Upper And Lower Gastrointestinal Bleeding

Upper and Lower Gastrointestinal Bleeding

Dr. Shatdal Chaudhary MD Assistant Professor Department of Internal Medicine, BPKIHS, Dharan

G I Bleeding • Acute Vs Chronic • Upper Vs Lower • Bleeding above/below the ligament of Treitz

Acute U G I Bleeding Introduction • Most common gastrointestinal emergency • Accounting for 50-120 admissions to hospital per 100 000 of the population each year in the U K. • Higher among males, elderly

Causes of Upper GI Bleed (UGIB) • • • • • • •

Peptic Ulcer Disease (60% cases of UGIB) Erosive Gastritis(10-20%) Esophagitis (10%) Esophageal and Gastric Varices (2-9%) Mallory-Weiss Syndrome(5%) Malignancy(2%) Others – Stress ulcer, arteriovenous malformation, Aortoduodenal Fistula, corrosive poisoning

Clinical Features: • History: Often misleading – Usually presents with obvious complaints (melaena, hematemesis, etc.) or may present with more subtle signs (hypotension, tachycardia, etc)

• • • • • •

Hematemesis Melaena Hematochezia H/o NSAIDs, Alcohol abuse, corrosive intake Weight loss/change in bowel habit (malignancy) Vomiting/retching followed by hematemesis (MalloryWeiss) • Hx aortic graft (possible aortocentric fistula)

Clinical Features: • Physical Exam – Hypotension, tachycardia – Skin: cool, clammy, jaundice, spider angioma and other stigmata of CLD – Lymph node – Abd: tenderness, masses, ascites, hepatosplenomegaly – PR Exam: blood

Estimation of blood loss

Estimated Fluid and Blood Losses in Shock Class 1

Class 2

Class 3

Blood Loss, mL

Up to 750

750-1500

1500-2000

>2000

Blood Loss,% blood volume

Up to 15%

15-30%

30-40%

>40%

<100

>100

>120

>140

Normal

Normal

Decreased

Decreased

Normal or Increased

Decreased

Decreased

Decreased

14-20

20-30

30-40

Slightly anxious

Mildly anxious

Anxious, confused

Crystalloid

Crystalloid

Crystalloid and blood

Pulse Rate, bpm Blood Pressure Respiratory Rate Urine Output, mL/h CNS/Mental Status Fluid Replacement, 3-for-1 rule

Class 4

>35 Confused, lethargic Crystalloid and blood

Investigations: Blood tests • Blood Group • Full blood count. Hb: may be normal or Low. • Urea and electrolytes. may show evidence of renal failure. • LFT. • Prothrombin time & Coagulation Profile. • Cross-matching of at least 2 units of blood.

• UGI Endoscopy: Diagnostic as well as therapeutic – should be carried out as early as possibe after adequate resuscitation. – A diagnosis will be achieved in 80% of cases. – Patients who are found to have major endoscopic stigmata of recent haemorrhage can be treated endoscopically

• Angiography: sometimes can localize, but requires brisk bleeding rate (0.5 to 2.0 ml/min) • Technetium-labeled red cell scan: more sensitive than angiography

Treatment • Primary – ABCs – Oxygen This should be given by facemask to all patients in shock. – Close monitoring – Immediate resuscitation, 2 wide bore IV cannula – NG tube in all patients with significant bleeding – Consider blood transfusion if no improvement after 2L of crystalloid or Hb < 10 gm/dL

Therapeutic Endoscopy – – – –

Early treatment indicated when significant upper GI bleed Sclerotherapy or band ligation used to treat varices thermal modality 'heater probe‘ injection of dilute adrenaline (epinephrine) into the bleeding point

– application of metallic clips.

Drug Therapy – Intravenous proton pump inhibitor infusions reduce rebleeding – Somatostatin and octreotide effective for reduction of acute variceal bleeding

Balloon Tamponade • Sengstaken-Blakemore tube can control variceal hemorrhage in 40 – 80% patients • Inflate gastric balloon first, the esophageal balloon if no improvement

Surgery – – if all other interventions are ineffective – endoscopic haemostasis fails to stop active bleeding – rebleeding occurs on one occasion in an elderly or frail patient, or twice in younger, fit patients

Prognosis: • Mortality following a diagnosis of acute upper gastrointestinal bleeding is approximately 10%.

RISK FACTORS FOR DEATH IN PATIENTS WITH ACUTE U GI HAEMORRHAGE Factor Comments • Increasing age: Risk increases over age 60 and especially in very elderly

•

Comorbidity:Advanced malignancy; renal and hepatic failure

• •

Shock: Diagnosis:

•

Endoscopic findings:

•

Rebleeding

Def as pulse > 100/min, BP < 100 Varices and cancer have the worst prognosis Active bleeding and a nonbleeding visible vessel at endoscopy Associated with 10-fold rise in mortality

Lower GI Bleeding • Bleeding below the ligament of Treitz • This may be due to haemorrhage from the – small bowel – colon or – anal canal

• Incidence: 20 per 100,000 population

CAUSES OF LOWER GI BLEEDING • Severe acute – – – –

Diverticular disease Angiodysplasia Ischaemia Meckel's diverticulum

• Moderate, chronic/subacute – – – – – – –

Anal disease, e.g. fissure, haemorrhoids Inflammatory bowel disease Carcinoma Large polyps Angiodysplasia Radiation enteritis Solitary rectal ulcer

ETIOLOGY Differential Diagnosis of Lower Gastrointestinal Hemorrhage COLONIC BLEEDING (95%) % SMALL BOWEL BLEEDING (5%) Diverticular disease

30-40 Angiodysplasias

Ischemia

5-10

Erosions or ulcers (potassium, NSAIDs)

Anorectal disease

5-15

Crohn's disease

Neoplasia

5-10

Radiation

Infectious colitis

3-8

Meckel's diverticulum

Postpolypectomy

3-7

Neoplasia

Inflammatory bowel disease

3-4

Aortoenteric fistula

Angiodysplasia

3

Radiation colitis/proctitis

1-3

Other

1-5

Unknown

10-25

Clinical Features • OCCULT GI BLEEDING • 'Occult' means that blood or its breakdown products are present in the stool but cannot be seen. • Occult bleeding may reach 200 ml per day

Options to diagnose and control the bleeding • Colonoscopy • technetium-99m labeled RBC scan: requires 0.5-1 ml/min bleeding • Mesenteric angiography: requires 1-1.5 ml/min bleeding • Meckels scan • Capsule Endoscopy • Surgery • faecal occult blood (FOB)

• Colonscopy: diagnostic and therapeutic • colonoscopy is necessary to exclude coexisting colorectal cancer. – subjects who also have altered bowel habit – and in all patients presenting at over 40 years of age,

Treatment • Acute bleeding tends to be self limiting • If bleeding persists perform endoscopy to exclude upper GI cause • Therapeutic colonoscopy • Consider selective mesenteric embolisation if life threatening haemorrhage • Proceed to laparotomy and consider on-table lavage an panendoscopy • If right-sided angiodysplasia perform a right hemicolectomy • If bleeding diverticular disease perform a sigmoid colectomy • If source of colonic bleeding unclear perform a subtotal colectomy and end-ileostomy

The End