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OUTLINE2

Introduction

Definition

Epidemology

classificationCause and risk factors

Aproach to patients with acute GI bleeding

Management

Introduction

3Figure 23.2

The principal function

of GIT is to provide the

body with a continuous

supply of nutrients, water

and electrolytes.

Introduction….

Histology of the Alimentary Canal

4

From esophagus to the anal canal the walls of the GIT

have the same four layers

From the lumen outward they are the

1. Mucosa,

2. Submucosa,

3. Muscularis externa, and

4. Serosa

Each layer has a predominant tissue type and a

specific digestive function

Introduction…Blood Supply to Digestive System

5

The blood vessels of the GI-system are part of a more extensive system called the splanchric circulation.

splanchnic BF =1000 ml/min

It includes the blood flow through the GIT itself plus through the spleen, pancreas and the liver.

All of the blood that courses through the gut, spleen and pancreas then flows immediately into the liver by way of the portal vein.

In the liver, blood passes through million of liver sinusoids and finally leaver the liver by way of the hepatic veins that empty into the inferior venacava of the general circulation.

Blood Supply to GIT (cont’d)

6

Gastrointestinal Bleeding:7

Bleeding from the gastrointestinal (GI) tract may present in five ways.

Hematemesis is vomitus of red blood or "coffee-grounds" material.

Melena is black, tarry, foul-smelling stool.

Hematochezia is the passage of bright red or maroon blood from the rectum.

Occult GI bleeding (GIB) may be identified in the absence of overt bleeding by a fecal occult blood test or the presence of iron deficiency.

Finally, patients may present only with symptoms of blood loss or anemia such as lightheadedness, syncope, angina, or dyspnea.

Classification of GI Bleeding8

UGIB blood loss proximal to ligament of

Treitz(DJ flexure)

LGIBblood loss distal to ligament of Treitz

(DJ flexure)

Ligament of treize….

Upper GI bleeding 4x more common

than lower GI bleeding

Suspencery ligament of doudenum

or ligament of tertz9

UGIB10

Upper GI bleeding refers to bleeding from

oesophagus, stomach, duodenum.

Can be:

Variceal bleeding

Non-variceal bleeding

Sources of Gastrointestinal

Bleeding11

Upper Gastrointestinal Sources of Bleeding

The annual incidence of hospital admissions for upper GIB (UGIB) in the United States and Europe is 0.1%, with a mortality rate of 5–10%.

Patients rarely die from exsanguination; rather, they die due to decompensation from other underlying illnesses.

The mortality rate for patients <60 years in the absence of major concurrent illness is <1%.

Independent predictors of rebleeding and death in patients hospitalized with UGIB include increasing age, comorbidities, and hemodynamic compromise (tachycardia or hypotension).

Sources of bleeding in patients hospitalized for upper gi

bleeding

12

Sources of Bleeding Proportion of Patients, %

Ulcers 31–67

Varices 6–39

Mallory-Weiss tears 2–8

Gastroduodenal erosions 2–18

Erosive esophagitis 1–13

Neoplasm 2–8

Vascular ectasias 0–6

13

Peptic ulcers are the most common cause of

UGIB, accounting for up to 50% of cases; an

increasing proportion is due to nonsteroidal anti-

inflammatory drugs (NSAIDs), with the prevalence

of Helicobacter pylori decreasing.

Mallory-Weiss tears account for 5–10% of cases.

The proportion of patients bleeding from varices

varies widely from 5 to 40%, depending on the

population.

Hemorrhagic or erosive gastropathy (e.g., due to

NSAIDs or alcohol) and erosive esophagitis often

cause mild UGIB, but major bleeding is rare.

14

PUD (DU & GU)

Are break in the gastric or duodenal mucosa

that arises when the normal factors are impaired

or overwhelmed by acid or pepsin

Erosive Gastritis

Because this process is superficial, it is a relatively

unusual cause of severe gastrointestinal bleeding (<

5% of cases).

MW TEAR (LACERATION)

15

Classically, Mallory-Weiss tears are mucosal lacerations at the GEJ or in the cardia of the stomach

associated with repeated retching or vomiting

another important cause of nonvariceal UGIB.

acute UGIB secondary to Mallory-Weiss tears bleeding episodes are self-limited.

ESOPHAGITIS16

Is a common medical condition,

usually caused by gastroesophageal reflux.

Less frequent causes include

infectious esophagitis (in patients whoare immunocompromised),

radiation esophagitis, and

esophagitis from direct erosive effects of medication or corrosiveagents.

VASCULAR ECTASIAS17

Vascular ectasias, also referred to as “angiomas,” “arteriovenousmalformations,” and “angiodysplasia,” are another source of acute and chronic nonvariceal UGIB

Abnormal communication

The severity of bleeding can also range from trivial to severe

Vascular ectasias are associated with chronic renal insufficiency or failure; valvular heart disease, specifically aortic stenosis; and congestive heart failure.

