Gastrointestinal Bleeding Amr Mohsen, M.D., FRCS(Ed) Professor of Surgery, Cairo University.

Gastrointestinal Bleeding

Amr Mohsen, M.D., FRCS(Ed)

Professor of Surgery, Cairo University

Gastrointestinal BleedingSpectrum of Disease

NOT one disease but various pathological processes Common problem Mortality rate still 10% Massive acute hemorrhage to occult, trivial Timely evaluation is critical to proper management

Gastrointestinal BleedingDefinition of Terms

Upper Gastrointestinal Bleeding: proximal to Ligament of Treitz

Lower Gastrointestinal Bleeding: distal to the ligament of Treitz

Hematemesis: vomiting of blood Melena: Passage of black tarry stools Hematochezia: Passage of fresh blood per rectum

Gastrointestinal BleedingDefinition of Terms

Manifest bleeding Occult bleeding Bleeding of obscure origin

I Chronic Gastrointestinal BleedingOccult Bleeding – Manifestations

Weakness Fatigue Shortness of breath Faintness Accidentally discovered anemia Routine screening

I Chronic Gastrointestinal BleedingOccult Bleeding – Causes - Diagnosis

GIT malignancy GERD & esophagitis Peptic ulcer NSAIDs GIT polyps

Detection depends on peroxidase activity of hemoglobin

Guaiac testHemoccult test

II Acute Gastrointestinal BleedingInitial Evaluation

Estimate severity of bleeding Institute resuscitation Localize site of bleeding (UGI vs LGI) Diagnose and treat specific lesion

II Acute Gastrointestinal BleedingEstimation of Severity

BEST METHOD: vital signs

Massive hemorrhage: shock (supine hypotension) 20-25% loss of vascular volume

Submassive hemorrhage: orthostatic hypotension

15-20% loss of vascular volume

Trivial hemorrhage: No change in vital signs < 15% loss of vascular volume

II Acute Gastrointestinal BleedingLocalization

Distinguishing LGI and UGI Clincal Signs

– Hematemesis: UGI bleeding – Melena: Usually UGI – Hematochezia: Usually LGI

Nasogastric aspirate (ALL PATIENTS) – Lavage +: UGI bleeding – 15% miss rate

IIa Acute UGI BleedingManagement

Hematemesis, or melena is an emergency.

Admission to an ICU for all patients with severe GI bleeding.

The team approach includes a gastroenterologist, a surgeon with expertise in GI surgery, and skilled nurses.

A major cause of morbidity and mortality is aspiration of blood. To prevent this complication in patients with altered mental

status, endotracheal intubation should be considered.

IIa Acute Gastrointestinal BleedingResuscitation

All patients need 2 large-bore IVs Crystalloid solutions until blood available Send blood for Hct, coagulation studies (PT, PTT,

platelet), crossmatch Transfuse blood for:

– Obvious massive blood loss – Hematocrit < 25% with active bleeding – Symtpoms due to low Hct

Correct coagulopathies – Fresh frozen plasma – Platelet transfusion

IIa Acute UGI BleedingEtiology (Egypt)

Esophageal varices 55%Acute gastric erosions 15% Chronic DU Chronic GU Esphagitis & erosions Mallory Weiss tears Duodenitis Gastric cancer Coagulopathies

IIa Acute UGI BleedingDiagnosis

History – of previous bleeding – of peptic ulcer symptoms – of previous surgery – of medications: NSAID

Physical Exam – Stigmata of cirrhosis: spider angiomata, jaundice,

gynecomastia, palmar erythema, testicular atropy, splenomegaly, ascites, noular liver.

– Surgical scars – Tenderness

IIa Acute UGI BleedingDiagnostic Procedures

Endoscopy – 90-95% accurate – Diagnosis and treatment

Barium radiography– 80% accurate – Barium makes further studies difficult

Arteriography (failure of localization / active bleeding) Nuclear Scanning (Technetium-99m) ??

