GI bleedingGI bleeding

Mackay Memorial Hospital

Department of Internal Medicine

Division of Gastroenterology

R4 陳泓達

97/6/22

GI BleedingGI Bleeding UGI bleedingUGI bleeding

Peptic ulcer diseasePeptic ulcer disease Variceal bleedingVariceal bleeding

LGI bleedingLGI bleeding

UGI bleeding: 5 times more common than LGI UGI bleeding: 5 times more common than LGI bleeding. bleeding.

Men > WomenMen > Women

Elderly persons.Elderly persons. Despite ongoing advances, fundamental Despite ongoing advances, fundamental

principles are the same !!!!principles are the same !!!!

immediate assessment and stabilization of immediate assessment and stabilization of

hemodynamic statushemodynamic status

Determine the source of bleedingDetermine the source of bleeding Stop active bleedingStop active bleeding Treat underlying abnormalityTreat underlying abnormality Prevent recurrent bleedingPrevent recurrent bleeding

hemodynamicshemodynamics Blood loss(% of Blood loss(% of intravascular volume)intravascular volume)

Severity of Severity of bleedingbleeding

normalnormal < 10< 10 minorminor

Orthostatic Orthostatic hypotension or hypotension or tachycardiatachycardia

10-2010-20 moderatemoderate

shockshock 20-2520-25 massivemassive

ResuscitationResuscitation

In hemodynamically unstable…In hemodynamically unstable…

Set up two large-bore IV catheterSet up two large-bore IV catheter

Colloid solution (NS or lactated Ringer’s) Colloid solution (NS or lactated Ringer’s) To restore vital sign !!To restore vital sign !!

ICU monitor is indicatedICU monitor is indicated

Central venous monitoringCentral venous monitoring

F/U vital sign and urine output F/U vital sign and urine output

History taking and physical examinationHistory taking and physical examination

UGI or LGI ?UGI or LGI ?

UGI UGI peptic ulcer disease or portal peptic ulcer disease or portal hypertension related (EV or GV)?hypertension related (EV or GV)?

Differentiate LGI and UGIDifferentiate LGI and UGIMelena – upper GI cause in 90%Melena – upper GI cause in 90%Hematochezia – upper GI cause in 10%Hematochezia – upper GI cause in 10%

The intermediate patientThe intermediate patient

Take more time….Take more time….

Re-examine,Re-examine,

Monitor vital signs,Monitor vital signs,

Re-check CBC, BUNRe-check CBC, BUN

Transfusion ?Transfusion ? In hemodynamic unstable, any sign of poor In hemodynamic unstable, any sign of poor

tissue oxygenation, continued bleeding, tissue oxygenation, continued bleeding, persistent low Ht level(20-25%)persistent low Ht level(20-25%)

Maintain adequate perfusionMaintain adequate perfusion Target ?Target ?

Other Blood tests on the Other Blood tests on the bleeding patient…bleeding patient…

INR, PTTINR, PTT

– coagulopathy anyone?

““There is no single value of There is no single value of hemoglobin concentration that hemoglobin concentration that

justifies or requires transfusion; justifies or requires transfusion; an evaluation of the patient’s an evaluation of the patient’s

clinical situation should also be a clinical situation should also be a factor in the decision.”factor in the decision.”

Capital Health Guide to Blood TransfusionCapital Health Guide to Blood Transfusion

You’ve decided to give You’ve decided to give blood…blood…

Options?Options?

O neg O neg Type Specific Type Specific Full Cross MatchFull Cross Match

– immediately available – 10 – 15 min. – 30 – 60 min.

What is in a unit of What is in a unit of packed cells?packed cells?

250 mL volume250 mL volumeContains citrate (anticoagulant), and preservContains citrate (anticoagulant), and preserv

ative.ative.1 unit packed cells will increase the Hb conc1 unit packed cells will increase the Hb conc

entration by approx. --?entration by approx. --? 0.5mg/dL

Massive TransfusionMassive Transfusion

Greater than 1 blood volume( or 10 units ) Greater than 1 blood volume( or 10 units ) transfused within 24 hourstransfused within 24 hours

May dilute platelets and clotting factorsMay dilute platelets and clotting factors

Dilution coagulopathyDilution coagulopathy

Monitor the patient for coagulopathyMonitor the patient for coagulopathyFollow the resuscitation (CBC, INR, PTT)Follow the resuscitation (CBC, INR, PTT)

Treatment of dilution coaTreatment of dilution coagulopathygulopathy

Plasma /FFPPlasma /FFP 10 – 15 mL / kg 10 – 15 mL / kg

Usual adult dose 2 units.Usual adult dose 2 units.

