Gastrointestional bleeding
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Transcript of Gastrointestional bleeding
Interdepartmental Conference“Upper And Lower Gastrointestinal Hemorrhage”PRESENTED BY : SORAWIT BOONYATHEE, MD.
Outline
Definition and Anatomical related
Upper Gastrointestinal Hemorrhage
Lower Gastrointestinal Hemorrhage
Section 1 : Definition and Anatomical related
DefinitionUpper and lower gastrointestinal bleeding• Upper gastrointestinal bleeding (or hemorrhage) is that originating proximal to the
ligament of Treitz; in practice from the esophagus, stomach and duodenum.
• Lower gastrointestinal bleeding is that originating from the small bowel and colon.
Ligament of Trietz
http://www.normanallan.com/Misc/mingmen.htm
Definition (Cont.)Hematemesis • Hematemesis is vomiting of blood from the upper gastrointestinal tract or
occasionally after swallowing blood from a source in the nasopharynx. • Bright red hematemesis usually implies active hemorrhage from the esophagus,
stomach or duodenum. This can lead to circulatory collapse and constitutes a major medical emergency.
Coffee-ground vomitus (Hb + acid)• Coffee-ground vomitus refers to the vomiting of black material which is assumed to
be blood. Its presence implies that bleeding has ceased or has been relatively modest.
Definition (Cont.)Melena•Melena is the passage of black tarry stools usually due to acute upper
gastrointestinal bleeding but occasionally from bleeding within the small bowel or right side of the colon.
Hematochezia• Hematochezia is the passage of fresh or altered blood per rectum usually due to
colonic bleeding. Occasionally profuse upper gastrointestinal or small bowel bleeding can be responsible.
Definition (Cont.)Varices• Varices are abnormal distended veins usually in the esophagus
(esophageal varices) and less frequently in the stomach (gastricvarices) or other sites (ectopic varices) usually occurring as aconsequence of liver disease. Bleeding is characteristically severe and may be life threatening.
• The size of the varices and their propensity to bleed is directlyrelated to the portal pressure, which, in the majority of cases, isdirectly related to the severity of underlying liver disease.
http://quizlet.com/9551975/portal-hypertension-flash-cards/
Section 3 : Upper Gastrointestinal Hemorrhage
Prevalence of Upper Gastrointestinal Hemorrhage ในประเทศไทย40-50 % Peptic ulcer disease
20-35 % Erosive gastritis/duodenitis
8-15 % variceal bleeding
8-15 % Mallory-Weiss syndrome
Initial Assessment and Resuscitation2
Supportive Treatment
- Maintain Airway- Hx and PE for assessment of
severity and causes- NG irrigations- Fluid resuscitation- Blood for CBC, Cross-match
blood group for blood transfusion
Scoring for Categorized Patient (Cont.)How Important to Classify patient• For predicting of prognosis and progress of disease
• For planning of definite management
Scoring systems for Upper Gastrointestinal Bleeding• Rockall Scoring System
• Forrest classification
• Glasgow-Blatchford Bleeding Score
Risk Stratification3
Host Factor
• Age ≥ 60
• Co-morbid conditions e.g.
Renal failure, Cirrhosis, CVD,
COPD
• Hemodynamic instability e.g.
orthostatic hypotension, pulse
> 100/min, SBP < 100 mmHg
• Coagulopathy including drug-
related
Bleeding Characters
• Continuous red blood from NG
after irrigation
• Red blood per rectum
Patient Course
• Need blood transfusion
• Rebleeding
• Hemodynamic instability
How to differentiated to variceal or non-varicealbleeding
Variceal Hemorrhage Non-Variceal Hemorrhage
Painless Bleeding Pain or Painless Bleeding
Usually Hematemesis Hematemesis, Coffee ground, Melena
> 90% Hemodynamic change or Hct < 30%
Vary
Sign of chronic liver disease none
Signs of Chronic Liver DiseaseSpider angioma
Jaundice
Scleral icterus
Palmar erythema
Gynecomastia
Ascites
Asterixis
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Medication Treatment for Non-varicealHemorrhageContinuous or Bolus intravenous Proton pump inhibitor or oral double doses PPI• Continuous dose -> 80 mg iv bolus then iv drip 8 mg/hr for 72 hours
• Bolus dose -> 40 mg iv twice daily
• Both doses consider used in high risk
หมายเหตุ การให้ท้ังสองวธิี พบว่าสามารถเพิ่ม Gastric pH >4 และ 6 ได้เท่ากัน
Brunner G, Luna P, Hartman M, Wurst W. Optimising the intra gastric pH as supportive therapy in upper GI bleeding.Yale J Biol Med 1996;69:225-31
Medication Treatment for Non-varicealHemorrhage Role of PPI before endoscopy(1,2)
• Effect -> decrease stage of stigmata of recent hemorrhage
• Not effect -> rebleeding, surgery and mortality
Role of PPI after endoscopy(3,4)
For low dose can reduce risk of rebleeding
For high dose can reduce risk of rebleeding and surgery rate
Both low and high dose cannot reduce mortality rate
Medication Treatment for Variceal Hemorrhage Mechanism for reducing venous blood flow and arterial flow to stomach and small intestine
Can reduce risk of rebleeding and surgery rate
Somatostatin
250 microgram iv bolus then iv drip 250 microgram/hr
Octreotide
50 microgram iv bolus then iv drip 50 microgram/hr
Sengstaken-Blakemore tube (S-B tube) Suspected in Variceal bleeding group and used somatostatin analog 1-2 hours that not improved bleeding
Esophageal Balloon Pressure -> 25 - 40 mmHg (20-30 ml of air)
Gastric Balloon volume ->50 ml then 250 – 300 ml of air
Section 4 : Lower Gastrointestinal Hemorrhage
Lower Gastrointestinal HemorrhageSites• 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
EtiologyDiverticulosis – 40-55%
Angiodysplasia – 3-20%
Neoplasia
Inflammatory conditions
Vascular
Hemorrhoids
Others
HemorrhoidDefinition:• Dilated or enlarged veins in the lower portion of the rectum or anus.
