GASTROINTESTINGASTROINTESTINAL BLEEDINGAL BLEEDING

Part 1Part 1

Stephanie Faith C. BautistaStephanie Faith C. Bautista

DEFINITION of DEFINITION of Gastrointestinal (GI) BleedingGastrointestinal (GI) Bleeding

refers to any bleeding that starts in the refers to any bleeding that starts in the gastrointestinal tract, which extends from the gastrointestinal tract, which extends from the mouth to the anus.mouth to the anus.

can occur from abnormal blood clottingcan occur from abnormal blood clotting

can be caused by vitamin K deficiencies and can be caused by vitamin K deficiencies and thrombocytopenia — a drop in platelets (the blood thrombocytopenia — a drop in platelets (the blood cells that normally initiate the clotting process). cells that normally initiate the clotting process).

The amount of bleeding can range from nearly The amount of bleeding can range from nearly undetectable to acute, massive, and life undetectable to acute, massive, and life threatening.threatening.

SITESITE

Divided into:Divided into: Upper GI bleeding: The upper GI tract is Upper GI bleeding: The upper GI tract is

located between the mouth and the located between the mouth and the upper part of the small intestine.upper part of the small intestine.

Lower GI bleeding: The lower GI tract is Lower GI bleeding: The lower GI tract is located between the upper part of the located between the upper part of the small intestine and the anus. The lower small intestine and the anus. The lower GI tract includes the small and large GI tract includes the small and large bowels.bowels.

CONSIDERATIONS CONSIDERATIONS can range from microscopic bleeding and massive can range from microscopic bleeding and massive

bleedingbleeding

important to be aware, because it may point to many important to be aware, because it may point to many significant diseases and conditions. significant diseases and conditions. • Prolonged microscopic bleeding can lead to loss of Prolonged microscopic bleeding can lead to loss of

iron, causing anemia. iron, causing anemia. • Acute, massive bleeding can lead to hypovolemic Acute, massive bleeding can lead to hypovolemic

shock, and even death.shock, and even death.

can occur at any age from birth on.can occur at any age from birth on.

the degree and suspected location of the bleeding the degree and suspected location of the bleeding determines what tests should be performed to find the determines what tests should be performed to find the cause. cause.

once a bleeding site is identified, many therapies are once a bleeding site is identified, many therapies are available to stop the bleeding.available to stop the bleeding.

COMMON CAUSES COMMON CAUSES Some of the possible causes of GI bleeding include:Some of the possible causes of GI bleeding include:

Anal Fissure Gastric (stomach) ulcer

Aorto-enteric fistula Hemorrhoids

Arterio-venous malformations (angiodysplasias)Bleeding diverticulum

Ischemic bowelIntestinal polyps

Cancer of the small intestine Intestinal obstruction (twisted bowel)

Celiac sprue Intestinal vasculitis

Colon cancer Intussusception

Cow's milk allergy Mallory-Weiss tear

Crohn’s disease Meckel’s diverticulum

Dieulafoy's lesion Nosebleed

Duodenal ulcer Portal hypertensive gastropathy

Dysentery Radiation injury to the bowel

(infectious diarrhea that causes bleeding)

Ruptured appendicitis

Esophageal varices Stomach cancer

Esophagitis Ulcerative colitis

Upper Gastrointestinal Upper Gastrointestinal BleedingBleeding

Upper GI bleeding originates in the first Upper GI bleeding originates in the first part of the GI tract - the esophagus, part of the GI tract - the esophagus, stomach, or duodenum (first part of the stomach, or duodenum (first part of the intestine). intestine).

Upper GI bleeding is caused by one of Upper GI bleeding is caused by one of the following: the following: – Peptic ulcersPeptic ulcers– GastritisGastritis– Esophageal varices Esophageal varices – Mallory-Weiss tearsMallory-Weiss tears

Lower Gastrointestinal Lower Gastrointestinal BleedingBleeding

Lower GI bleeding originates in the portions of the Lower GI bleeding originates in the portions of the GI tract farther down the digestive system-the GI tract farther down the digestive system-the segment of the small intestine farther from the segment of the small intestine farther from the stomach, large intestine, rectum, and anus. stomach, large intestine, rectum, and anus.

Lower GI bleeding is caused by one of the following: Lower GI bleeding is caused by one of the following: – Diverticular diseaseDiverticular disease– AngiodysplasiaAngiodysplasia– PolypsPolyps– HemorrhoidsHemorrhoids– Anal fissuresAnal fissures

Blood in the stool can result from cancers, Blood in the stool can result from cancers, inflammatory bowel disease, and infectious inflammatory bowel disease, and infectious diarrhea.diarrhea.

