GASTROINTESTINAL HEMORRHAGE

1. GASTROINTESTINAL HEMORRHAGE or, “What’s that smell…?” Roger P. Tatum, MD Assistant Professor, University of Washington Department of Surgery

2. GASTROINTESTINAL HEMORRHAGE CASE #1 • 54 y/o male complains of fatigue and multiple dark, tarry stools for 2 days • PMH: HTN, hypercholesterolemia; no surgical history; never had colonoscopy • PEX: abdomen—soft, nontender, nondistended; rectal—no masses, heme+

3. GASTROINTESTINAL HEMORRHAGESigns and Symptoms of GI Bleed • Hematemesis/ “coffee ground” emesis • Melena—dark, tarry, foul-smelling stool • Hematochezia—bright red blood per rectum • Microcytic anemia • Chronic fatigue—secondary to anemia • Hypotension, tachycardia, mental status change—serious problem

4. GASTROINTESTINAL HEMORRHAGEUpper GI Bleed • Bleeding from the foregut—mouth to ligament of Treitz • Acute or chronic • History is key element in workup

5. GASTROINTESTINAL HEMORRHAGEUpper GI Bleed—Acute Sources • Epistaxis (often overlooked) • Oropharyngeal lesions • Esophageal varices • Mallory-Weiss syndrome • Hemorrhagic gastritis • Gastric or duodenal ulcer

6. GASTROINTESTINAL HEMORRHAGEUpper GI Bleed—Chronic Sources • Esophageal Cancer • Erosive esophagitis • Paraesophageal hiatus hernia/Cameron lesions • Gastric tumor • Gastritis • Gastric or duodenal ulcer

7. GASTROINTESTINAL HEMORRHAGEUpper GI Bleed—Workup • History—as often, one of the most important elements: • Hematemesis or “coffee grounds” most common in acute bleed • Melena often presents later • History of NSAID use—suggests gastritis or PUD • Alcohol, cirrhosis—suggests varices or Mallory-Weiss • GERD—in chronic bleed, esophagitis or Cameron lesions

8. GASTROINTESTINAL HEMORRHAGEUpper GI Bleed—Workup • History—cont’d • Antecedent pain—suggests ulcer or gastritis • H/o recent trauma or major surgery—stress gastritis (Cushing’s ulcer, Curling’s ulcer)

9. GASTROINTESTINAL HEMORRHAGEUpper GI Bleed—Workup • Physical Exam • Not as helpful as history • Abdominal tenderness uncommon • Check nasopharynx, oropharynx

10. GASTROINTESTINAL HEMORRHAGEUpper GI Bleed—Workup • Laboratory • Hgb/Hct (remember, may not reflect true blood volume in patient with acute rapid bleed) • PT/PTT—may need to correct coagulopathy • Electrolytes—assess for dehydration, guide resuscitation • Radiologic studies usually not initially helpful

11. GASTROINTESTINAL HEMORRHAGEUpper GI Bleed—Workup • Nasogastric aspiration (acute bleed only) • If completely negative, UGI source is not ruled out • Can irrigate—if able to clear, then bleed may no longer be active • Can be helpful in preparation for upper endoscopy

12. GASTROINTESTINAL HEMORRHAGEUpper GI Bleed—Workup • Upper Endoscopy • Most useful single diagnostic tool—90% success • Nearly all sources of UGI bleeding may be identified • Can be done (and often should) in ICU • Often therapy delivered simultaneously

13. GASTROINTESTINAL HEMORRHAGEAcute Upper GI Bleed—Treatment • RESUSCITATION! • Patient should be transferred to ICU setting • Ensure large bore IV access, may need central line • Aggressive hydration • Place Foley catheter to monitor hydration and efficacy of resuscitation • Type and cross for 4U PRBCs • Correct any coagulopathy • Transfuse depending on Hgb/Hct and history of patient

14. GASTROINTESTINAL HEMORRHAGEAcute Upper GI Bleed—Treatment • Endoscopic • Can be therapeutic for many sources of UGI bleed • Ulcer—can inject epinephrine or coagulate with heater probe in setting of “visible vessel” or “cherry red spot” • Varices—banding or injection

15. GASTROINTESTINAL HEMORRHAGEAcute Upper GI Bleed—Treatment • Angiography • Typically reserved for failure of endoscopic treatment • Localization of bleeding vessel • Embolization with Gelfoam, coils • Injection of vasopressin • Can also aid localization of source when not evident by endoscopy

16. GASTROINTESTINAL HEMORRHAGEAcute Upper GI Bleed—Treatment • Surgery—indications • Failure of endoscopic control (usually after 2+ attempts) • Transfusion requirement of 6 or more U PRBCs • Hemodynamic instability despite resuscitation • Usually for bleeding ulcers • Occasionally for hemorrhagic gastritis, Mallory Weiss tears, varices (see next)

17. GASTROINTESTINAL HEMORRHAGEAcute Upper GI Bleed—Treatment • Surgery—approach and strategy • Preop localization is essential • Typically, midline epigastric incision (celiotomy) • For DU: duodenotomy, oversew vessel, vagotomy and pyloroplasty or antrectomy (particularly if patient already on anti-secretory therapy)

18. GASTROINTESTINAL HEMORRHAGEAcute Upper GI Bleed—Treatment

19. GASTROINTESTINAL HEMORRHAGEAcute Upper GI Bleed—Treatment • Surgery—approach and strategy—cont’d • Gastric ulcer—gastrotomy and oversew, wedge gastrectomy (depends on location), subtotal gastrectomy • Mallory-Weiss tears—gastrotomy, oversew bleeding site

