Gi Bleeding- Nurses

Gastrointestinal Bleeding Dr Christopher Khor Senior Consultant Gastroenterologist Division of Gastroenterology & Hepatology National University Hospital

GI Bleeding Introduction Causes of GI Bleeding Management Principles Assessment Management

Introduction Common: UGIB 30-100/100,000 vs. LGIB 20/100,000 (5x less common) Risk increased in aspirin (dose-related) & NSAID Decreased hosp stays due to endoscopy, 25% therapeutic endoscopy Reductions in surgery, rebleed, mortality

Introduction Upper GI Bleeding (UGIB) Non-Variceal Bleeding Variceal Bleeding

Lower GI Bleeding (LGIB) ‘Obscure’ cause 5% Small bowel

Introduction Non-variceal Bleeding Mortality 3.5-14%

Variceal Bleeding Mortality 30-50% 2/3 die within 1 year

Introduction 80% stop spontaneously Mortality correlated with comorbidity Diagnosis facilitates endotherapy, lowers mortality

Causes of GI Bleeding

Upper GI Bleeding- Etiology 3 major causes: Peptic Ulcer Gastric Erosions Varices

No diagnosis in 10-15%, >1 in 20-30%

Diagnosis of UGIB in 2225 patients Duod ulcer Gastric erosions Gastric ulcer Varices Mallory-Weiss tear Esophagitis Erosive duodenitis Neoplasm Stomal ulcer Esophageal ulcer Misc

24.30% 23.40% 21.30% 10.30% 7.20% 6.30% 5.80% 2.90% 1.80% 1.70% 6.80%

Silverstein FE et al, GI Endosc 1981; 21:73

Peptic Ulcer Bleeding

Variceal Bleeding

Rarer causes of UGIB Angiodysplasia Aortoenteric fistula Dieulafoy disease Hemobilia Hemosuccus pancreaticus Factitious bleeding or non-GI source

Lower GI Bleeding- Causes Diverticulosis

43%

Angiodysplasia

20%

Undetermined

12%

Neoplasia

9%

Colitis

9%

Other

7%

Boley SJ et al Am J Surg 1979

Diverticular Bleeding

Evaluation & Management of GI Bleeding

Management Principles Rapid, accurate assessment Severity Site ? Variceal NSAID use

Resuscitation Stabilize before diagnosis, therapy & rebleeding prevention Endoscopic therapy Gold standard

Suspect Variceal Bleeding if: Prior history Ethanol abuse Jaundice or stigmata of liver disease

Poor Prognostic Features Severity of initial bleed Transfusion, BRB in NG aspirate, hypotension, tachycardia

Age >60 Comorbid disease Onset of bleeding in hospital Mortality 25% vs. 4%, Hb drop >1g/day

Emergency surgery Mortality up to 30%

Bleeding Site (Upper vs. Lower) NG tube Significance of negative aspirate

Stool color Melena Rectal bleed: massive UGI vs LGI

Mild elevation in Urea

Resuscitation IV access Large-bore x 2, CVP, +-S-G catheter

Replete volume with NS PCT ASAP When to transfuse? Age, comorbidity, ongoing bleed

Resuscitation Correct coagulopathy >6 Units bld consider FFP, plt, Ca

Close monitoring (+-in ICU) Protect airway If massive hematemesis

Other IV Omeprazole IV Somatostatin / Octreotide

•

Suspicion of variceal bleeding

Non-endoscopic Treatment: Nonvariceal Bleeding

IV Omeprazole Evidence for benefit

No benefit IV H2RA Iced saline lavage

Non-endoscopic Treatment: Variceal Bleeding

IV Somatostatin / Octreotide Suspicion of variceal bleeding

Sengstaken-Blakemore tube IV Antibiotics Gram neg coverage Ceftriaxone, Ciprofloxacin

Endoscopy Within 24 hrs Diagnostic & therapeutic benefit Reduction in rebleed, surgery, mortality • Cook et al Gastroenterol 1992

Early endoscopy Ongoing bleed after resuscitation Suspicion of variceal bleeding Poor prognostic factors

OGD, colonoscopy Small bowel evaluation

Non-endoscopic evaluation Radionuclide scan Angiography Enteroclysis Capsule Endoscopy

Tagged Red Cell Scan

Mesenteric Angiography & Embolization

Enteroclysis

Enteroscopy

Capsule Endoscopy Now the gold standard for small bowel evaluation

Double-Balloon Enteroscopy

Double-Balloon Enteroscopy

Endo stigmata & rebleeding 90%

50% 30%

3% Clean Base

18% Post-Tx

7% Flat Spot

Adherent Clot

Visible Vessel

Arterial Bleed

Endoscopic Therapy Thermal methods heater probe electrocoagulation Nd:YAG laser Argon Plasma Coagulation (APC)

Electrocoagulation

Electrocoagulation

Heater Probe

Argon Plasma Coagulator (APC)

APC

Endoscopic Therapy Non-thermal Injection therapy Sclerosants: ulcer and variceal bleed Vasoconstrictors: ulcer eg. Adrenaline Histoacryl: variceal bleed

Endoscopic variceal ligation for bleeding esophageal varices

Endoscopic Accessories

Bleeding Duodenal Ulcer

Double-Balloon Enteroscopy

Variceal Bleeding Different pathophysiology Portal Venous HPT >12mmHg due to cirrhosis Varices most commonly in esophagus, gastric fundus/cardia Bleeding risk related to varix size

Variceal Bleeding

Treatment of Variceal Bleeding IV antibiotics IV Octreotide / Somatostatin Esophageal Ligation vs. sclerotherapy vs. histoacryl injection Sengstaken tube TIPS

Gastric Histoacryl injection TIPS

Esophageal Varices

Band Ligation of Varices

Multi-band Ligator

Variceal Ligation

Portal Hypertensive Gastropathy

Gastric Varices

Histoacryl injection

Sengstaken Tube

Transjugular Intrahepatic Porto-Systemic Shunt (TIPS)

Bleeding in Cirrhosis

Lower GI BleedingCauses Diverticulosis Angiodysplasia Undetermined Neoplasia Colitis Other Boley SJ et al Am J Surg 1979

43% 20% 12% 9% 9% 7%

Diverticular Bleeding

Lower GI Bleed

Post-endoscopy care Vital signs Urine output Continued/recurrent bleed Repeat FBC- when? ? Repeat endoscopy

Summary GI bleeding is common Variceal bleeding has different pathophysiology, a/w increased mortality Evaluation & management are key Endoscopic Mx is definitive for most

When to call the surgeon Only with Registrar/GI approval, prompt decision First approach with endotherapy Continued bleed > 24 hrs > 6 unit transfusion Recurrent bleed despite endotherapy

Gastric Angiodysplasia

Dieulafoy Lesion- Prepyloric

Bleeding Duodenal Diverticulum

Bleeding Duodenal Diverticulum

Hemosuccus Pancreaticus

Aorto-Enteric Fistula

Gastric Cancer

Gastric Cancer