Acute GI Bleeding

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Acute GI Bleeding

• Louis Chaptini MD

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Forms of GI Bleeding

• Upper
• Lower
• Occult
• Obscure

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Acute GI bleeding

• 300,000 hospitalizations/year
• Mortality rate
• 3.5-7 with UGI bleed
• 3.6 with LGI bleed

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Acute GI bleeding
Historical Features Important in Assessing the
Etiology of Gastrointestinal Bleeding

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Patient Assessment

• Determine the urgency
• Signs of shock
• Tachy, sometimes brady, hypotension..
• Shock occurs if 40 of blood volume is lost
• Orthostatic hypotension
• Decrease 10mm in SBP, 20 loss of blood volume

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Management

• Large bore IV lines
• Blood work
• ht
• Plt
• Coag factors
• Type and cross
• (Liver enzymes)

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Management of UGI bleeidng
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Resuscitation

• The decision to transfuse should not depend on ht
  (it takes 24 to 48 hrs to equilibrate)
• Hematemesis, bloody NG lavage, hematochezia
  should be taken into consideration

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Resuscitation
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Location

• UGI bleeding is defined as bleeding above the
  ________________
• In the absence of hematemesis, what elements
  indicate UGI bleeding?
• ________
• ________
• ________

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Location

• UGI bleeding is defined as bleeding above the
  ligament of Treitz
• In the absence of hematemesis, what elements
  indicate UGI bleeding?
• Melena
• High BUN
• Positive NG lavage
• Hematochezia indicates LGI source

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Location

• How much blood do you need to have melena?
  _______
• Can melena be indicative of bleeding below the
  ligament of Treitz?
• ______
• ______
• What is the significance of NG lavage?

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Location

• How much blood do you need to have melena?
  100-200 ml
• Can melena be indicative of bleeding below the
  ligament of Treitz?
• Small bowel
• Proximal colon
• What is the significance of NG lavage?
• If bloody?UGIB, If not still can be UGIB

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Prognosis
Adverse Prognostic Variables in Acute UGIB

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Causes

• Of these diagnoses, which one is the most common
  cause of UGI bleed?
• Dieulafoys
• Mallory Weiss Tear
• AVM
• cancer

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Causes

• Of these diagnoses, which one is the most common
  cause of UGI bleed?
• Mallory Weiss Tear

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Causes

• Of these diagnoses, which one is the most common
  cause of UGI bleed?
• Duodenal Ulcer
• GAVE
• Gastritis
• esophagitis

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Causes

• Of these diagnoses, which one is the most common
  cause of UGI bleed?
• Duodenal Ulcer

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Causes of acute UGIB
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Causes of acute UGIB
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Causes of acute UGIB
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Esophagitis

• 8 of UGI Bleeding
• Usually cause of occult bleeding unless the
  disease is extensive or coag problems
• Treatment antisecretory agents

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Case

• 33 y/o male admitted with DKA, started vomiting
  blood.
• What other elements in the history might help?
• What is the most likely diagnosis?

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Mallory Weiss Tear

• 5-10 of UGI Bleeding
• Usually laceration of gastric mucosa
• Mechanism retching
• Stops spontaneously in 80-90 of the cases

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Portal Hypertension Related causes of bleeding

• Several lesions
• Esophageal varices
• Gastric varices
• Portal hypertensive gastropathy
• 10 of UGI bleeding

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Portal Hypertension

• Usually hemodynamic instability in esophageal
  varices
• v/s
• Low volume occult bleeding in the case of
  hypertensive gastropathy

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Ulcers

• Most common cause of UGI bleeding
• Ulcers erode in the lateral wall of a vessel
• Ulcers located in high in the lesser curvature
  and in the posterior wall of duodenal bulb are
  most likely to bleed (and rebleed)

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Predisposing factors for bleeding

• Acid
• H.pylori
• NSAID
• Also, chronic pulmonary disease, cirrhosis,
  cardivascular and cerebrovascular diseases are
  associated with PUD

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Predisposing factors for bleeding

• Drugs other NSAIDs and ASA
• Alendronate
• Steroids (only with NSAIDs)
• Ethanol (can potentiate the damage caused by
  NSAID)
• Anticoagulants (facilitate bleeding)

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Predisposing factors for bleeding

• ASA and NSAIDs
• Decrease prostaglandins, platelet dysfunction
• The risk of bleeding varies with individual NSAID
  and is dose dependent
• The risk of gastric ulceration is greater than
  duodenal ulceration
• Multiple cofactors contribute to NSAID risk
• Age
• Previous GI bleeding
• Hx of PUD
• Hx of heart disease

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Management of bleeding ulcers
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Gastric Erosions

• Gastritis is a histological diagnosis
• Hemorrhagic gastritis and erosive gastritis are
  dg on EGD
• Causes of subepithelial erosions
• NSAID
• Stress related medical illness
• Ethanol?
• In stress related med illness ranitidine has been
  shown to be effective
• Ethanol as a cause of gastric erosions is
  controversial

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Duodenitis

• Risk factors similar to PUD
• Rare cause of acute bleeding

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Neoplasms

• Usually are associated with occult bleeding
• The most frequent in the case of UGIB is gastric
  adenocarcinoma

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Dieulafoys lesion

• Abnormally large artery approaching the mucosa
• 6 of cases of UGI Bleeding
• Usually in proximal portion of stomach, 6cm from
  the GE junction
• EUS may be used for detection

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Case

• 67 y/o male with renal failure and hx of
  recurrent gi bleed, on estrogen for prevention of
  bleeding, presents for hematemesis.
• Whats your diagnosis?

