Gastrointestinal Bleeding

Gastrointestinal Bleeding

Gastrointestinal Bleeding Background Definition: Internal bleeding in the digestive tract Gastrointestinal bleeding can occur anywhere within the gastrointestinal tract

This includes: the esophagus leading to the stomach the stomach itself and the intestines

Gastrointestinal Bleeding Background Infections (disease) some medicines (drugs) and alcohol ► can damage tissue in the GI tract and produce bleeding

Gastrointestinal Bleeding Background The diagnosis and therapy for gastrointestinal bleeding (GIB) has evolved over the past 3 decades: 1) from passive diagnostic esophagogastroduodenoscopy with medical therapy 2)To active intervention with endoscopic techniques followed by: angiographic and surgical approaches if endoscopic therapy failed

Gastrointestinal Bleeding Background Gastrointestinal (GI) bleeding are classified into: upper or lower depending on their location in the GI

tract

Gastrointestinal Bleeding Background ► Upper gastrointestinal bleeding: Upper GI bleeding originates in the first part of the GI tract: the esophagus, stomach, or duodenum (first part of the intestine) ► Lower gastrointestinal bleeding: Lower GI bleeding originates in the portions of the GI tract farther down the digestive system: the segment of the small intestine farther from the stomach, large intestine, rectum, and anus

Upper Gastrointestinal Bleeding (UGIB) Background: Upper gastrointestinal (GI) bleeding (UGIB) is defined as hemorrhage that emanates proximal to the ligament of Treitz It is a common and potentially life-threatening condition More than 350, 000 hospital admissions are attributable to UGIB, which has an overall mortality rate of 10%

Upper Gastrointestinal Bleeding (UGIB) Background: Although more than 75% of cases of bleeding cease with supportive measures, a significant percentage of patients require further intervention, which often involves the combined efforts of: gastroenterologists surgeons and interventional radiologist

Upper Gastrointestinal Bleeding (UGIB) Background: Race: No well-described racial predilection for UGIB exists Sex: The male-to-female ratio is approximately 2:1 in both countries ****The mortality rates are similar in both sexes

Age: Morbidity and mortality rates increased with age; 73.2% of deaths occurred in patients older than 60 years

Upper Gastrointestinal Bleeding (UGIB) Background: Anatomy UGIB arises from branches of the: celiac artery and superior mesenteric artery (SMA)

Upper Gastrointestinal Bleeding (UGIB)

Clinical Presentation History

Upper Gastrointestinal Bleeding (UGIB) The patient history findings include: ► weakness

► dizziness

► syncope associated with: ► hematemesis (coffee ground vomitus) ► melena (black stools with a rotten odor) and ► hematochezia (red or maroon stool)

Upper Gastrointestinal Bleeding (UGIB)

Clinical Presentation History Patients may have a history of previous: dyspepsia (especially nocturnal symptoms) ► peptic ulcer disease Early satiety and nonsteroidal anti-inflammatory drug or aspirin use

Upper Gastrointestinal Bleeding (UGIB) Clinical Presentation History Many patients with UGIB who are taking nonsteroidal anti-inflammatory drugs present without dyspepsia but with:

* hematemesis or * melena as their first symptom

Clinical Presentation History Low-dose aspirin (81 mg) has been associated with UGIB Patients with a prior history of ulcers are at an especially increased risk for UGIB when placed on: aspirin or NSAID therapy and should receive continuous acid suppression with a PPI

Clinical Presentation History ►Because recurrence of ulcer disease is common, history findings are relevant:

*

Patients may present in a more subacute phase with a history of: dyspepsia and occult intestinal bleeding manifesting: as a positive fecal occult blood test result or as iron deficiency anemia

Upper Gastrointestinal Bleeding (UGIB) Clinical Presentation History

*

A history of recent aspirin ingestion suggests that the patient may have nonsteroidal antiinflammatory drug gastropathy with an enhanced bleeding diathesis from poor platelet adhesiveness