SYMPTOMSSYMPTOMS Acute gastrointestinal bleeding first will appear as Acute gastrointestinal bleeding first will appear as

vomiting of blood, bloody bowel movements, or black, vomiting of blood, bloody bowel movements, or black, tarry stools. Blood may look like "coffee grounds."tarry stools. Blood may look like "coffee grounds."

Symptoms associated with blood loss can include the Symptoms associated with blood loss can include the following: following:

FatigueFatigue Weakness Weakness Shortness of breath Shortness of breath Abdominal painAbdominal pain Pale appearancePale appearance Vomiting of blood usually originates from an upper GI source.Vomiting of blood usually originates from an upper GI source.

Bright red or maroon stool can be from either a lower Bright red or maroon stool can be from either a lower GI or an upper GI sourceGI or an upper GI source. .

Long-term GI bleeding may go unnoticed or may Long-term GI bleeding may go unnoticed or may cause fatigue, anemia, black stools, or a positive test cause fatigue, anemia, black stools, or a positive test for microscopic bloodfor microscopic blood..

WHEN TO SEEK MEDICAL WHEN TO SEEK MEDICAL CARECARE

Call for an appointment with your doctor if:Call for an appointment with your doctor if:

You have black, tarry stools (this may be a sign of You have black, tarry stools (this may be a sign of upper GI bleeding)upper GI bleeding)

You have blood in your stoolYou have blood in your stool

You vomit blood or you vomit material that looks like You vomit blood or you vomit material that looks like coffee groundscoffee grounds

Any presence of blood in the stool or the Any presence of blood in the stool or the upper gastrointestinal tract is significant and needs upper gastrointestinal tract is significant and needs medical investigation. Black or dark stools may medical investigation. Black or dark stools may represent slow bleeding into the GI tract and should be represent slow bleeding into the GI tract and should be investigated by a physician. investigated by a physician.

Any significant bleeding into the GI tract, either Any significant bleeding into the GI tract, either vomited blood or blood through the rectum, should be vomited blood or blood through the rectum, should be evaluated.evaluated.

What to expect at your What to expect at your health care provider's health care provider's

office:office: GI bleeding is diagnosed by a doctor GI bleeding is diagnosed by a doctor GI bleeding can be an emergency condition requiring GI bleeding can be an emergency condition requiring

immediate medical attention. immediate medical attention.

You will also be asked questions about your symptoms, You will also be asked questions about your symptoms, including:including:

When did you first notice symptoms?When did you first notice symptoms? Did you have black, tarry stools or red blood in the Did you have black, tarry stools or red blood in the

stools?stools? Have you vomited blood?Have you vomited blood? Did you vomit material that looks like coffee grounds?Did you vomit material that looks like coffee grounds? Do you have a history of peptic or duodenal ulcers?Do you have a history of peptic or duodenal ulcers? Have you ever had symptoms like this before?Have you ever had symptoms like this before? What other symptoms do you have?What other symptoms do you have?

EXAMS AND TESTSEXAMS AND TESTSTests that may be done include:Tests that may be done include:

Abdominal CT scanAbdominal CT scan Abdominal MRI scanAbdominal MRI scan Abdominal x-rayAbdominal x-ray Angiography Angiography Bleeding scan (tagged red blood cell Bleeding scan (tagged red blood cell

scan)scan) Capsule endoscopy (camera pill that is Capsule endoscopy (camera pill that is

swallowed to look at the small intestine)swallowed to look at the small intestine) ColonoscopyColonoscopy Complete blood count (CBC)Complete blood count (CBC) EGD (EsophagogastroduodenoscopyEGD (Esophagogastroduodenoscopy)) EnteroscopyEnteroscopy SigmoidoscopySigmoidoscopy

MEDICAL TREATMENTMEDICAL TREATMENT Serious gastrointestinal bleeding can destabilize your vital Serious gastrointestinal bleeding can destabilize your vital

signs. signs. The physician may need to resuscitate you with IV fluids The physician may need to resuscitate you with IV fluids

and medicine through a veinand medicine through a vein Blood transfusionsBlood transfusions In some cases, you may need surgery.In some cases, you may need surgery. Tube through the mouth into the stomach to drain the Tube through the mouth into the stomach to drain the

stomach contents (gastric lavage)stomach contents (gastric lavage) Once the condition is stable, a physical examination, Once the condition is stable, a physical examination,

including a detailed abdominal examination, will be including a detailed abdominal examination, will be performed.performed.

