Acute Gastrointestinal Hemorrhage Overview

Acute Gastrointestinal Hemorrhage

• A potentially life-threatening emergency
• Common complication of critical illness
• Can occur from upper or lower gastrointestinal tract

Upper Gastrointestinal Tract Bleeding

• Peptic ulcer disease: Most common cause
  • Often results from breakdown of gastromucosal lining
  • Factors:
    • Chronic ingestion of NSAIDs, aspirin, and alcohol
    • Presence of Helicobacter pylori (H. pylori) infection
    • Stress-related erosive syndrome:
      • Stress ulcer
      • Stress gastritis

Lower Gastrointestinal Tract Bleeding

• Diverticulosis: Outpouching of the bowel wall
• Inflammatory bowel disease
  • Crohn's disease
  • Ulcerative colitis: causes friability of the bowel wall
• Trauma
• Neoplasm
• Infectious colitis
• Radiation colitis
• Angiodysplasia
• Ischemia
• Aortoenteric fistula
• Hemorrhoids: Presence of varicosities in the rectal and anal vein

Pathophysiology

• Characterized by acute, massive bleeding
• Results in hypovolemic shock, activation of the shock response, and potential development of multiple organ dysfunction syndrome if left untreated

Clinical Classification of Hemorrhage

• Classified into four classes based on blood loss percentage and clinical signs/symptoms

Hallmarks of Gastrointestinal Hemorrhage

• Hematemesis: Vomiting of blood, can be bright red or coffee ground/brownish
• Hematochezia: Presence of bright red stool
• Melena: Black tarry or dark red stool

Priorities in Management

• Airway protection
• Fluid resuscitation
• Correction of co-morbid conditions (e.g., coagulopathy)
• Therapeutic procedures: control or stop bleeding and diagnostic procedures to determine the cause

Stabilization: Initial Treatment Priority

• Initiate fluid resuscitation
  • Intravenous infusions of crystalloids, blood, and blood products
• Administer Vitamin K for coagulopathy
• Vasopressor medications: dopamine, epinephrine, or norepinephrine
• Supplemental oxygen therapy
• Monitor hemodynamic parameters
• Insert large nasogastric tube

Controlling the Bleeding

• Peptic Ulcer Disease (PUD)
  • Endoscopic injection therapy with hemostatic clips
  • Endoscopic thermal therapy
  • Intra-arterial infusion of vasopressin or embolizing agent
• Stress-Related Mucosal Disease
  • Intra-arterial infusion of vasopressin and intraarterial embolization
• Esophagogastric Varices: Control may be achieved through pharmacologic agents and endoscopic therapies
  • Intravenous administration of vasopressin, somatostatin, and octreotide
  • Endoscopic treatments: endoscopic injection sclerotherapy (EIS) and endoscopic variceal ligation (EVL)
  • If EIS and EVL fail: Transjugular Intrahepatic Portosystemic Shunting (TIPS)
• Surgical Intervention: For patients unresponsive to conservative medical management
  • PUD: Vagotomy and pyloroplasty
  • Esophageal Varices: Decompression procedures such as portacaval shunt procedure

Key Points:

• H. pylori is a primary factor in the development of peptic ulcer disease.
• Stress-related erosive syndrome is a major cause of upper GI hemorrhage.
• Fluid resuscitation is essential for stabilizing patients with GI hemorrhage.
• Endoscopic therapies are the preferred treatment for controlling bleeding from PUD and esophageal varices.
• Vasopressin is a potent vasoconstrictor used in managing upper GI hemorrhage, but it can have significant side effects.
• TIPS is a surgical procedure used for severe cases of variceal hemorrhage.

This quiz covers the critical aspects of acute gastrointestinal hemorrhage, including its definitions, common causes, and complications associated with upper and lower gastrointestinal tract bleeding. Test your understanding of conditions such as peptic ulcers, diverticulosis, and the pathophysiology underlying these emergencies.