5 –8 mL / kg dose for warfarin revers5 –8 mL / kg dose for warfarin reversalal

Treatment of dilution coagulTreatment of dilution coagulopathyopathyPlateletsPlatelets

Keep the count greater than 50 ,000 in the Keep the count greater than 50 ,000 in the bleeding patientbleeding patient

1 unit should increase platelet count by 1 unit should increase platelet count by 5 ,000– 10, 000 / L5 ,000– 10, 000 / L

Dose: 6 packDose: 6 pack

Massive TransfusionMassive TransfusionWhat else can go wrong?What else can go wrong?

HypothermiaHypothermia

PotassiumPotassium

Citrate toxicity (hypocalcemia)Citrate toxicity (hypocalcemia)

Vomiting BloodVomiting BloodHematemesisHematemesis

Upper GI BleedingUpper GI Bleeding

EtiologyEtiology

Peptic Ulcer 50 %Peptic Ulcer 50 %Gastritis 20%Gastritis 20%Esophageal varices 10%Esophageal varices 10%The rest: Tears, AVM, CA,etc 20%The rest: Tears, AVM, CA,etc 20%

More about bleeds….More about bleeds….

80 % of Non – variceal upper GI ble80 % of Non – variceal upper GI bleeds will stop spontaneouslyeds will stop spontaneously

60 % of variceal bleeds will stop spo60 % of variceal bleeds will stop spontaneouslyntaneously

What else can I do for GI bleeding, What else can I do for GI bleeding, before endoscopybefore endoscopy

NG lavageNG lavage

DrugDrug

ABCABC

Patient and family AgreePatient and family Agree

( Sign permit first)( Sign permit first)

Urgent Endoscopy ?Urgent Endoscopy ?Initial evaluation: Initial evaluation: 初始出血量是否大量 初始出血量是否大量 ??出血量大者出血量大者 ,rebleeding ,rebleeding 機會也大機會也大觀察重點觀察重點 : vital sign (tachycardia, orthost: vital sign (tachycardia, orthost

atic atic hypotension resting hypotension, shock),hypotension resting hypotension, shock),

吐血或吐血或血便黑便的頻次與量血便黑便的頻次與量 , NG lavage, NG lavage 的結果的結果

NG lavage NG lavage

15 – 20 % of upper GI bleeds have a n15 – 20 % of upper GI bleeds have a negative aspirate egative aspirate

Sensitivity 79%, Specificity 55%Sensitivity 79%, Specificity 55%Cuellar et al, Arch of Int Med Jul 1990Cuellar et al, Arch of Int Med Jul 1990

•For endoscopic preparation( not contraindicated in patients with varices)

EndoscopyEndoscopy

DiagnosticDiagnosticTherapeuticTherapeuticPrognosticPrognostic

Endoscopic features and risk of Endoscopic features and risk of re-bleedingre-bleeding

Active bleedingActive bleeding

55 – 90%

Endoscopic features and risk of re-Endoscopic features and risk of re-bleedingbleeding

Non bleeding visible vesselNon bleeding visible vessel

40 – 50 %

Endoscopic features and risk of re-Endoscopic features and risk of re-bleedingbleeding

Adherent clotAdherent clot

10 – 33%

Endoscopic features and risk of re-Endoscopic features and risk of re-bleedingbleeding

Flat spotFlat spot

7 – 10 %

Endoscopic features and risk of re-Endoscopic features and risk of re-bleedingbleeding

Clean baseClean base

3 – 5%

Variceal bleedingVariceal bleeding

Non-variceal bleedingNon-variceal bleeding

Drugs: Peptic ulcer bleedingDrugs: Peptic ulcer bleeding

Manipulation of gastric pH Manipulation of gastric pH

Use of PPI’sUse of PPI’s

Theory : raise gastric pHTheory : raise gastric pHBetter platelet activityBetter platelet activity

Pepsinogen requires acid to become Pepsinogen requires acid to become activated to pepsinactivated to pepsin

Clots will form, clots not digestedClots will form, clots not digested

High Risk PatientsHigh Risk PatientsElderlyElderly

Co – MorbidityCo – MorbidityMore severe bleeding (hemo-dynamically uMore severe bleeding (hemo-dynamically u

nstable, ongoing bleedingnstable, ongoing bleeding

Other helpful medication Other helpful medication

somatostatin / octreotide somatostatin / octreotide associated with a reduced risk of contassociated with a reduced risk of continued bleeding and rebleeding in PUinued bleeding and rebleeding in PUD D

When endoscopic / pharmacological treatment When endoscopic / pharmacological treatment fail…fail…

◎ ◎ angiography angiography to localize bleeder and to localize bleeder and hemostasishemostasisgenerally reserved for patient: generally reserved for patient: poor surgical candidatespoor surgical candidates control of bleeding in an unstable patient control of bleeding in an unstable patient awaiting surgeryawaiting surgery

SurgerySurgery

Hemodynamic instability despite Hemodynamic instability despite vigorous resuvigorous resuscitationscitation (more than a three unit transfusion) (more than a three unit transfusion)

Recurrent hemorrhage after initial stabilization Recurrent hemorrhage after initial stabilization (attempts at obtaining (attempts at obtaining endoscopic hemostasisendoscopic hemostasis) )

ShockShock associated with recurrent hemorrhage associated with recurrent hemorrhage Continued slow bleeding with a transfusion reContinued slow bleeding with a transfusion re

quirement exceeding three units per day.quirement exceeding three units per day.