Endoscopy is routinely used first, particularly in patients with significant hemorrhage

IIa Acute UGI BleedingContrast radiography

IIa Acute UGI BleedingEndoscopy

NormalVarices


Acute gastric erosions

Signs of recent bleeding


DU – signs of recent bleeding


GU

Blood clot Visible vessel


Mallory Weiss tear

IIa Acute UGI BleedingTreatment of Specific Lesions

Esophageal varices

URGENT

1. Endoscopic sclerotherapy or banding

2. Vasopressin infusion

3. Surgery


Esophageal varices

Sengstaken tube Temporary measure


Esophageal varices1. Endoscopic sclerotherapy or banding


Esophageal varices1. Endoscopic sclerotherapy or banding

– Highly successful– Failure Repeat injection– Followed by chronic sclerotherapy– Failure rate ~15%

From esophageal varicesMissing fundal varicesDifficulty injecting fundal varices


Esophageal varices

2. Vasopressin (1 unit/min) IV infusion

Beware of coronary heart disease


Esophageal varices3. Urgent surgery

Emergency shunt surgery is losing favor


Esophageal varices3. Urgent surgery

Most popular procedure


Peptic Ulcers– Antacids or H2 blockers and proton

pump antagonists promote healing but DON’T stop acute bleeding

URGENT

– Endoscopic coagulation– Angiographic embolization– Surgery


Peptic UlcersSurgery

IIb Acute LGI BleedingGeneral Considerations

Spontaneous remission rate is 80%

Bleeding has usually ceased by the time the patient presents to hospital

No source of bleeding can be identified in 12%

Bleeding is recurrent in 25%

IIb Acute LGI BleedingCommon causes

Hemorrhoidal bleeding• Fresh bright red• Jet or drops separate from stools• With straining at end of defecation

Massive bleeding in adults1. Diverticula 2. UC 3. Ischemic colitis

4. Angiodysplasia 5. Massive bleeding from upper GIT

Massive bleeding in childrenMeckel’s diverticulum

IIb Acute LGI BleedingGeneral Considerations

Initial evaluation is the same – Judge severity – Resuscitate – Localize site (usually difficult)

Patient usually notes hematochezia (bright red rectal bleeding)

Most of LGI bleeding is from anus or rectum especially trivial bleeding

Hematochezia should be considered an emergency.

Admission to an ICU is recommended for all patients with severe GI bleeding.

The team approach includes a gastroenterologist, a surgeon with expertise in GI surgery, and skilled nurses.

IIb Acute LGI BleedingManagement

IIb Acute LGI BleedingDiagnosis

History – Previous bleeding episodes – Rectal pain/hemorrhoids – IBD – Change in stool caliber – Weight loss

Physical Exam – Rectal examination: hemorrhoids, tears, fissures, fistulas – Anoscopy: hemorroids, fissures

Sigmoidoscopy

IIb Acute LGI BleedingEvaluation

Nasogastric tube if massive bleeding

Sigmoidoscopy Colonoscopy

Angiography require blood loss > 0.5 ml/min Isotope scanning

Barium enema not for initial diagnosis


Angiodysplasia (usually Rt colon)


Diverticula (usually Lt colon)


UCNormal colon


Ischemic colitis (usually splenic flexure)


Diverticula (usually Lt colon)

1. 80% of bleeding cases stop spontaneously

2. Arteriography & embolizationAngiodyaplasia Argon beam coagulation

3. Urgent surgeryPreoperative localization ResectionNo localization + I.O. colonoscopy High failure

After treatment and follow-up

IIb Acute LGI BleedingManagement

the cause of the bleeding has not been determined after an initial gastrointestinal evaluation

May be occult or manifest

III Bleeding of obscure originDefinition

In 38% of patients the source of bleeding is located in the distal duodenum and proximal jejunum

Duodeno-jejunal arteriovenous malformations (AVMs) are the most common cause for bleeding

III Bleeding of obscure originSources

1. Repeat upper and/or lower GI endoscopy

2. Enteroscopy– Push enteroscopy. can be advanced as much as

100 cm past the ligament of Treitz– Sonde enteroscopy, a tube is advanced by peristalsis

into the small intestine. Lengthy and uncomfortable– Swallowed capsule endoscopy

III Bleeding of obscure originManagement steps

3. Isotope-labelled RBCs scan (0.1-0.4ml/min)

4. Mesenteric angiography (>0.5ml/min)

5. Meckel’s scan

6. Barium meal for chronic cases (limited value in AVM)

7. intraoperative enteroscopy

III Bleeding of obscure originManagement steps

Application

Case variation Surgeon’s experience Hospital facilities

Individualize management

Don’t hesitate to TRANSFER

Gastrointestinal Bleeding Amr Mohsen, M.D., FRCS(Ed) Professor of Surgery, Cairo University.

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Transcript of Gastrointestinal Bleeding Amr Mohsen, M.D., FRCS(Ed) Professor of Surgery, Cairo University.