20. GASTROINTESTINAL HEMORRHAGEAcute Upper GI Bleed—Treatment • A word on varices: • Can start IV octreotide prior to endoscopy (increases success rate) • Endoscopic therapy is treatment of choice, may need several treatments • Use of the Sengstaken-Blakemore tube (includes football helmet) for severe, rapid hemorrhage—80-90% success, but 60% rebleed

21. GASTROINTESTINAL HEMORRHAGEAcute Upper GI Bleed—Treatment • A word on varices—cont’d: • Surgery rarely indicated—only with complete failure of above methods • Emergency portacaval shunt or • Esophageal division or devascularization

22. GASTROINTESTINAL HEMORRHAGEChronic Upper GI Bleed—Treatment • Nearly always managed medically; • Therefore, we will not discuss this (and you can’t make me…)

23. GASTROINTESTINAL HEMORRHAGELower GI Bleed--Presentation • Defined by bleeding source distal to ligament of Treitz • Mean age of presentation 63-77 y/o • Can present with melena or bright red blood per rectum with or without clots • 20% presents as acute “massive” bleeding • Often more difficult to localize than UGI bleed

24. GASTROINTESTINAL HEMORRHAGELower GI Bleed—Acute Sources • Diverticulosis • Angiodysplasia (AVM)—more common in >65 • Ischemic colitis • Meckel’s diverticulum • Infectious colitis (C. diff, E. coli, campylobacter) • IBD (ulcerative colitis>Crohn’s disease) • Malignancy (rare cause of acute bleed)

25. GASTROINTESTINAL HEMORRHAGELower GI Bleed—Chronic Sources • Malignancy (most common chronic LGI source) • Benign small or large bowel polyps • Angiodysplasia • IBD • Hemorrhoids • Anal fissure

26. GASTROINTESTINAL HEMORRHAGE Lower GI Bleed—Workup • History • Character and quantity of blood • History of HTN, CAD, PVD (ischemic colitis) • History of IBD • Anticoagulation or coagulopathy

27. GASTROINTESTINAL HEMORRHAGE Lower GI Bleed—Workup • Exam • Look for abdominal masses • Listen for bruits • Rectal—masses, characterize blood, look for anal pathology such as hemorrhoids, fissures

28. GASTROINTESTINAL HEMORRHAGELower GI Bleed—Workup • Laboratory (look familiar?) • Hgb/Hct (remember, may not reflect true blood volume in patient with acute rapid bleed) • PT/PTT—may need to correct coagulopathy • Electrolytes—assess for dehydration, guide resuscitation • Radiologic studies—CT may show thickening of bowel in case of mesenteric ischemia; diverticulosis usually easily identified

29. GASTROINTESTINAL HEMORRHAGELower GI Bleed—Workup • Rule out Upper GI bleed source! • Follow initial steps in algorithm for UGI bleed • Patient may need EGD for differentiation

30. GASTROINTESTINAL HEMORRHAGELower GI Bleed—Workup • Colonoscopy • Often 1st maneuver • Visualization difficult secondary to invariably poor prep

31. GASTROINTESTINAL HEMORRHAGELower GI Bleed—Workup • Tagged RBC scan (nuclear medicine) • 99mTc-pertechnaetate-labeled RBCs, IV injection • Demonstrates bleeding source when rate of bleed=0.1-0.5ml/minute • Allows repeated evaluation over course of 24 hours • May not exactly localize source—may not be able to differentiate colon from small bowel • Typically not used alone for localization

32. GASTROINTESTINAL HEMORRHAGELower GI Bleed—Workup • Angiography • Better for specific localization • Sensitive for bleeding rate 0.5-1.5ml/minute • Often requires large amount of contrast (beware renal insufficiency) • Can be therapeutic (embolization, vasopressin)

33. GASTROINTESTINAL HEMORRHAGELower GI Bleed—Workup • Provocative Angiography • When bleeding is recurrent and suspected to be from colonic source, can inject heparin and/or tPA • Treatment then delivered immediately when bleeding discovered • May require urgent trip to OR if angiographic therapy fails

34. GASTROINTESTINAL HEMORRHAGELower GI Bleed—Workup • Capsule Endoscopy • When unable to localize intermittent bleed via above methods, may be effective in defining source • May be the only way to identify small bowel source

35. GASTROINTESTINAL HEMORRHAGEAcute Lower GI Bleed—Treatment • RESUSCITATION! (once again, in case you forgot) • Patient should be transferred to ICU setting • Ensure large bore IV access, may need central line • Aggressive hydration • Place Foley catheter to monitor hydration and efficacy of resuscitation • Type and cross for 4U PRBCs • Correct any coagulopathy • Transfuse depending on Hgb/Hct and history of patient

36. GASTROINTESTINAL HEMORRHAGEAcute Lower GI Bleed—Treatment • Colonoscopy • Often unsuccessful due to difficulties in localization • May be effective in situations such as sclerosis of AVM

37. GASTROINTESTINAL HEMORRHAGEAcute Lower GI Bleed—Treatment • Angiography • As in UGI bleed, embolization with coils or gelfoam, vasopressin injection • 5-10% risk of bowel infarction

38. GASTROINTESTINAL HEMORRHAGEAcute Lower GI Bleed—Treatment • Surgery • Typically, segmental resection of small bowel or colon (NOT enterotomy and repair) • Usually very dependent on preoperative localization • In cases where localization not possible, can do on-table push enteroscopy to look past ligament of Treitz