GI Bleed How to Mannage Edited

8/8/2019 GI Bleed How to Mannage Edited

1/44

GI Bleed

Adapted from source


2/44

GI Bleed

Upper GI

Lower GI


3/44

Upper GI

Defined as bleeding that arises proximal to the

Ligament of Treitz

80% of acute bleeds


4/44

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%


5/44

Upper GI Bleeding

80% are self-limited

20% with continuous bleeding mortality is

about 20-40%


6/44

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


7/44

Haemodynamic Stability Assessment

Active bleeding:

Ongoing haematemesis

Bright red blood from NGT

Haematochezia

Unstable:

Shocked

Hypotensive

Anaemic

Transfuse >2U PRBC


8/44

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 (


9/44

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


10/44

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


11/44

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


12/44

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


13/44

Endoscopy

Perform early diagnostic endoscopy (


14/44

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),


15/44

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


16/44


17/44


18/44


19/44


20/44


21/44


22/44

Peptic Ulcer

Previously up to 50% ofUGI bleed

Overall incidencedecreased

Proportion of bleeds

associated with NSAIDSincreasing

Mortality: 5-10%


23/44

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%


24/44

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


25/44

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


26/44

Tumours

Ulcerated mass

Endoscopic management

may allow time for formaltreatment strategies suchas resection

If endoscopy

unsuccessful,angiographic strategiescan be used


27/44

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


28/44

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?


29/44

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?


30/44

Lower GI Bleed

Causes:

Anatomic (Diverticulosis)

Vascular (Angiodysplasia, Ischaemic, radiation-induced)

Inflammatory (Infectious, idiopathic)

Neoplastic


31/44

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


32/44

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


33/44

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


34/44

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(


35/44

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


36/44

Radionuclide Imaging

Detects bleeding at a rate of 0.1-0.5ml/min:

More sensitive than angiography

Major disadvantage: Localise bleeding togeneral area of abdomen. Poor localisation

occurs as blood can move in peristaltic or

antiperistaltic direction


37/44

CTA Abdomen

Sensitivity of 90% and specificity of 99%

Limitations: Potential artifacts obscuring

contrast extravasation and requires activebleeding


38/44

Angiography

Requires active blood loss of 1-1.5mls/min

100% specific but sensitivity is variable according to

the pattern of bleeding

Advantage: Does not require bowel prep and

anatomic localisation is accurate

Embolisation can be performed but there is up to

20% risk of bowel infarction


39/44

Other Considerations:

Barium studies have no role in lower GI bleed

Rarely, patient with exsanguinating lower GI

bleed may need immediate surgery


40/44

Warnings

Patients with minimal PR bleeding in the

following categories should undergo

additional testing regardless of age


41/44

Warnings

History of malaena, dark red blood per rectum or

postural vital sign abnormalities should be

evaluated for upper gastrointestinal tract

pathology first Even if a lower GI tract source is possible, these

patients are more likely to have proximal rather

than distal colonic lesions and should undergo

colonoscopy after upper GI tract investigations.


42/44

Warnings

Patients with symptoms suggestive of

malignancy such as anaemia, or change in

frequency, consistency of stools, should

have a colonoscopy.


43/44

Warnings

Family history suggesting familial

polyposis or hereditary nonpolyposis colon

cancer syndromes who present with

bleeding per rectum should have

colonoscopy


44/44

Warnings

Patients with minimal PR bleeding who did

not to require initial colonoscopy or

sigmoidoscopy and then develop new

constitutional symptoms or a change in

bowel habits should undergo colonoscopy

GI Bleed How to Mannage Edited

Documents

Transcript of GI Bleed How to Mannage Edited