GASTROINTESTINAL TRACT BLEEDING

1
GASTROINTESTINAL TRACT BLEEDING

• By
• Dr. Wasfi M Salayta
• KHMC

2
Epidemiology

• Upper GI bleeding
• Is defined as bleeding from a gastrointestinal
  source that is proximal to the ligament of
  Treitz.
• It is more common than lower GI bleeding.
• Annual incidence 149-172/100,000.
• Increased in males and in older patients.
• Over 50 of upper GI bleeds are due to erosive or
  ulcerative disease of the stomach or duodenum.
• The mortality associated with GI bleeding remains
  significant at 5 to 11.
• The following factors increased the mortality
  rate in upper GI bleeding
• Age gt 60.
• Co morbid diseases especially pulmonary and
  hepatic diseases.
• Physical findings consistent with
  cardiorespiratory or hemodynamic compromise.
• Blood transfusion requirement greater than 5
  units.
• Requirement for surgery (patients requiring
  emergency surgery had increased mortality
  compared with those undergoing more elective
  surgery).
• Recurrent bleeding after hospitalization.
• Those who develop GI bleeding after
  hospitalization for other reasons.

3
Epidemiology

• lower GI bleeding
• Is defined as bleeding distal to the ligament of
  Treitz. It can range in severity from trivial to
  massive.
• LGIB accounts for approximately 20 of all major
  GI bleeds.
• More commonly bleeding is from a colonic rather
  than a small bowel source.
• Annual incidence 21 cases per 100,000.
• Increased in males and in older patients (mean
  age at presentation of 63 to 77 years).
• 80-90 of cases will stop bleeding spontaneously.
• As many as 25 will re-bleed either during or
  after their hospital admission.
• While most patients have a self-limited illness,
  the reported mortality ranges from 2-4.
• Among all patients presenting with lower GI
  bleeding, diverticular disease is the most
  common cause, followed by, vascular anomaliesor
  ischemic colitis.

4
Etiology- Upper GI bleeding

• Chronic Peptic ulcer disease is the most common
  cause of upper GI bleeding ,over 50 of cases
• Duodenal ulcer 29.
• Gastric ulcer 16.
• Stomal ulcer 5
• Acute mucosal ulceration(Stress gastritis )
• 1-33 of the upper GI bleeding causes.
• Often multiple and not extend through muscularis
  mucosa.
• Diffuse and typically involve the gastric body
  and fundus.
• More frequently seen in the following conditions
  ( shock-sepsis-surgery-trauma-burn-renal
  failure-respiratory failure-jaundice).
• The pathogenesis is due to an imbalance between
  aggressive and protective mucosal factors.
• Both H2-blocker and Antacid are effective in
  prevention.

5
Etiology- Upper GI bleeding

• Mallory-Weiss tear
• A mucosal laceration of the gastric cardia or
  gastroesophageal junction.
• Account for approximately 5 to 15 of all cases
  of upper GI bleeding and are relatively common in
  alcoholics.
• The classic presentation is that of repeated
  retching, vomiting or coughing followed by
  hematemesis.
• Up to 50 of patients do not give a history of
  antecedent retching or vomiting.
• Only 10 present with hemodynamic compromise.
• Bleeding is self-limited in 90 of cases
• Esophagitis/esophageal ulcer (seen in HIATUS
  HERNIA )

6
Etiology- Upper GI bleeding

• Esophageal/gastric varices.
• The incidence of bleeding is approximately 10 to
  15 per year, and in patients with large varices
  is 20 to 30.
• Bleeding due to varices is typically brisk and
  associated with hemodynamic compromise.
• The mortality associated with the first variceal
  bleed ranges from 30 to 50.
• Treatment
• Endoscopic sclerotherapy and band ligation of
  varices are the mainstay of emergent therapy.
• medical therapy for variceal hemorrhage has been
  extensively studied, the benefit of such therapy
  remains uncertain (vasopressin , More recently
  somatostatin and the somatostatin analogue,
  octreotide)
• The Senkstaken-Blakemore tube remains an
  important therapeutic tool in patients with brisk
  esophageal or gastric variceal hemorrhage that
  cannot be controlled on initial endoscopy.
• Patients who continue to bleed or who have more
  than one rebleeding episode despite endoscopic
  and medical therapy should be considered for
  portal decompression.

