sensitive

Detection of 0.1 ml/min bleeding

Localization is imprecise

Intermittent bleeding (can repeat till 30 h)

Positive TC => AngiogaphyTo localize bleeding (the most definite for

localization)

Detection of 0.5 cc/min

Infusion of vasopressin or angioembolization (Therapeutic)

Catheter can left for laparotomy

Barium EnemaDouble contrastDifficult, poor prep, unsuccessful

colonoscopy

Obscure GI Bleeding

90% lesions for GI Bleeding are within the reach EGD and colon

<10 % GI Bleeding, No source by endoscopic studiesOvert 80 % : Hematemesis, Melena, Hematochezia Occult 20% : Iron-Deficiency Anemia, Positive GuaiacMost lesions in small intestine Angiodysplasia 75 % Neoplasms 10 % Meckel’s diverticulum: most common in children

Crohn’sInfectious enteritisNSAID induced ulcers & erosionsVasculitisIschemiaVaricesDiverticulaIntussusception

EnteroscopyPush => 60 cm Jejunum (+ therapeutic)

Sonde => 50-75 % of the small intestinal mucosa can be examined (No Biopsy or therapy)

Wireless Capsule => Success rate 90% Radiotelemetry, portable, detectors attached to the patient’s body, stable patient but continues to bleed, success rate 90 %

Enteroscopy

Intraoperative EnteroscopyOral CecumEnterotomyExam during insertion rather than

withdrawal

Enteroclysis

Small Bowel follow – throughMR Enterography

Angiography (angiodysplasia, vascular tumors)

99 mTC – labeled RBC Scan (Meckel’s Diverticulum)