Clinical Presentation History A history of chronic: alcohol use of more than 50 g/d or hepatitis (B or C)▼ ► increases the risk of:

*variceal hemorrhage *gastric antral vascular ectasia (GAVE) or *portal gastropathy

• Illustration: portal gastropathy

Upper Gastrointestinal Bleeding (UGIB) Clinical Presentation History

* The presence of postural hypotension► indicates: more rapid and severe blood loss

Upper Gastrointestinal Bleeding (UGIB)

Clinical Presentation Physical Examination

Upper Gastrointestinal Bleeding (UGIB) Physical Examination The goal of the patient's physical examination is to evaluate for: shock and blood loss Pulse and blood pressure should be checked with the patient in : ► supine and ► upright positions to note the effect of blood loss

Upper Gastrointestinal Bleeding (UGIB) Clinical Presentation Physical Examination ► Significant changes in vital signs with postural changes indicate ► an acute blood loss of approximately 20% or more

Upper Gastrointestinal Bleeding (UGIB) Clinical Presentation Physical Examination ► Other signs of shock include: ► extremities: cool, pale and often cyanotic ► Skin: grayish, moist, diaphoresis ► oliguria ► chest pain, dyspnea ► Tachypnea ► presyncope: lethargy, somnolence, confusion, and delirium

Upper Gastrointestinal Bleeding (UGIB) Clinical Presentation Physical Examination ► Other signs of shock include: ► Peripheral pulses are weak and typically rapid ► BP < 90 mmHg

Upper Gastrointestinal Bleeding (UGIB) Clinical Presentation Physical Examination Hematemesis and melena should be noted ►The redder the stool ► the more rapid the transit, ►►which suggests a large upper tract hemorrhage

Upper Gastrointestinal Bleeding (UGIB) Clinical Presentation Physical Examination Signs of chronic liver disease should be noted, including: spider angiomata gynecomastia splenomegaly ascites pedal edema and asterixis

Upper Gastrointestinal Bleeding (UGIB) Clinical Presentation Physical Examination Signs of tumor are uncommon but portend a poor prognosis

► Signs include: a nodular liver abdominal mass and enlarged and firm lymph nodes

Upper Gastrointestinal Bleeding (UGIB) Clinical Presentation Physical Examination The finding of subcutaneous emphysema with a history of vomiting is suggestive of Boerhaave syndrome (esophageal perforation) and requires prompt consideration of surgical therapy

Upper Gastrointestinal Bleeding (UGIB) Causes

Causes The major causes of UGIB are: duodenal ulcer hemorrhage (25%) gastric ulcer hemorrhage (20%) mucosal tears of the esophagus or fundus (MalloryWeiss tear) esophageal varices erosive gastritis

Upper Gastrointestinal Bleeding (UGIB) Causes erosive esophagitis Dieulafoy lesion gastric varices gastric cancer and ulcerated gastric leiomyoma

Upper Gastrointestinal Bleeding (UGIB) Rare Causes Include: aortoenteric fistula gastric antral vascular ectasia angiectasias and Osler-Weber-Rendu syndrome

Remember 1: The proportion of UGIB cases caused by peptic ulcer disease has declined This decline is believed to be due to the use of: PPIs and H pylori therapy

Patients should be considered for upper endoscopy if blood loss from the upper gastrointestinal tract is suspected

Upper Gastrointestinal Bleeding (UGIB) Remember 2: A high level of suspicion of UGIB should exist when the patient has a history of intake of aspirin or NSAID, even if no history of: hematemesis or melena exists

Remember 3: The color of stool containing blood depends on the transit time Rapid transit from the upper gastrointestinal tract can result in red or maroon stools Melena results from more than 100 mL of blood with moderate transit time Slow transit of blood from the lower intestine can result in melena in the presence of obstruction

Remember 4: Urgent endoscopy is indicated when patients present with: hematemesis melena or postural changes in blood pressure

