GI Hemorrhage

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GI Hemorrhage

• October 10, 2009
• 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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Site

• Upper
• Esophageal
• Stomach
• Doudenum
• Hepatic
• Pancreatic
• Lower
• Small bowel
• Colon
• Anus

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Etiology

• 85 are due to
• Peptic ulcer disease
• Variceal hemorrhage
• Colonic diverticulosis
• Angiodysplasia

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Chain of events

• Recognize severity
• Establish access for resusitation
• Resusitate
• Identify source
• Intervention

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Question 1

• JB a 30 y/o with hematemesis presents with
  orthostatic hypotension, clammy hands, but
  without tachycardia. How much blood has he lost?
• gt40
• 20-40
• 10-20
• lt10

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Question 1

• JB a 30 y/o with hematemesis presents with
  orthostatic hypotension, clammy hands, but
  without tachycardia. How much blood has he 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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Gastric varices
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Gastric varices
Esophageal Varices
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Gastric varices
Bleeding ulcers
Esophageal Varices
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Gastritis
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Gastritis
Dieulafoys lesion
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Mallory-weiss
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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 lt1mm diameter
• Causes
• H. pylori 40-50
• NSAIDs 40-50
• Other (Z-E syndrome)

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Peptic ulcer hemorrhage

• 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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Peptic ulcer hemorrhage

• Medical management
• Anti-ulcer medication
• H. pylori treatment
• Stop NSAIDs
• Follow up EGD for gastric ulcer in 6 weeks

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Peptic ulcer hemorrhage

• 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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Peptic ulcer hemorrhage

• Surgical intervention
• Only 10 of patients
• Indications
• Failure of endoscopy
• Significant rebleeding after 1st endoscopy
• Ongoing transfusion requirement
• Need for gt6 units over 24 hours
• Earlier for elderly, multiple co-morbidities

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Peptic ulcer hemorrhage

• 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 for rebleeding
• Bottom line still recommended but without
  definitive evidence

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Peptic ulcer hemorrhage

• Doudenal ulcer
• Expose ulcer with duodenotomy or
  duodenopyloromyotomy
• Direct suture ligation, four quadrent ligation,
  ligation of gastroduodenal artery
• Anti-secretory procedure
• Truncal, parietal cell vagotomy
• If unstable can use meds

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Peptic ulcer hemorrhage

• 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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Variceal hemorrhage

• Cirrhotics usually
• 25 mortality for each bleeding episode
• 75 will rebleed
• 50 mortality with surgery
• Based on Childs class

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Somatostatin or vasopressin w/wo NTG
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TIPS
Shunt procedures
Sugiura procedure
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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
• gt50 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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Colonic angiodysplasia
Bleeding diverticulosis
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LGI hemorrhage

• Etiology
• Diverticulosis 40-55
• Right sided lesions gt left
• 90 stop spontaneously
• 10 rebleed in 1st year and 25 at 4 years
• Angiodysplasia 3-20
• Most common cause of SB bleeding in gt50 y/o
• gt50 are in right colon
• Neoplasia
• Typically bleed slowly
• Inflammatory conditions
• 15 of UC patients, 1 of chrons patients
• Radiation, infectious, AIDS rarely
• Vascular
• Hemorrhoids
• gt50 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 gt0.5 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 angiodysplasia with extravasation
Small bowel ulceration due 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, gt6 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 lt30 years old
• Endoscopy
• Push or pull endoscopy
• Video capsule endoscopy
• Intraoperative endoscopy 70 successful

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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
  1639093, 1992.

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Treatment

• Surgery
• Without localization only for acute
  exsanguinating hemorrhage
• Intraoperative endoscopy
• Segmental resection