GI bleeding Lecture.pdf

GASTRO-INTESTINAL BLEEDING BY: DR. MARIAM WAGIH UNDER SUPERVISION OF: DR. SOHA SOUD CLASSIFICATION Upper Gi Bleeding: bleeding above the ligament of Treitz Lower Gi Bleeding: bleeding below the ligament of Treitz DEFINITIONS He...

GASTRO-INTESTINAL BLEEDING BY: DR. MARIAM WAGIH UNDER SUPERVISION OF: DR. SOHA SOUD CLASSIFICATION Upper Gi Bleeding: bleeding above the ligament of Treitz Lower Gi Bleeding: bleeding below the ligament of Treitz DEFINITIONS Hematemesis: - vomiting of blood. -often blood, quickly degraded by stomach acid, causing “ coffee ground” Hematochezia: - red or maroon-colored blood in the stool. - can occur with both lower GI bleeds and rapidly bleeding upper GI. DEFINITIONS ( CONT.) Melena: - Passage of soft , tarry and offensive stools. - usually indicates upper Gi bleeding as the blood has been digested to hematin by gastric acid. - Small bowel and right sided colonic hemorrhages may also produce melena. - It only takes 50 ml of GI blood loss per day to cause melena. DIFFERENTIAL DIAGNOSIS OF MELENA Bismuth subsalicylate Iron Spinach Charcoal ALL can produce black stools, but with negative stool guaiac. CAUSES OF GI BLEEDING UPPER GI SOURCE Gastritis ( erosions secondary to NSAID, Entero-aortic fistula ( in aortic grafts) alcohol or stress) Duodenitis Ulcers ( often caused by H.pylori or NSAID) Inflammatory bowel disease (crohn’s Mallory-Weiss tear ( often secondary to disease) excessive vomiting) Neovascularization (arteriovenous Biliary ( hemobilia, secondary to trauma or malformations)…..more common with recent hepatobiliary procedure) lower GI bleeding Large varices ( in portal hypertension) Gastric cancer Esophagitis or Esophageal ulcer CAUSES OF GI BLEEDING (CONT.) LOWER GI SOURCE Diverticulosis ( most common cause of lower Infectious colitis….. Usually accompanied GI bleeding)…. Usually painless with diarrhea Radiation proctitis…..common after Neoplasms ( benign or malignant)…. radiation of prostate and cervix/uterus Usually causes chronic bleeding Arteriovenous malformations ( angiodysplasia) N.B.: Ischemia Painful bleeding suggests a non diverticular cause Inflammatory bowel disease…. Usually accompanied with diarrhea APPROACH TO THE PATIENT A) Patient History - Is helpful for distinguishing between an upper and lower source of bleeding - Is poor for determining the exact cause of the bleeding. - Ask about: - No. of episodes - Most recent episode - Use of NSAID , aspirin, or other antiplatelet agents. - Use of anticoagulants. - Alcohol abuse. - Use of PPI ( regular use makes an upper GI source less likely) - Cirrhosis ( increases probability of bleeding varices) - vomiting before hematemesis. - Presence and location of abdominal pain - Prior aortic surgery APPROACH TO THE PATIENT (CONT.) B) PHYSICAL EXAMINATION - Vital signs -Complexion - lungs and heart -Abdomen - Rectum (rectal masses) - Neurological examination - Skin ( signs of liver disease) APPROACH TO THE PATIENT (CONT.) C) DIAGNOSTIC TESTS Laboratory: Radiological: - Blood typing and cross matching - chest and abdominal radiographs - Complete blood pictures - Electrocardiography - Electrolytes - Blood urea nitrogen and creatinine levels - Liver tests - PT, PTT APPROACH TO THE PATIENT (CONT.) D) GENERAL GUIDELINES - In a patient with GI bleeding, do not delay management because you have not figured out the cause of the bleeding. - GI bleeding is a situation in which the initial management is similar, regardless of the exact cause. APPROACH TO THE PATIENT (CONT.) *) Assess hemodynamically stability by evaluating ABCs ( airway, breathing, circulation) shock?!! *) Clinical assessment/ Resucitation by fluid replacement *) Risk stratify (ICU admission?!! / Endoscopy?!! / Inpatient or outpatient?!!) *) Furthur tests to Diagnose ( Endoscopy/ Technetium-99m/ angiogram/ capsule endoscopy) APPROACH TO THE PATIENT (CONT.) *) Clinical assessment/ Resucitation by fluid - Place NGT: confirm UGI source