Symptoms• Rectal Bleeding, Bright red blood in stool, Pain during bowel movements, Anal
Itching, Rectal Prolapse, Thrombus
Cause• Pressure -> Constipation, Diarrhea, Sitting or standing for long periods of time,
Obesity, Pregnancy
Non-surgical TreatmentWASH regimen•Warm water
•Analgesic agent
•Stool softeners
•High fiber diet
If prolapses, gently push back into anal canal Use a sitz bath with warm water Use moist towelettes or wet toilet paper instead
of dry toilet paper. Increased fluid intake Avoidance of straining
Painful or persistent hemorrhoids:Banding
Sclerotherapy
Infered Light
Laser Therapy
Freezing
Electrical Current
Surgery
Indication for surgical management
Persistent itching
Anal bleeding
Pain
Blood clots
Infection
ComplicationReactions to medications of anesthesia
Bleeding
Infection
Narrowing of the anus
*The outcome is usually very good in the majority of cases.
PreventionEat high fiber diet
Drink Plenty of Liquids
Fiber Supplements
Exercise
Avoid long periods of standing or sitting
Don’t Strain
Go as soon as you feel the urge
Anal FissureFissure is a tear in the anal canal extending from just below the dentate line to the anal verge.
Most commonly in young and middle age adults.
The cardinal symptom is pain during and for minutes to hours following defecation.
Bright red blood is common
Anal fissure (cont.)90% in the posterior midline
25% anterior midline in women, 8% in men
3% have anterior and posterior fissures
Lateral positions should raise concern for other disease processes—Crohn’s, TB, syphilis, HIV/AIDS, or anal ca
Early (acute) fissures appear as a simple tear in the anoderm
Chronic fissures (symptoms more than 8-12 wks) have edema and fibrosis
Etiology Trauma due to passage of a hard stool
History of constipation or diarrhea
Associated with increased resting pressures• Sustained resting hypertonia
Symptoms Hallmark is pain during, and particularly after, a BM
May be short-lived or last hours or all day
Described as passing razor blades or glass shards
Bleeding usually limited to bright red blood on the tissue
Conservative ManagementAlmost half will heal Sitz baths
Fiber supplement
+/- topical anesthetics or anti-inflammatory ointments
WASH regimen• Warm water
• Analgesic agent
• Stool softeners
• High fiber diet
Medical ManagementSphincter relaxants--“Chemical sphincterotomy”Nitrate formulasNTG, GTN, ISDN
Predominant nonadrenergic, noncholinergic neurotransmitter
Oral and topical calcium channel blockersAs effective as nitrates without the headache
Topical muscarinic agonistsBethanechol
Phophodiesterase inhibitors
Botulinum toxin
Operative TreatmentPrimary goal is to decrease abnormally high resting anal tone
Anal Dilatation93-94% healing with few complicationsLong term outcomes sparseIncontinence can occur in around 12-27%
Lateral Internal SphincterotomyKeyhole deformity if done in posterior midlineIncontinence rates up to 36% but vary widelyOpen or closed technique
Question and Answer
Thank you for your kind attention
Reference1. Dorward S, Sreedharan A, Leonatiadis GI, et al. Proton pump inhibitor
treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2006;18(4):CD005415
2. Lau JY, Leung WK, Wu JCYN, et al. Omeprazole before endoscopy in patients with gastrointestinal bleeding. N Engl J Med 2007;356:1631-40
3. Leontiadis GI, Sharma VK, Howden CW, et al. Proton pump inhibitor treatment for acute peptic ulcer bleeding. Cochrane Database Syst Rev. 2006 Jan 25;(1):CD002094
Reference4. Sung JJ, Chan FK, Lau JY, et al. The effect of endoscopic therapy in patients
receiving omeprazole for bleeding ulcers with nonbleeding visible vessels or adherent clots: a randomized comparison. Ann Intern Med 2003;139:237-43.
5. Mallinkrodt Medical product information leaflet for Sengstaken-Blakemore tube product no: 156-20.
6. Hudak C, Gallo B, and Morton P (1998).Critical Care Nursing A Holistic Approach.(7th ed) Lippincott, New York.
7. Henneman PL (1998).”Gastrointestinal bleeding “ in Emergency Medicine, edPeter Rosen et al. Mosby.St Louis.