Varices

18

There is communication between the intra-abdominal

splanchnic circulation and the systemic venous circulation

through the esophagus.

When portal venous blood flow into the liver is impeded by

cirrhosis or other causes, the resultant portal hypertension

induces the formation of collateral bypass channels.

The increased pressure in the esophageal plexus produces

dilated tortuous vessels called varices.

Variceal rupture produces massive hemorrhage into the lumen.

produce no symptoms until they rupture

LGIB19

Lower GI bleed refers to bleeding arising distal to

the ligament of Treitz (DJ flexure)

Although this includes jejunum and ileum bleeding

from these sites is rare.

Vast majority of lower GI bleeding arises from

colon/rectum/anus

over 90% of cases arise from the colon

CAUSES OF Acute LGIBMajorcauses

Diverticulosis(40%)

Colitis

IBD

Ischemia

Infection

Angiodysplasia

(avm)(30%)

Neoplasia

Anorectal

Hemorrhoids

Fissure

20

Causes...21

Causes of Colon

bleeding

Causes of

Rectal bleeding

Causes of Anal

bleeding

Diverticular

Disease

Polyps Haemorrhoids

Polyps Malignancy Fissure

Malignancy Proctitis Malignancy

Colitis

IBD22

Chronic inflammation of the colon.

ulcerative colitis & Crohn disease

is characterized by severe inflammation and

ulceration of the colon and rectum

Patients with inflammatory bowel disease

(especially ulcerative colitis) often have

diarrhea with variable amounts of

hematochezia

23

Hematemesis indicates an upper GI source of bleeding (above the ligament of Treitz).

Melena indicates that blood has been present in the GI tract for at least 14 h (and as long as 3–5 days).

The more proximal the bleeding site, the more likely melena will occur.

Hematochezia usually represents a lower GI source of bleeding, although an upper GI lesion may bleed so briskly that blood does not remain in the bowel long enough for melena to develop.

When hematochezia is the presenting symptom of UGIB, it is associated with hemodynamic instability and dropping hemoglobin.

Differentiation of Upper from Lower Gib

24

Bleeding lesions of the small bowel may present as melena or hematochezia.

Other clues to UGIB include hyperactive bowel sounds and an elevated blood urea nitrogen level (due to volume depletion and blood proteins absorbed in the small intestine).

A nonbloody nasogastric aspirate may be seen in up to 18% of patients with UGIB—usually from a duodenal source.

Even a bile-stained appearance does not exclude a bleeding postpyloric lesion because reports of bile in the aspirate are incorrect in 50% of cases.

Testing of aspirates that are not grossly bloody for occult blood is not useful.

25

Obscure GIB is defined as persistent or recurrent

bleeding for which no source has been identified

by routine endoscopic and contrast x-ray studies;

it may be overt (melena, hematochezia) or occult

(iron-deficiency anemia).

Current guidelines suggest angiography as the

initial test for massive obscure bleeding, and

video capsule endoscopy, which allows

examination of the entire small intestine, for all

others.

GIB of Obscure Origin

26

Push enteroscopy, with a specially designed enteroscope or a pediatric colonoscope to inspect the entire duodenum and part of the jejunum, also may be considered as an initial evaluation.

A systematic review of 14 trials comparing push enteroscopy to capsule revealed "clinically significant findings" in 26% and 56% of patients, respectively.

However, in contrast to enteroscopy, lack of control of the capsule prevents its manipulation and full visualization of the intestine; in addition, tissue cannot be sampled and therapy cannot be applied.

Clinical Presantation :

27

Hematemesis

Melena

Hematochezia

Syncope

Dyspepsia

Epigastric pain

Heartburn

Diffuse abdominal pain

Dysphagia

Weight loss

Jaundice

Approach to the Patient:

Gastrointestinal Bleeding28

History

Physical examination

Lab investigation

APROACH TO PATIENT………….. Con’t

29

History:

• Abdominal pain

• Haematamesis

• Haematochezia

• Melaena

• Features of blood loss: shock, syncope, anemia

• Features of underlying cause: dyspepsia, jaundice, weight loss

30

o Drug history: NSAIDs, Aspirin, anticoagulants,

o History of epistaxis or hemoptysis to rule out the GI

source of bleeding.

o Past medical :previous episodes of upper

gastrointestinal bleedin; coronary artery disease;

chronic renal or liver disease;

o Past surgical: previous abdominal surgery

Approach

Cont…..31

Physical Examination :

• General examination and systemic examinations

• VITALS:

Pulse = Feable pulse

BP = Orthostatic Hypotension

• SIGNS of shock:

Cold extremeties, Tachycardia, Hypotension

Chest pain, Confusion, Delirium, Oliguria, and etc.

