GI Bleed How to Mannage Edited

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    GI Bleed

    Adapted from source

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    GI Bleed

    Upper GI

    Lower GI

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    Upper GI

    Defined as bleeding that arises proximal to the

    Ligament of Treitz

    80% of acute bleeds

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    Upper GI Bleed Causes

    Peptic Ulcer 30-50%

    Mallory Weiss Tears 15-20%

    Gastritis / Duodenitis 10-15% Oesophagitis 5-10%

    Arteriovenous malformations

    Tumours 2% Others 5%

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    Upper GI Bleeding

    80% are self-limited

    20% with continuous bleeding mortality is

    about 20-40%

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    Upper GI Bleeding

    History:

    Aspirin and other NSAIDS use

    Alcohol

    History of liver disease or variceal bleeding History of ulcers

    Weight loss

    Dysphagia

    Heartburn

    AAA or AAA graft Concern wrt aortoenteric fistula

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    Haemodynamic Stability Assessment

    Active bleeding:

    Ongoing haematemesis

    Bright red blood from NGT

    Haematochezia

    Unstable:

    Shocked

    Hypotensive

    Anaemic

    Transfuse >2U PRBC

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    Upper GI Bleed Resuscitation

    Two large IVCs or CVL

    Crystalloid

    FBC, ELFT, Coag Profile, X-M

    Transfusion if Hb low or high risk patient (eg. IHD)

    Correction of coagulopathy (INR>1.5) or thrombocytopaenia (

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    Other resuscitation considerations

    Octreotide: May decrease risk of bleeding from non

    variceal sources (Decreases bleeding by decreasing

    splanchnic blood flow and inhibiting gastric acid

    secretion)

    Erythromycin: Given 30-90min prior to endoscopy

    can clear gut of pooled blood / clot by acting as

    motilin receptor agonist

    PPI infusion: Reduces rate of rebleeding from ulcers

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    Rockall Prognostic Scoring

    System

    Variable Score 0 Score 1 Score 2 Score 3

    Age 80

    Shock No shock Pulse >100 SBP < 100

    Comorbidity Nil major CCF, IHD, major

    morbidity

    Renal failure, liver

    failure,

    metastatic

    cancer

    DiagnosisMallory-Weiss

    Tear

    All other

    diagnosesGI malignancy

    Evidence of

    bleedingNone

    Blood, adherent

    clot, spurting

    vessel

    A score less than 3 carries good prognosis but total score more than 8 carries high risk of mortality

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    Diagnostic Studies

    Endoscopy: Highly sensitive and specific for locatingand identifying bleeding lesions in upper GI tract

    Helpful to irrigate stomach prior to endoscopy toremove residual blood and other gastric contents

    Despite irrigation, stomach can be obscured by blood difficult to establish diagnosis

    If bleeding stopped spontaneously, second-lookendoscopy may be required

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    Other Diagnostic Studies

    Angiography

    Radio-labelled red cell scan

    UGI barium studies are contraindicated in thesetting of UGI bleeding as they will interfere

    with subsequent endoscopy, angiography or

    surgery

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    Endoscopy

    Perform early diagnostic endoscopy (

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    Endoscopic Treatment

    Thermal coagulation: Coagulating bleeding artery atulcer base

    Endoclips: Ligation of bleeding vessel

    Injection can slow bleeding and allow endoclips orthermal coagulation: Adrenaline (1:10000),

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    Refractory Bleeding

    Recurrent bleeding after two endoscopic trial ofhaemostasis

    Angiographic haemostasis: High risks surgical

    patients Surgery: Recurrent haemorrhage, continued slow

    bleeding with ongoing transfusion requirements,haemodynamically unstable despite resuscitation.