FOLLOW-UPFOLLOW-UP Maintain a proper diet and take the medications prescribed Maintain a proper diet and take the medications prescribed

to you as your doctor directs.to you as your doctor directs. Follow up with your physician on a regular basis to monitor Follow up with your physician on a regular basis to monitor

progress, so that your doctor can prevent further progress, so that your doctor can prevent further progression and complications of your gastrointestinal progression and complications of your gastrointestinal bleeding.bleeding.

TREATMENTTREATMENT Early endoscopy is recommended, both as a Early endoscopy is recommended, both as a

diagnostic and therapeutic approach, as endoscopic diagnostic and therapeutic approach, as endoscopic treatment can be performed through the endoscope. treatment can be performed through the endoscope.

Patients with esophageal varices typically have Patients with esophageal varices typically have coagulopathy, plasma products may have to be coagulopathy, plasma products may have to be administered. Vitals signs are continuously administered. Vitals signs are continuously monitored.monitored.

Endoscopic Therapy depends on the lesion identifies, Endoscopic Therapy depends on the lesion identifies, and can include:and can include:• Injection of adrenaline or other sclerotherapyInjection of adrenaline or other sclerotherapy• ElectrocauteryElectrocautery• Endoscopic clipping orEndoscopic clipping or• Banding of varicesBanding of varices

Bleeding lesion are usually removed in order to Bleeding lesion are usually removed in order to determine the underlying pathology, and to determine the underlying pathology, and to determine the risk for rebleeding.determine the risk for rebleeding.

PHARMACOTHERAPYPHARMACOTHERAPY Includes the following:Includes the following:

• Proton pump inhibitorsProton pump inhibitors (PPIs) - reduce gastric acid (PPIs) - reduce gastric acid production and accelerate healing of certain gastric, production and accelerate healing of certain gastric, duodenal and esophageal sources of hemorrhage. duodenal and esophageal sources of hemorrhage. Administered orally / intravenouslyAdministered orally / intravenously

• Octreotide is a somatostatinOctreotide is a somatostatin - shunt blood away from - shunt blood away from the splanchnic circulation. Found to be a useful in the splanchnic circulation. Found to be a useful in management of both variceal and non-variceal upper GI management of both variceal and non-variceal upper GI hemorrhage. hemorrhage.

• Terlipressin is a vasopressinTerlipressin is a vasopressin - most commonly used for - most commonly used for variceal upper GI hemorrhage.variceal upper GI hemorrhage.

• Antibiotics are prescribed in upper GI bleedsAntibiotics are prescribed in upper GI bleeds - - associated with portal hypertensionassociated with portal hypertension

If Helicobacter pylori is identified as a contributant to the source If Helicobacter pylori is identified as a contributant to the source of hemorrhage, then therapy with antibiotics and a PPI is of hemorrhage, then therapy with antibiotics and a PPI is suggested.suggested.

PREVENTIONPREVENTION

You can prevent some causes of You can prevent some causes of gastrointestinal bleeding. gastrointestinal bleeding.

Avoid foods and factors, such as Avoid foods and factors, such as alcohol and smoking, that increase alcohol and smoking, that increase gastric secretions.gastric secretions.

Eat a high-fiber diet to increase the Eat a high-fiber diet to increase the bulk of the stool, which helps bulk of the stool, which helps prevent diverticulosis and prevent diverticulosis and hemorrhoids.hemorrhoids.

Ligament of Ligament of TreitzTreitz

Upper gastrointestinal Upper gastrointestinal bleeding. Ulcer with a clean bleeding. Ulcer with a clean

base. base.

Upper gastrointestinal bleedingUpper gastrointestinal bleeding

Ulcer with a black spotUlcer with a black spot Ulcer with an overlying clotUlcer with an overlying clot

Upper gastrointestinal Upper gastrointestinal bleeding. Ulcer with a visible bleeding. Ulcer with a visible

vessel. vessel.

Upper gastrointestinal Upper gastrointestinal bleeding. Ulcer with active bleeding. Ulcer with active

bleedingbleeding

Intussusception - x-ray:Intussusception - x-ray:Abdominal x-ray showing an intestinal condition in which a loop of bowel has slipped into another section of bowel called INTUSSUSCEPTION.

causing swelling, reduced blood flow, obstruction, and tissue damage.