32

SKIN changes:

Cirrhosis – Palmer erythema, spider nevi

Bleeding disorders – Purpura /Echymosis,

Haemarthrosis, Muscle hematoma.

• Signs of dehydration (dry mucosa, sunken eyes, skin

turgor reduced).

• Signs of a tumour may be present (nodular liver,

abdominal mass, lymphadenopathy, and etc.

• DRE : fresh blood, occult blood, bloody diarrhea

• Respiratory, CVS, CNS For comorbid diseases

Lab Diagnosis :

33

CBC with Platelet Count, and Differential

A complete blood count (CBC) is necessary to assess the level of blood loss.

CBC should be checked frequently(q4-6h) during the first day.

Hemoglobin Value, Type and Crossmatch Blood

The patient should be crossmatched for 2-6 units, based on the rate of active bleeding.

The hemoglobin level should be monitored serially in order to follow the trend.

An unstable Hb level may signify ongoing hemorrhage requiring further intervention.

34

LFT- to detect underlying liver disease

The BUN-to- creatinine ratio increases with

upper gastrointestinal bleeding (UGIB).

A ratio of greater than 36 in a patient without

renal insufficiency is suggestive of UGIB.

The patient's prothrombin time (PT), activated

partial thromboplastin time, should be checked

to document the presence of a coagulopathy

Endoscopy 35

• Initial diagnostic examination for all patients

presumed to have UGIB.

• Endoscopy should be performed immediately

after endotracheal intubation (if indicated),

hemodynamic stabilization, and adequate

monitoring in an intensive care unit (ICU) setting

have been achieved.

36

Endoscopy

Imaging 37

• CHEST X-RAY-Chest radiographs should be

ordered to exclude aspiration pneumonia,

effusion, and esophageal perforation.

• Abdominal X-RAY- erect and supine films should

be ordered to exclude perforated viscous and

ileus.

Angiography

:38

Angiography may be useful if bleeding persists

and endoscopy fails to identify a bleeding site.

Angiography along with transcatheter arterial

embolization (TAE) should be considered for all

patients with a known source of arterial UGIB that

does not respond to endoscopic management,

with active bleeding and a negative endoscopy.

In cases of aortoenteric fistula, angiography

requires active bleeding (1 mL/min) to be

diagnostic.

Nasogastric

Lavage39

A nasogastric tube is an important diagnostic tool.

This procedure may confirm recent bleeding

(coffee ground appearance), possible active

bleeding (red blood in the aspirate that does not

clear), or a lack of blood in the stomach (active

bleeding less likely but does not exclude an upper

GI lesion).

40

41

1. Better visualization during endoscopy

2. Give crude estimation of rapidity of bleeding

3. Prevent the development of Porto systemic

encephalopathy in cirrhosis

4. Increases PH of stomach, and hence, decreases clot

desolation due to gastric acid dilution

5. Tube placement can reduce the patient's need to vomit

During gastric lavage use saline and not use large volume

of to avoid water intoxication.

Gastric lavage should be done in alert and cooperative

patient to avoid bronco-pulmonary aspiration

BENEFITS OF LAVAGE :

Identifies patients at risk of adverse outcome following acute upper GI bleed

Score <3 carries good prognosis

Score >8 carries high risk of mortality

Risk Stratification: Rockall

Score

Variable Score 0 Score 1 Score 2 Score 3

Age <60 60-79 >80 -

Shock Nil HR >100 SBP <100 -

Co-morbidity Nil major - IHD/CCF/major morbidity Renal failure/liver failure

Diagnosis Mallory Weiss tear All other diagnoses GI malignancy -

Endoscopic Findings None - Blood, adherent clot,

spurting vessel

-

Management

43

Priorities are:

1. Stabilize the patient: protect airway,

restore circulation.

2. Identify the source of bleeding.

3. Definitive treatment of the cause.

Takes priority over determining the

diagnosis/cause

ABC (main focus is ‘C’)

Oxygen: 15L Non-rebreath mask

2 large bore cannulae into both ante-cubital

fossae

Take bloods at same time for FBC, U&E,

LFT, Clotting, X match 6Units

Catheterise

Emegency Resuscitation

45

IVF initially then blood as soon as available (depending on urgency: O-, Group specific, fully X-matched)

Monitor response to resuscitation frequently (HR, BP, urine output, level of consciousness, peripheral temperature, CRT)

Stop anti-coagulants and correct any clotting derrangement

NG tube and aspiration (will help differentiate upper from lower GI bleed)

Organise definitive treatment (endoscopic/radiological/surgical)

Emergency resuscitation as already described

Endoscopy

Urgent (within 24hrs) – diagnostic and therepeutic

Treatment administered if active bleeding, visible vessel, adherent blood clot

Treatment options include injection (adrenaline), coagulation, clipping

If re-bleeds then arrange urgent repeat endoscopy.