    Procedure includes oversew of artery, antrectomy,pyloroplasty, gastrojejunostomy

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    Peptic Ulcer

    Previously up to 50% ofUGI bleed

    Overall incidencedecreased

    Proportion of bleeds

    associated with NSAIDSincreasing

    Mortality: 5-10%

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    Peptic Ulcer

    Causes: Decreased gastric/duodenal mucosaldefence associated with NSAIDS or aspirin, H. Pyloriinfection or both

    Risk of rebleeding can be stratified during endoscopyusing Forrest Classification:

    Active arterial bleeding: 90%

    Non bleeding visible vessel: 50% Adherent clot: 30%

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    Mallory Weiss Tear

    Mucosal or submucosal lacerationsthat occur at GOJ and usually extenddistally into hiatal hernia

    Presents with haematemesis / coffeeground vomit after recent non bloodyvomitting

    At endoscopy usually a single tearfrom GOJ distally into hiatal herniasac. Clean base with ooze or activespurting

    Usually self limited and mild but canbe severe

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    Gastritis / Oesophagitis

    Multiple superficial erosions

    May present as malaena orhaematemesis

    Diagnosed at endoscopy butendoscopic treatment has norole unless there is a focalulcer with active bleeding orrecent bleeding

    Treat with PPI

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    Tumours

    Ulcerated mass

    Endoscopic management

    may allow time for formaltreatment strategies suchas resection

    If endoscopy

    unsuccessful,angiographic strategiescan be used

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    Dieulafoys Lesion

    Dilated aberrant submucosal vessel which

    erodes overlying epithelium in the absence

    of an ulcer

    Usually located in upper stomach along

    lesser curvature but can be found in

    oesophagus and duodenum

    Etiology unknown. Possibly congenital

    Treatment: Combination of adrenaline

    injection and bipolar coagulation

    Other options: Band ligation, haemoclips

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    Case 1 (UGI Bleed)

    45 year old female

    Two days of malaena and one episode of small

    to moderate amount of haematemesis.Otherwise well. Haemodynamicall stable. Hb

    134.

    When endoscopy?

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    Case 2 (UGI Bleed)

    84 year old male.

    Large amount of haematemesis, malaena,

    dizziness. Has HTN and otherwise well.Haemodynamically unstable: PR 110, BP

    85/50. Hb 43.

    When endoscopy?

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    Lower GI Bleed

    Causes:

    Anatomic (Diverticulosis)

    Vascular (Angiodysplasia, Ischaemic, radiation-induced)

    Inflammatory (Infectious, idiopathic)

    Neoplastic

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    Lower GI Bleed

    Incidence:

    Diverticulosis: 5-42%

    Ischaemia: 6-18%

    Anorectal (Haemorrhoids, anal fissures): 6-16%

    Neoplasia: 3-11%

    Unknown: 6-23%

    Angiodysplasia

    Postpolypectomy

    Inflammatory bowel disease

    Radiation colitis

    Small bowel / upper GI bleed Other causes

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    Lower GI Bleed

    Bright red blood or blood clots per rectum

    Blood from left colon is typically bright red

    Blood from right colon is maroon and may be mixed

    with stool

    Rapid transit of blood from right colon may be bright

    red

    Malaena suggest UGI though bleeding from caecumcan be similar

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    Stratification Of Risks

    Low risk: Young and otherwise well with self-

    limited PR bleeding can be reviewed in OPD

    High risk: Haemodynamic instability, seriouscomorbid disease, multiple transfusions or

    evidence of acute abdomen

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    Lower GI Bleed Resuscitation

    Two large IVCs or CVL

    Crystalloid

    FBC, ELFT, Coag Profile, X-M

    Transfusion if Hb low or high risk patient (eg. IHD)

    Correction of coagulopathy (INR>1.5) or thrombocytopaenia(

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    Colonoscopy

    Advantage: Potential to precisely localise bleeding

    points, obtain specimens and potential therapeutic

    intervention

    Disadvantage: Poor visualisation in unprepared colonand risks of sedation in acutely bleeding patient

    Timing depends on patients clinical condition