Comprehensive Guide to Gastrointestinal Bleeding: Causes, Symptoms, and Management

1. GIBDr. Anas KhanChairman, Department of Emergency Medicine

3. Upper GIB: • Intraluminal bleed originating proximal to the ligament of Treitz • Esophagus, stomach & duodenum • MR 14% • 35% present with shock • 65% requires Tx • 25% requires intervention

4. Lower GIB: • Intraluminal bleed originating distal to the ligament of Treitz • SB & colon. • MR 4% • 19% present with shock • 36% requires Tx

5. Haematemesis: • Vomiting of blood from UGIT or after swallowing blood from the nasopharynx. • Bright red haematemesis  active, risky. • Coffee-ground vomitus  black material

6. Melena: • Black tarry stools due to acute UGIB, or bleeding within the small bowel or right side of the colon. • > 200 mL blood in stomach, or Up to 150 mL blood in cecum).

7. Hematochezia: • Passage of fresh or altered blood per rectum. • > 100 mL blood in Lt colon, or > 150 mL blood in Rt colon, or > 1 L upper bleed (orthostatic) • 76% colon • 11% UGIB • 9% small bowel • 6 % unknown

8. Hematochezia: • Hematochezia: • Pain: • No pain + elderly: • Blood oozing w/o BM:

9. Pathophysiology UGIB:

11. Varices: • Abn distended veins, (esophageal, gastric or other ectopic). • Bleeding is severe (life threatening). • Size of the varices and their propensity to bleed  portal pressure severity of underlying liver disease. • Large varices with red spots are at highest risk of rupture.

12. Pathophysiology LGIB:

13. LGIB: • Diverticulosis: 33% • Colon CA or polyps: 19% • Colitis (IBD, infectious, ischemic, radiation, vasculitis, etc.): 18% • Angiodysplasia: 8% • Other intestinal lesions (post-polypectomy, Ao-enteric fistula, stercoral ulcer, etc.): 8% • Ano-rectal: 4% • Unknown: 16%

14. ENDOSCOPY

15. Clinical: • If severe bleeding  hypovolemic shock • TC, anxiety, confusion, tachypnea, cool clammy skin, oliguria, hypotension. • Orthostatic @ 3 min: BPs drop =/> 10 mmHg and/or HR increase > 20 bpm  20% bl loss. • Normotensive patient may still be shocked and require resuscitation. • Subtle: angina, dizziness, weakness..

16. Clinical: • V & retching, hematemesis  Mallory-Weiss • Hx of aortic graft  aorto-enteric fistula • Spider angiomata, palmer erythema, ascites, jaundice, gynecomastia  liver disease • Wt loss, change in bowel habits  CA

17. Triage: • A system of initial assessment & Mx, whereby a group of patients is classified according to the seriousness of their injuries or illnesses so that treatment priorities can be allocated between them.

18. Hx: • Amount • Appearance • RF • Comorbidities • Syncope

20. P/Ex: • V/S • Mental status • Abd Ex • PR Ex

21. DDx: • GIB may not be obvious • Careful ENT exam • PR: blood or masses • F+ve: (melena: iron, bisthmus), (hematochezia: beets)  guaiac test

22. Tests: • Severe: Blood type & cross-X • CBC, U&E, coagulation, LFT, LA • Initial Hct !!! • Cardiac enz, ECG, XRs

23. NGT: • 50% of duodenal bleeding have -ve aspirate. • Vs. endoscopy, NGT aspirate: 79% Sn & 55% Sp for active bleeding. • 14% with clear aspirate have high-risk lesions. • 42% with blood in aspirate, have “clean base” or “pigmented spot”.

24. NGT: • Localize: • Dx, not Rx • R/I not R/O UGIB • No risk in varices • NGT aspiration does not change Mx (Dx, Px, Rx, or visualization). • Painful!! • Erythromycin

25. Investigations: • UGI Endoscopy  diagnostic study of choice • Angiography in severe LGIB: detects site & Mx (embolize or infuse vasoactive substances) • Scintography: localize bleeders in obscure hge • Timing of colonoscopy, multi-detector CT  !!

26. RF for Poor OC: • Age: 60 ys – 75 ys • Comorbidity: HF, CA, RF, varices, liver, drugs (Alcohol, ASA, NSAIDs, anticoag), inpatient • Initial Hct < 30%, high BUN • Initial shock (SBP < 100) • Continued bleeding • Active hematemesis or hematochezia, blood in NGT aspirate

27. Management: • Early recognition & aggressive treatment • Monitored bed • Initial resuscitation: • Airway: secure • Breathing: oxygen • Circulation: IV lines, fluids, blood products

28. Management: • FFP for coagulopathy (15 mL/kg) • Platelet transfusion if platelets < 50K (1 single donor unit, or 1 random pooled unit/ 10 kg) • Erythromycin 250 mg IV, 30-120 min before EGD (clears stomach) • Reversal of anti-coagulant or anti-platelets agents:

29. Medications: • PPIs • Octreotide: consider in uncontrolled UGIB, portal HTN: 25-50 mcg IV, then 25-50 mcg/h • H2B: not beneficial in acute GIB • If cirrhotic  ABx

30. Tx: • Restrictive (not liberal) • Reverse known or suspected Coagulopathy

31. Management: • Endoscopy: Dx & Rx (injection, coaptive, clips, band ligation) • Immediate vs. Delayed

32. Device: • Sengstaken-Blackmore tube can control documented variceal hge, but used only temporally until endoscopy

33. Surgical Intervention: • Despite medical and endoscopic Mx: • Active bleeding not controlled with endoscopy. • Recurrent hge after stabilization & endoscopies. • HD instability after resuscitation and 3 units of PRBC. • Recurrent bleed with shock. • Continuous slow bleed of > 3 units PRBC/day.

34. Prognosis: • Shock • Re-bleeding: generally high, figure are variable, so many factors. • Infection: UTI (20-25%), SBP (15-20%), Respiratory (8%), Bacteremia (8%). • Tx complications

35. Hypovolemic Shock:

36. Case 1: • 76 yo, F, HTN, brought unconscious • HR: 90, RR: 24, BP: 120/80

37. Case 2: • 21 yo, M, severe epigastric pain, hematochezia • HR: 135, RR: 24, BP: 110/90

38. Case 3: • 35 yo, M, 1 mo epigastric pain, melena? • HR: 90, RR: 18, • BP: 120/80 (orthostatic 100/65)

39. Approach: • Resuscitate • Upper vs. Lower GIB • Variceal vs. Non-variceal • Definitive Rx