Maltoma Causing Massive Upper Gastrointestinal (GI) Bleed ...
GI Bleed How to Mannage Edited
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Transcript of 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
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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
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CTA Abdomen
Sensitivity of 90% and specificity of 99%
Limitations: Potential artifacts obscuring
contrast extravasation and requires activebleeding
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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
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Other Considerations:
Barium studies have no role in lower GI bleed
Rarely, patient with exsanguinating lower GI
bleed may need immediate surgery
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Warnings
Patients with minimal PR bleeding in the
following categories should undergo
additional testing regardless of age
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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.
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Warnings
Patients with symptoms suggestive of
malignancy such as anaemia, or change in
frequency, consistency of stools, should
have a colonoscopy.
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Warnings
Family history suggesting familial
polyposis or hereditary nonpolyposis colon
cancer syndromes who present with
bleeding per rectum should have
colonoscopy
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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