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Vascular lesions

• Vascular ectasia
• Seen in CREST, Ehler Danlos, von willebrand
  disease, renal failure, cirrhosis
• Usually cause occult bleeding or LGI bleeding
• Hormonal therapy controversial
• AVM
• rare

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Case

• Patient with hx of epistaxis, presents for
  hematemesis. His mother had the same problem. On
  exam he has telangiectasia on his skin.
• Whats your diagnosis?

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Vascular lesions

• HHT (osler-rendu-weber disease)
• Autosomal dominant disease characterized by
  telangiectasia of the skin, mucous membranes and
  GI tract
• Epistaxis most common manifestation of the
  disease
• Estrogen and progesterone showed mixed results

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Vascular lesions

• Hemangiomas
• Usually upper small intestine
• Blue rubber nevus
• Hemangiomas in skin, gi tract and other viscera
• Gastric vascular ectasia
• Aggregates of red spots, when linear in the
  antrum? GAVE (water melon stomach)
• Difficult to differentiate from portal hypert
  gastropathy
• TRT endoscopy, ethinyl estradiol

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Acute Lower GI Bleeding

• Important historical information
• Age
• HIV
• NSAID
• Abd pain
• Radiation
• Change in bowel habits

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Management of LGI Bleeding
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Colonoscopy

• Urgent colonoscopy (after prep)
• Probably the best diagnostic test
• Frequently leads to diagnosis
• Possibility of treatment

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Tagged RBC scintigraphy and Angiograohy

• RBC scan
• Controversial
• Detects bleeding of ________ ml/min
• ?helpful before surgery
• Angiography
• _______ ml/min
• Accurate localization
• Complications arterial thrombosis

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Tagged RBC scintigraphy and Angiograohy

• RBC scan
• Controversial
• Detects bleeding of 0.1 to 0.5 ml/min
• ?helpful before surgery
• Angiography
• 0.5 to 1 ml/min
• Accurate localization
• Complications arterial thrombosis

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Causes

• Of these diagnoses, which one is the most common
  cause of LGI bleed?
• IBD
• Hemorrhoids
• AVM
• Radiation colitis

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Causes

• Of these diagnoses, which one is the most common
  cause of LGI bleed?
• AVM

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Causes

• Of these diagnoses, which one is the most common
  cause of LGI bleed?
• Rectal ulcer
• Diverticulosis
• Neoplasia
• Rectal varices

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Causes

• Of these diagnoses, which one is the most common
  cause of LGI bleed?
• Diverticulosis

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Causes
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Causes
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Causes
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Diverticulosis

• Acute painless hematochezia
• In 10 to 40 the bleeding recurs
• Surgery should be considered if recurrence occurs

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Vascular ectasia

• Common cause of acute, chronic and occult LGI
  bleeding
• Most common in R colon
• Common in renal failure patients
• Association with aortic valve disease is
  questionable
• Trt therapeutic endoscopy (risk of perforation)

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Neoplasia

• Uncommon cause of acute bleeding
• History of intermittent hematochezia, change in
  caliber of stools, evidence of chronic bleeding
  suggest this diagnosis
• Post polypectomy bleeding can occur up to 3 weeks
  after polypectomy

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Hemorrhoids

• Extremely common
• 5 to 10 of LGI bleeding
• Usually history of blood o the toilet tissue, not
  mixed with stools, straining
• Even when present, work-up with colonoscopy
  should be pursued especially in elderly patients

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Meckels diverticulum

• Terminal 100cm of ileum
• Gastric mucosa secreting acid and causing
  ulceration of adjacent mucosa
• Usually in children and young adults

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Colitis

• IBD
• Most common
• Infectious colitis
• Salmonella, Shigella, E.Coli, C.Diff
• Radiation
• Ischemia
• Sudden, crampy abdominal pain with bleeding

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Take home message

• Acute GI bleeding is a life threatening condition
  that needs immediate care
• History is key in determining the diagnosis and
  initiating treatment before endoscopy
• Emergent EGD is diagnostic and therapeutic in the
  setting of UGI bleed
• Colonoscopy is probably the best test for LGI
  bleed
• Ulcers, MWT and varices are the most common
  causes of UGIB
• Diverticulosis and vascular ectasia are the most
  common causes in LGIB