replacement - I.V. access should be obtained ( two - IV acid suppression therapy ( PPI large bore cannulae) decreases risk of acute rebleed) - NPO - Antibiotics ?!! - use crystalloid first, use pRBCs if > 2-3 - Octreotide in those with a portal crystalloids needed or signs of EKG ischemia hypertension cause - Oxygen - Vitamin K if patient’s PT or PTT is - Foley catheter - CXR, EKG abnormal - labs - Hold antihypertensive or diuretics APPROACH TO THE PATIENT (CONT.) NASOGASTRIC TUBE INSERTION is done if there is any possibility an upper GI exists. ……….. Remember that some patients with upper GI bleeding will have hematochezia. a) NGT aspirate may be negative even in the presence of upper GI bleeding if: - The source of the bleeding is below the end of the NGT ( e.g. duodenal ulcer) - The bleeding is transient. - Nasogastric lavage that dose not contain bile is not adequate to assess duodenal bleeding. b) The tube should be kept in place if there is active bleeding or signs of small bowel obstruction. Otherwise, the tube can be removed after the aspirate has been assessed. APPROACH TO THE PATIENT (CONT.) N.B. - Patients with coronary artery disease are often transfused to keep their Hematocrit > 30% or Hb > 10 mg/dl. - Patient with active bleeding, consider a platelet transfusion if the patient’s platelet count is < 50,000/ µl or if the patient is on antiplatelet agents. - Transfusion of one unit of blood should raise the patient’s HB level by approximately one gram/dl. Failure to rise may indicate hemolysis or ongoing blood loss. APPROACH TO THE PATIENT (CONT.) *) Risk assessment: Clinical Triage for inpatient management: Triage for outpatient management: - unknown or suspected variceal bleed Pts with low risk of requiring intervention - Hemodynamic instability such as endoscopic therapy or transfusion - -ongoing symptopms of bleeding Factors - Recurrent bleeding - BUN< 6.5 - Comorbidity requiring hospitalization - Hb >13 (Men) , >12 (Women) (angina) - Systolic bl. Pr. >110 - Mental impairment or noncompliance - HR < 100 - Coagulopathy - Anemia requiring transfusion APPROACH TO THE PATIENT (CONT.) Criteria for admission of ICU:.Variceal bleeding.. Instability of vital signs.. Serious comorbid conditions ( coronary artery disease, COPD). Active bleeding or Advanced age APPROACH TO THE PATIENT (CONT.) *) Role of Endoscopy - After resuscitation, patients with evidence of ongoing upper Gi bleeding should undergo URGENT upper endoscopy within few hours….. To assess the source of bleeding and allow attempt of hemostasis. - Patients with no clear ongoing upper Gi bleeding, endoscopy should be performed within 12- 24 hours. - For suspected lower GI bleeding that stops, a colonoscopy is indicated. Stable patients should be prepared for colonoscopy the night of admission. - Unstable patients can be rapid prepared with nasogastric tube for emergent colonoscopy. ENDOSCOPY UPPER ENDOSCOPY COLONOSCOPY  APPROACH TO THE PATIENT (CONT.) *) Role of Technetium-99m labeled red blood cell scan: Indications - In patients with ongoing significant GI bleeding without obvious source. - In patients with lower GI bleeding who are not candidate for endoscopic evaluation. Value: Helps identify and localize a small bowel or colonic source of bleeding. Amount of bleeding: Must be at least 0.05-0.1 ml/min for this test to be useful APPROACH TO THE PATIENT (CONT.) *) Role of Visceral Angiogram: Indication When a source has been identified on a labeled red blood cell scan. Value: For both diagnostic and therapeutic ( embolization) purposes. Amount of bleeding: Must be at least 0.5- 1.0 ml/min for this test to be useful APPROACH TO THE PATIENT (CONT.) *) Role of Capsule Endoscopy : Indication - In chronic GI bleeding with negative colonoscopy and upper endoscopy. - In semi-acute bleeding suggestive of a small bowel source. Value:. Assess bleeding from the small bowel.. It is a diagnostic modality with no therapeutic role & Monitor BUN/Cr ratio