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GI bleeding

GI bleedingTerm:Hematemesis : bloody vomitusMelena: tarry stool passageMaroon : tarry- bloody stool

passageHematochezia: bloody stool

passage

2

GI bleeding Bleeding > 5~10ml OB (+)Bleeding > 50~100ml tarry stool

Bleeding above Treitz lig. hematemesisBleeding above ileocecal valve tarry

stoolBleeding below ileocecal valve fresh

bloody stool1. R’t side colon blood mixed inside

the stool2. L’t side colon blood coated outside

the stool 3.rectosigmoid fresh bloody discharge

Common cause of acute UGI bleeding

Erosive, hemorrhagic gastropathy ( aspirin, other NSAIDs) (3~11%)Ulcer: Gastric or duodenal ulcer (35~62%)Mallory-Weiss tear (4~13%)Varices – portal hypertensive gastropathy(4~31%)Arteriovenous malformationMaligancy (1~4%)No source identified ( 7~25%)

3

Common cause of acute LGI bleeding

< 55 y/o1. Anorectal disease

( hemorrhoid, fissures)

2. Colitis (IBD, infection)

3. Diverticulosis4. Polys, cancer5. Angiodysplasia

> 55 y/o1. Anorectal disease

(hemorrhoid, fissures)2. Diverticulosis3. Angiodysplasia4. Polys, cancer5. Enterocolitic

(ischemic, infection, IBD, radiation)

Evaluated blood loss

>35%

20~35%

10~20%

0~10%

%

+ shock<60bpmSBP<90>1750

+oliguria>120bpm90<SBP<1201000~1750

Peripheral cool

<120bpmPosturehypotension

500~1000

NoneNo changeNo change0~500

S/SHRBPBlood loss (ml)

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Peptic ulcerPhase of GU, DU

Active stage:A1: well-defined, deep ulceration;

marked bleeding from the ulcer base marginal welling

A2: stop bleedingHealing stage (H): H1,H2,H3Scarred stage (S): S1( red scar), S2(white scar)

Forrest Grade I

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Forrest Grade IIA IIB

Forrest GradeIIC III

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Peptic ulcerRisk of recurrent bleeding

SRH: stigmata of recent hemorrhageexposure vesselsadherent clotsarterial spurting or oozingEndoscopic therapyHSE (hypertonic saline and epinephrine),bipolar electrocoagulation, heat probe, hematoclip, APC

Risk factors > 60 y/o ageMore than one comorbid illnessBlood loss > 5 unitsShock on admissionBright-red hematemesis with hypotensionCoagulopathyLarge ( > 2cm) ulcerRecurrent hemorrrhage ( within 72 hrs)Requirement for emergency surgery

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GI bleeding – goals of management

Hemodynamic stableActive bleeding stoppedRecurrent bleeding prevented

Hemodynamic stablePulse pressure > 30 mmHgSBP > 110 mmHgDBP > 70 mmHgHR < 100 bpmGood skin turgor

8

UGI bleeding -- managementRestoration of intravascular volumeHct: > 25% Hct: > 30% in cardiac or pulmonary dz

Vasopressors indicated ?Vol resuscitation end-pointCVP=15 mmHgWedge pressure = 10 to 12 mmHgBlood lactate < 4 mmol/ LBase deficit –3 to +3 mmol/LC.I. > 3L/min/m2

UGI bleeding -- managementO2 consumption ( V O2) = Q * Hb *

(SaO2-SvO2) Volume deficit = % loss * normal blood volumeMales – 70 ml / kg or 3.2 L/ M2

Females – 60 ml / kg or 2.9 L/ M2

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UGI bleeding -- managementCorrection of coagulopathyInitial infusion: FFP 2~4 uProtamine infusion ( 1mg antagonizes

=100 u of heparin)Vit-K (10 mg,IM): warfarin, hepatobiliary

diseasePLT transfusion: > 50000/cummAirway protection

PUD-- treatmentAntacidsdrug interaction – Tetracyclines, Quinolone, ketoconazole,Peptic ulcer ( with evidence)

H2-blocker: Ranitidine (Zantac, Quicran)side effect: headache, lethargy, confusion,

depressiondrug interaction: Cimetidineβ-blockers, Metformin, Phenytoin, Procainamide,

Theophylline, TCA and Warfarin.

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PUD -- treatmentPeptic ulcer ( with evidence)

PPIs: Omeprazole ( Losec)-- elder-- intractable bleeding-- combine with theophylline

Raise intragastric pH to 6~7Enhance clot stablity decreased further bleeding (but not mortality)

UGI bleeding -- treatmentVariceal hemorrhage 1. Stabilize hemodynamic ( crystal with colloid

supply) 2. Airway patent3. NG decompression of early detect of re-

bleeding4. Octreotide: Somatostatine (Somatosan)

2Amp add N/S to 50ml loading 2ml and maintain 2ml/ hr

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UGI bleeding -- treatmentVariceal hemorrhage

5. Endoscopic therapy with ligation6. Sclerotherapy7. Balloon tamponade Sengstaken-Blakemore

tube8. Avoid hepatic encephalopathy9. Prophylaxis: reduce portal hypertensoion

-- Inderal, nitrates10. Surgery

Recurrent bleeding prevented

Eradication of H.P rebleeding rate < 5%Avoid NSAIDs

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if no hemodynamic change andno dropping Hb:

routine endoscopy

ICU for 1 dayward for 1 to 2 days

Endoscopic therapy

active bleedingor visible vessel

ward for 3 days

no Endoscopic therapy

adherent clot or flat,pigmented spot

discharge

no Endoscopic therapy

clear base

ulcer

ICU for 1~2 dayward for 2 to 3 days

ligation orsclerotherapy

EV

ward for 1~2 days

Endoscopic therapy

active bleeding

discharge

no Endoscopic therapy

no active bleeding

Mallory-Weiss tear

hemodynamic change anddropping Hb:

urgent endoscopy

acute UGI bleeding