Intussusception requires emergency treatment (barium enema or surgery) to prevent intestinal tissue death (necrosis), intestinal perforation, peritonitis, and death.

Volvulus - x-ray:Volvulus - x-ray:

Patient with a twisted bowel

(volvulus).

Normal anatomy:Normal anatomy:The Gastrointestinal Tract starts at the mouth, which leads to the esophagus, stomach, small intestine, colon, & finally, the rectum and anus.

The GI tract is a long, hollow, muscular tube through which food passes & nutrients are absorbed.

Indication:Indication:Bleeding from the GI tract is a common medical problem.

Patients usually notice either dark red blood or bright red blood in their stool.

Ulcers of the stomach and duodenum are common causes of bleeding from the upper GI tract.

Bleeding can also occur in the lower GI tract (colon). Diverticular bleeding is a common cause of lower GI bleeding.

ENDOSCOPYENDOSCOPYProcedure, part 1Procedure, part 1

The first step in the treatment of GI bleeding is to locate the source of the bleeding. Patients who have lost significant amounts of blood are transfused with blood.

Next, an endoscopy is used to locate the source of the bleeding. Upper endoscopy is generally performed first, and if no bleeding source is located, then lower endoscopy is performed. During an endoscopy, the patient is usually sedated but awake.

Procedure, part 2Procedure, part 2

In many cases, GI bleeding will stop on its own, with no treatment.

In other cases, treatment can be provided with the endoscope, most often in the form of cautery (electrocoagulation) of the site of bleeding.

Procedure, part 3:Procedure, part 3:

If the bleeding cannot be stopped using the endoscope, surgery may be required. The bleeding segment of intestine or stomach is removed. However,

most cases of GI bleeding are managed succesfully with endsocopy.

Endoscopic Endoscopic TherapyTherapy

Endoscopic TherapyEndoscopic Therapy

UPPER GASTROINTESTINAL UPPER GASTROINTESTINAL BLEEDING BLEEDING

Endoscopic image of a posterior wall duodenal ulcer with a clean base, which is a common cause of upper GI hemorrhage.

Gastric ulcerGastric ulcer in antrum of stomach with overlying in antrum of stomach with overlying clot. Pathology was consistent with gastric clot. Pathology was consistent with gastric

lymphoma. lymphoma.

Endoscopic image of image of small gastric ulcer with small gastric ulcer with

visible vessel visible vessel Same ulcer seen Same ulcer seen after endoscopic after endoscopic

clippingclipping

Mallory-Weiss Syndrome Mallory-Weiss Syndrome 34-year-old male physician who had been ingesting alcoholic beverages, presented with bleeding of the g.i. tract.

43-year-old male who presented with vomiting after ingestion of alcoholic beverages. Also note the signs of reflux esophagitis as well as a blood clot from a gastro esophageal tear.

Peptic ulcerPeptic ulcer

Peptic ulcer caused by excess acid in the stomach...

Acute Acute Gastritis Gastritis

Chronic Chronic Gastritis Gastritis

Esophageal Esophageal VaricesVarices

Hematemesis and Melena Hematemesis and Melena

Hypovolemic Hypovolemic ShockShock

Types of LOWER Types of LOWER GASTROINTESTINAL (GI) GASTROINTESTINAL (GI)

BLEEDINGBLEEDING

AlgorithAlgorithm for m for

Massive Massive Lower Lower

Gastro-Gastro-intestinaintestina

l (GI) l (GI) Bleeding Bleeding

Basic Algorithm for the Basic Algorithm for the Management of Lower GI BleedManagement of Lower GI Bleed

Diverticular disease Diverticular disease - a cause of - a cause of LGIBsLGIBs

Acute Variceal Bleed Acute Variceal Bleed

Exact site of the bleeding of acute variceal bleeding

Endoscopy is an essential step in the diagnosis and

treatment of acute variceal bleeding

Endoscopic Variceal Ligation Endoscopic Variceal Ligation (Banding)(Banding)

ENDOSCOPIC VARICEAL LIGATION is like rubber-band ligation of hemorrhoids

Esophageal mucosa and submucosa containing varices are ensnared, causing subsequent strangulation, sloughing, and eventual fibrosis, resulting in obliteration of the varices.

Endoscopic ligation requires placement of an opaque cylinder over the end of the endoscope. This decreases the endoscopic field of view and may allow pooling of blood. Thus, in patients with active bleeding, visualization may be impaired more with ligation than with sclerotherapy.

Local complications are less common with ligation compared to sclerotherapy.