7
Etiology- Upper GI bleeding

• Neoplasm
• Gastric cancer
• Esophageal cancer
• Stromal tumor

8
Etiology- Upper GI bleeding

• Vascular anomalies
• An unusual cause of upper GI bleeding, accounting
  for only 5 of cases..
• Angiodysplasia, whether sporadic or secondary, is
  the most common vascular anomaly seen in the GI
  tract.
• Angiodysplasia/ectasia
• Are dilated, tortuous vessels in the mucosa and
  submucosa.
• The pathophysiology unclear, but is felt to be
  due to intermittent obstruction of the submucosal
  veins because of the colonic wall tension, which
  is highest in the cecum.
• May be sporadic, usually developing in the
  elderly.
• May be found in association with a number of
  disorders including renal failure, cirrhosis, the
  CREST syndrome, radiation injury, von
  Willebrands disease, and aortic stenosis.
• May occur anywhere in the GI tract, but are more
  commonly found in the colon(most common in the
  cecum and ascending colon) , followed by the
  small intestine and the stomach.
• These lesions usually lead to occult blood loss,
  but can also cause overt GI bleeding.
• Usually apparent at endoscopy, at which time
  therapy with laser or thermal probes may be
  applied.
• Bleeding that is refractory to endoscopic or
  medical therapy is an indication for surgical
  resection
• Dieulafoy lesion
• is characterized by an aberrantly large and
  tortuous submucosal artery that may erode through
  a small mucosal defect, resulting in massive
  hemorrhage
• 75 to 95 occur in the proximal stomach, usually
  on the lesser curvature and within 6 cm of the
  gastroesophageal junction, although they have
  been reported to occur thoughout the GI tract
• These lesions often respond to endoscopic therapy
  with injection of saline or 110,000 epinephrine
  and/or endoscopic application of thermal probes
• Patients who do not respond to endoscopic therapy
  require surgical intervention
• wide wedge resection of the artery and bleeding
  site is preferable to oversewing the artery in
  the area of the mucosal defect
• Patients who are poor surgical candidates may
  respond to angiographic embolization

9
Etiology- Upper GI bleeding

• Aortoduodenal erosion or fistula
• Representing 80 of all aortoenteric fistulas.
• It is estimated that 0.4 to 4 of patients with
  aortic grafts develop an aortoenteric fistula.
• Primary aortoduodenal fistulas associated with
  atherosclerotic aneurysms or trauma are much less
  common.
• rarely is seen endoscopically
• Angiography is seldom helpful unless a
  pseudoaneurysm is seen
• CT visualization of an aneurysm with associated
  extraluminal gas is virtually diagnostic, this
  finding is also uncommon.
• The diagnosis is usually made or confirmed on
  laparotomy. Surgical repair is the only
  therapeutic option.

10
Etiology- Upper GI bleeding

• Hemobilia
• Is usually associated with intraductal neoplasm,
  trauma, or iatrogenic injury such as percutaneous
  liver biopsy and cystic artery pseudoaneurysm.
• Suggested by jaundice, right upper quadrant pain
  and gastrointestinal bleeding.
• May be confirmed at endoscopy but often requires
  angiography.
• Angiographic therapy is the treatment of choice,
  although occasionally surgical therapy is
  necessary
• Hemosuccus pancreaticus (This is most commonly
  due to a pseudoaneurysm of the splenic artery in
  patients with a pancreatic pseudocyst or chronic
  pancreatitis but rarely may occur in patients
  with pancreatic duct malignancy
• Non-GI source (epistaxis)
• Factitious bleeding (ingestion of animal blood or
  human blood after auto-phlebotomy).

11
Etiology- lower GI bleeding

• Anorectal causes
• Include hemorrhoids -anal fissure and rectal
  ulcer.
• Bleeding from hemorrhoids and fissure is
  uncommonly associated with hemodynamic
  instability or large volume of blood loss.
• While rectal ulcer can cause severe hemorrhage
  and hemodynamic instability
• Possible causes of rectal ulcer are
• Radiation.
• Sexual transmitted disease.
• NSAIDs.
• Liver disease.
• Trauma.

12
Etiology- lower GI bleeding

• Diverticular disease
• Contributes 20-60 of the cases of LGIB.
• In 75 of patients bleeding will stop
  spontaneously.
• Rebleeding rate after first episode 25 and
  increase to 50 after two episodes.
• 5 will have severe hemorrhage.
• diverticular bleeding is distributed equally
  between the right and left sides of the colon.
• Observation alone is generally recommended
  following the first episode of diverticular
  hemorrhage. However, following a second episode,
  the risk of subsequent episodes appears to
  approximate 50, and thus elective resection has
  been recommended.