Management (Non-variceal)

47

Pharmacology

PPI (infusion) – pH >6 stabilises clots and

reduces risk of re-bleeding following

endoscopic haemostasis

If H pylori positive then for eradication

therapy

Stop

NSAIDs/aspirin/clopidogrel/warfarin/steroids

if safe to do so (risk:benefit analysis)

Surgery Reserved for patients with failed medical management

(ongoing bleeding despite 2x endoscopy)

Nature of operation depends on cause of bleeding (most

commonly performed in context of bleeding peptic ulcer:

DU>GU)

E.g. Under-running of ulcer (bleeding DU), wedge excision

of bleeding lesion (e.g. GU), partial/total gastrectomy

(malignancy)

Management (Non-variceal)

Suspect if upper GI bleed in patient with history of

chronic liver disease/cirrhosis or stigmata on clinical

examination

Liver Cirrhosis results in portal hypertension and

development of porto-systemic anastamosis

(opening or dilatation of pre-existing vascular

channels connecting portal and systemic

circulations)

Variceal Bleeds

50

Sites of porto-systemic anastamosis include:

Oesophagus

(P= eosophageal branch of L gastric v, S= oesophageal branch of azygous v)

Umbilicus

(P= para-umbilical v, S= infeior epigastric v)

Retroperitoneal

(P= right/middle/left colic v, S= renal/supra-renal/gonadalv)

Rectal

(P= superior rectal v, S= middle/inferior rectal v)

Furthermore, clotting derrangement in those with chronic liver disease can worsen bleeding

Emergency resuscitation as already described

Drugs

Somatostatin/octreotide – vasoconstricts splanchniccirculation and reduces pressure in portal system

Terlipressin – vasoconstricts splanchnic circulation and reduces pressure in portal system

Propanolol – used only in context of primary prevention (in those found to have varices to reduce risk of first bleed)

Endoscopy

Band ligation

Injection sclerotherapy

Management of Variceal bleeds

52

Balloon tamponade – sengstaken-blakemore tube

Rarely used now and usually only as temporary measure if failed

endoscopic management

Radiological procedure – used if failed medical/endoscopic Mx

Selective catheterisation and embolisation of vessels feeding the

varices

TIPSS procedure: transjugular intrahepatic porto-systemic shunt

shunt between hepatic vein and portal vein branch to reduce

portal pressure and bleeding from varices): performed if failed

medical and endoscopic management

Can worsen hepatic encephalopathy

Surgical

Surgical porto-systemic shunts (often spleno-renal)

Liver transplantation (patients often given TIPP/surgical shunt

whilst awaiting this)

Sengstaken-Blakemore

Tube

TIPSS

Prognosis closely related to severity of underlying chronic liver disease (Childs-Pugh grading)

Child-Pugh classification grades severity of liver disease into A,B,C based on degree of ascites, encephalopathy, bilirubin, albumin, INR

Mortality 32% Childs A, 46% Childs B, 79% Childs C

Variceal Bleed: Prognosis

Emergency resuscitation as already described

Pharmacological Stop NSAIDS/anti-platelets/anti-coagulants if safe

Endoscopic 15% of patients with severe acute PR bleeding will have an upper

GI source!)

Colonoscopy – diagnostic and therepeutic (injection, diathermy, clipping)

Management-lower GI

BLEEDING

Radiological CT angiogram – diagnostic only (non-invasive)

Determines site and cause of bleeding

Mesenteric Angiogram – diagnostic and therepeutic

(but invasive)

Determines site of bleeding and allows embolisation of

bleeding vessel

Can result in colonic ischaemia

Management

Surgical – Last resort in management as very

difficult to determine bleeding point at

laparotomy Segmental colectomy – where site of bleeding is

known

Subtotal colectomy – where site of bleeding unclear

Beware of small bowel bleeding – always

embarassing when bleeding continues after large

bowel removed!

Management

Resuscitate

Management Flow Chart for

Severe lower GI bleeding

Endoscopy (to exclude upper GI cause for severe PR bleeding)

Colonoscopy (to identify site and cause of

bleeding and to treat bleeding by

injection/diathermy/clipping) – often

unsuccesful as blood obscures views

CT angiogram (to identify

site and cause of

bleeding)

Mesenteric angiogram (to identify

site of bleeding and treat

bleeding by embolisation of

vessel)

Surgery

As 85% of lower GI bleeds will settle

spontaneously the interventions mentioned on

previous slide are reserved for: Severe/Life threatening bleeds

In the 85% where bleeding settles spontaneously

OPD investigation is required to determine

underlying cause: Endoscopy: flexible sigmoidoscopy, colonoscopy

Barium enema

Management

REFERENCE 60

Harrison principles of intrnal medicine 18th edi.

Kumar .clinical medicine 8th edit.

On line search

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