Variceal BleedingVariceal Bleeding

EGD finding:EGD finding:

F1-4F1-4

Ls-m-iLs-m-i

Cb / CwCb / Cw

Red color signRed color sign

After endoscopic treatment…After endoscopic treatment…

Fail to achieve hemostasis or rebleeding Fail to achieve hemostasis or rebleeding

Balloon tamponadeBalloon tamponade Transjugular Intrahepatic Portosystemic Shunt Transjugular Intrahepatic Portosystemic Shunt

(TIPS)(TIPS) Surgery for shuntSurgery for shunt

Balloon TamponadeBalloon Tamponade-Buy time-Buy timeAvailable in MMHAvailable in MMH

S-B tube S-B tube

McCormick. British Journal of Hospital McCormick. British Journal of Hospital Medicine. 43, Apr. 1990Medicine. 43, Apr. 1990

SB tube

Gastric ballon

Esophageal ballon

McCormick. British Journal of Hospital McCormick. British Journal of Hospital Medicine. 43, Apr 1990Medicine. 43, Apr 1990

never exceed 45mmHg.

Volume 200ml

Tamponade Tube Tamponade Tube Sengstaken-Blakemore (S-B) tubeSengstaken-Blakemore (S-B) tube

Radiographic confirmation of the gastric balRadiographic confirmation of the gastric balloon’s position -- 30cc air inflate the gastric loon’s position -- 30cc air inflate the gastric balloonballoon

Insufflation of the esophageal balloon to 35Insufflation of the esophageal balloon to 35mmHgmmHg

Compression of varices for not excess 48 Compression of varices for not excess 48 hourshours

Deflate the esophageal balloon for about 3Deflate the esophageal balloon for about 30 mins every 12 hours0 mins every 12 hours

Major complications -- aspiration and esoMajor complications -- aspiration and esophageal perforation phageal perforation

Control hemorrhage >90%, but it is tempoControl hemorrhage >90%, but it is temporaryrary

Bridging procedureBridging procedure buy time buy time

Definite therapeutic management must be Definite therapeutic management must be performed.performed.

Lower GI BleedingLower GI Bleeding

Hematochezia 90%Hematochezia 90%

Melena 10%Melena 10%

EtiologyEtiology

Most blood passed per rectum is from Most blood passed per rectum is from the upper GI tract.the upper GI tract.

Lower GI BleedsLower GI Bleeds

Diverticulosis, angiodysplasia, CA, cDiverticulosis, angiodysplasia, CA, colitis, ischemia, hemorrhoidsolitis, ischemia, hemorrhoids

More about Lower GI More about Lower GI BleedsBleeds

80% resolve spontaneously80% resolve spontaneously25 % will re–bleed25 % will re–bleedUsually painlessUsually painlessIf painful, r/o mesenteric ischemiaIf painful, r/o mesenteric ischemia

Investigation of the lower Investigation of the lower GI bleedGI bleed

The usual suspects: CBC, BUN, CreThe usual suspects: CBC, BUN, Creatinine, INR, PTT, T/Satinine, INR, PTT, T/S

Investigation of the lower Investigation of the lower GI bleedGI bleed

Plain X-rays and abd. CT – not much help Plain X-rays and abd. CT – not much help unless you clinically suspect perforation, ounless you clinically suspect perforation, o

bstruction, ischemia (PAIN)bstruction, ischemia (PAIN)

Diagnostic procedureDiagnostic procedureEndoscopyEndoscopy : 80% accuracy : 80% accuracy

Poor visibility with heavy bleedingPoor visibility with heavy bleeding

•Angiography : 40–80% accuracy Requires heavy bleeding Able to perform embolization or vasopressin infusion

Diagnostic procedureDiagnostic procedure

RBC scans RBC scans 25–90% accurate25–90% accurateAble to do with lower bleeding ratesAble to do with lower bleeding rates

What if the patient is What if the patient is really bleeding?really bleeding?

Involve your consultants early. Involve your consultants early.

Radiologist for angiographyRadiologist for angiography

Procto. If tumor or ischemic bowelProcto. If tumor or ischemic bowel