13
Etiology- lower GI bleeding

• Angiodysplasia
• Only about 15 of patients with vascular ectasia
  will develop gastrointestinal hemorrhage.
• The incidence in most recent studies is only 3
  compared to 15-27 previously as cause of LGIB.
• Colorectal neoplasm
• Although colorectal cancer is most commonly
  associated with occult blood loss rather than
  overt bleeding, patients with rectosigmoid
  lesions may present with hematochezia.
• CR-cancers are source of LGIB in 9-13 of
  patients.

14
Etiology- lower GI bleeding

• Ischemic colitis
• Occurs in 9-18 of patients.
• Results from a sudden and often temporary
  reduction in mesenteric blood flow, typically
  caused by hypoperfusion, vasospasm, or occlusion.
• The usual areas affected are the watershed
  areas of the colon the splenic flexure and the
  rectosigmoid junction.
• Patients tend to be elderly, often with
  significant atherosclerosis or cardiac disease.
• Other colonic etiologies
• Inflammatory bowel disease
• Acute hemorrhage occurs 0.9-6 in CD and 1.4-4
  in UC.
• Bleeding occurred in both young and old patients
  and not related to disease duration.
• Malignant lesion must be considered in patient
  with long standing history of IBD and LGIB.
• Infectious colitis or enteritis
• Radiation colitis/proctitis.
• Trauma, hematologic disorders and NSAIDs.
• Post polypectomy (occurs in 0.3 to 6.1 of
  polypectomies).
• Bleeding from CR-anastomosis (o.5-1.8).

15
Etiology- lower GI bleeding

• Small bowel sources account for 3-5 of all cases
  of LGIB
• Angiodysplasia is most common cause of small
  bowel hemorrhage (70-80).
• small bowel diverticula,
• Meckels diverticula,
• neoplasia,
• Crohns disease,
• aorto-enteric fistulas.

16
Obscure Gastrointestinal Bleeding

• Defined as recurrent acute or chronic GI bleeding
  for which no source has been found despite
  evaluation with EGD and colonoscopy with or
  without routine small bowel follow-through.
• It accounts 1.19-9 of LGIB.
• The most frequent causes are
• Small bowel tumors.
• Angiodysplasia.
• Ulcer\erosion.
• The diagnosis needs more procedures than patients
  with upper GI and colonic bleeding include
• Capsule endoscopy.
• Double balloon enteroscopy.

17
MANAGEMENT OF GI BLEEDING

• Initial assessment, resuscitation and triage
• GI bleeding may have different clinical
  presentations
• hematemesis or hematochezia with hemodynamic
  instability.
• melena or rectal bleeding without hemodynamic
  compromise.
• patients may have chronic GI bleeding with
  asymptomatic iron-deficiency anemia, or
  hemoccult-positive stool on screening for
  colorectal cancer.
• Patients presenting to the emergency room with
  hemodynamic instability require rapid clinical
  assessment.
• Intravenous access with at least two large-bore
  lines.
• nasogastric tube placement,
• determination of hematocrit and coagulation
  studies, and type and cross for blood products.
• Patients with altered mental status should
  undergo endotracheal intubation for airway
  protection
• . Emergent evaluation by a gastroenterologist
  should be requested.
• The patient should be stabilized before
  proceeding to endoscopy.

18
MANAGEMENT OF GI BLEEDING

• it is important to determine whether the bleeding
  is from an upper or lower GI source ( usually
  relatively straightforward )
• approximately 5-10 of patients who present with
  hematochezia are bleeding from an upper GI
  source.
• If there is uncertainty about the presence of an
  upper GI bleeding source, such as when the
  gastric aspirate is not bile-stained, patients
  with hematochezia and hemodynamic compromise
  should undergo upper endoscopy before evaluation
  of the lower GI tract.
• Admission to the hospital is required for most
  patients presenting with GI bleeding
• Those who present with frank hypotension or who
  have evidence for ongoing bleeding require
  monitoring in an intensive care unit and urgent
  endoscopic evaluation
• Those who present with mild or no orthostasis,
  have no evidence for continued bleeding, but have
  had a significant drop in hematocrit are
  generally hospitalized on a medical/surgical
  floor.
• young patients with self-limited GI bleeding who
  present without orthostasis or hemodynamic
  instability and who have no significant comorbid
  conditions may be managed as outpatients.