Remember 5: Primary surgical intervention should be considered in patients with a perforated viscus from: duodenal ulcer gastric ulcer or Boerhaave syndrome

Remember 6: In patients who are poor operative candidates: ► conservative treatment with nasogastric suction ► and broad-spectrum antibiotics can be instituted

►Endoscopic clipping or sewing techniques have also been used in such patients

Upper Gastrointestinal Bleeding (UGIB) Differentials Diagnosis 1) Duodenum, Ulcers 2) Esophagus: Tear , Varices, Cancer, Esophagitis, Boerhaave syndrome 3) Gastric: Carcinoma, Ulcer, Gastritis 4) Portal Hypertension

Upper Gastrointestinal Bleeding (UGIB) Labworkup CBC with platelet count. Basic metabolic profile (BMP): BUN Creatinine Electrolytes Glucose level Fluid balance

Upper Gastrointestinal Bleeding (UGIB) Labworkup Coagulation parameter: PT, aPPT

Liver profile: The liver profile can identify: ► hepatic comorbidity and ► suggest underlying liver disease

Labworkup Calcium level: A calcium level is useful to identify the patient with: ► hyperparathyroidism ► as well as to monitor calcium in patients receiving multiple transfusions of citrated blood

Upper Gastrointestinal Bleeding (UGIB) Labworkup Gastrin level: A gastrin level can identify the rare patient with gastrinoma as the cause of: UGIB and multiple ulcers

Upper Gastrointestinal Bleeding (UGIB) Imaging Studies Chest radiographs should be ordered to exclude: aspiration pneumonia effusion esophageal perforation Upright films should be ordered to exclude perforated viscus and ileus

Upper Gastrointestinal Bleeding (UGIB) Imaging Studies Barium contrast studies are not usually helpful and can make endoscopic procedures more difficult (i.e. white barium obscuring the view)

Upper Gastrointestinal Bleeding (UGIB) Imaging Studies Angiography may be useful if: ► bleeding persists and ► endoscopy fails to identify a bleeding site

Imaging Studies CT scan and ultrasonography may be indicated to evaluate: ► liver disease with cirrhosis ► cholecystitis with hemorrhage ► pancreatitis with pseudocyst and hemorrhage aortoenteric fistula ►and other unusual causes of upper gastrointestinal hemorrhage

Other Tests: An ECG should be ordered to exclude: arrhythmia and acute myocardial infarction ► due to hypotension

Performing a troponin test may be useful to identify patients with: severe coronary ischemia or atypical myocardial infarction

Upper Gastrointestinal Bleeding (UGIB) Procedures

Nasogastric lavage (1): This procedure may confirm recent bleeding (coffee ground appearance) Possible active bleeding (red blood in the aspirate that does not clear)

Upper Gastrointestinal Bleeding (UGIB) Procedures Nasogastric lavage (2): A nasogastric tube is an important diagnostic tool, and tube placement can reduce the patient's need to vomit Placement for diagnostic purposes is not contraindicated in patients with possible esophageal varices

Upper Gastrointestinal Bleeding (UGIB)

Treatment Medical Care Surgical Care

Upper Gastrointestinal Bleeding (UGIB)

Treatment Medical Care The goal of medical therapy is to correct: shock coagulation abnormalities and to stabilize the patient ► so that further evaluation and treatment can proceed

Treatment Medical Care Stabilize the patient with intravenous fluids: * usually normal saline: except in patients with severe liver disease, ascites, or heart failure * and transfuse to maintain a hemoglobin level of 8-10 g * *

Promptly correct any abnormalities in coagulation Early aggressive resuscitation can reduce mortality in acute UGIB *

Upper Gastrointestinal Bleeding (UGIB) Treatment Surgical Care Endoscopic Celiotomy

Upper Gastrointestinal Bleeding (UGIB) Consultations Consultation with a surgeon should be considered for all patients with gastrointestinal hemorrhage

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