19
MANAGEMENT OF GI BLEEDING

• Diagnosis
• History and physical
• During the initial stabilization and evaluation,
  a complete history and physical should be
  performed.
• History
• Patients with upper GI bleeding should be
  questioned about
• Peptic ulcer disease
• liver disease,
• malignancy,
• abdominal surgery
• bleeding disorder,
• weight loss,
• alcohol,
• aspirin or non-steroidal antiinflammatory drug
  (NSAID) use.
• A history of antecedent retching suggests a
  Mallory-Weiss tear
• Patients with suspected lower GI bleeding should
  also be asked about
• hemorrhoids,
• associated diarrhea,
• change in bowel habits,
• personal or family history of inflammatory bowel
  disease,

20
MANAGEMENT OF GI BLEEDING

• Physical examination
• Orthostatic blood pressure and pulse even if the
  patient appears stable.
• cutaneous stigmata of liver disease
• splenomegaly or ascites, abdominal tenderness, an
  abdominal mass or lymphadenopathy
• cutaneous or mucocutaneous manifestations of
  systemic disorders associated with GI bleeding
• ENT EXAMINATION,RECTAL EXAMINATION.

21
MANAGEMENT OF GI BLEEDING

• Diagnostic studies
• Upper GI endoscopy
• the preferred diagnostic modality in patients
  with upper GI bleeding
• advantages of endoscopy include
• the ability to obtain biopsies for an accurate
  histologic diagnosis,
• Determine the risk of rebleeding .
• Provide endoscopic therapy.
• Patients with severe upper GI bleeding should
  have an upper endoscopy, or esophagogastroduodenos
  copy (EGD), performed as soon as they are stable.
• Patients in whom endoscopy cannot be performed
  due to torrential bleeding should be considered
  for laparotomy, with or without prior mesenteric
  angiography

22
MANAGEMENT OF GI BLEEDING

• Sigmoidoscopy and colonoscopy
• Patients with bright red hematochezia and minimal
  blood loss can undergo initial evaluation with
  anoscopy and flexible sigmoidoscopy, unless the
  patient is age 50 or older(a full colonoscopy is
  generally recommended to rule out a colonic
  neoplasm)
• Those with dark hematochezia or bright red blood
  per rectum and evidence for significant blood
  loss should undergo full colonoscopy
• Active, brisk bleeding and continued hemodynamic
  instability despite ongoing resuscitation is an
  indication for emergency angiography rather than
  colonoscopy.
• Since lower GI bleeding can originate anywhere in
  the small bowel or colon, angiography is also
  preferable to laparotomy in the setting of such
  bleeding.
• Surgery is generally reserved for patients whose
  bleeding site is identified by angiography but
  who are inappropriate for, or fail, angiographic
  therapy

23
MANAGEMENT OF GI BLEEDING

• Angiography
• bleeding rate of 0.5 mL/min is necessary in order
  for angiography to be positive
• helpful in the patient with massive GI bleeding
  from either an upper or lower source
• reveals a bleeding site in up to 75 of patients
  with massive upper GI bleeding
• success rate in LGIB 60-90 rebleeding rate 0-33
  and significant ischemia 7

24
MANAGEMENT OF GI BLEEDING

• Radionuclide scanning
• Red blood cells obtained by venipuncture are
  labeled with technetium 99m (99mTc) and
  reinjected into the patient.
• red blood cell scans detect lower rates of
  bleeding (0.1cc/min)
• Since prolonged or repeated scanning is possible,
  bleeding can be detected even if it is
  intermittent or too slow to be detected on
  angiography.
• If the red blood cell scan is negative, the
  angiogram is very unlikely to demonstrate active
  bleeding
• Helpful in some patients with recurrent lower GI
  bleeding in whom all other diagnostic studies are
  negative.
• is particularly helpful in the setting of
  bleeding from a Meckels diverticulum
• Multidetector row CT
• Blood flow can be detected at the rate of 0.3
  ml\min
• Considered positive when vascular contrast
  material is extravasated into bowel lumen.
• Capsule endoscopy double balloon enteroscopy for
  obscure GI bleeding.

25
Surgery - Indications in upper GI bleeding

• Age gt60 years.
• Massive bleeding.
• Continued bleeding more than4 units of blood
  transfused.
• Endoscopic stigmata.
• Vessel in base of ulcer.
• Arterial spurter.
• Adherent clot.
• Rebleeding within hours or days.
• Unique and shortage of blood.

26
Surgery - Indications in lower GI bleeding

• ? The majority of patients with LGIB will stop
  spontaneously and never require surgery
• ? approximately 10-25 of patients will require
  operative intervention
• ? The indications for surgery include
• 1. Continued or recurrent hemorrhage despite
  nonoperative attempts.
• 2. Transfusion requirement gt6 units within 24
  hours.
• 3. hemodynamic instability patients who have
  massive ongoing bleeding and are unresponsive to
  initial resuscitation.