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Gastrointestinal (GI) Bleeding

Gastrointestinal (GI) Bleeding. Ralph Lee, MD, FRCPC Gastroenterologist and Assistant Professor University of Ottawa, September 19, 2014. Objectives. Define upper and lower gastrointestinal (GI) bleeding. Outline the etiologies and clinical features of upper and lower GI bleeding

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Gastrointestinal (GI) Bleeding

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  1. Gastrointestinal (GI) Bleeding Ralph Lee, MD, FRCPC Gastroenterologist and Assistant Professor University of Ottawa, September 19, 2014

  2. Objectives • Define upper and lower gastrointestinal (GI) bleeding. • Outline the etiologies and clinical features of upper and lower GI bleeding • Apply a systematic clinical approach to GI bleeding. • Outline the investigation and management of GI bleeding • Recognize clinical indicators suggesting urgent versus non‐urgent assessment.

  3. What is Gastrointestinal Bleeding? (1) • Bleeding from anywhere in the GI tract • Esophagus to rectum • Traditionally, classified into two groups, based on presumed location of bleeding: • Upper • Lower • 3rd category, ‘Mid- GI’ bleeding, is present, but infrequently used

  4. What is Gastrointestinal Bleeding? (2) • Upper GI (UGI) Bleeding • Traditional: Proximal to the Ligament of Treitz • New: Proximal to the Ampulla of Vater • Lower GI (LGI) Bleeding • Traditional: Distal to Ligament of Treitz • New: Distal to terminal ileum • Mid GI bleeding • New: Ampulla of Vater to terminal ileum

  5. Upper GI Bleeding

  6. UGI Bleeding • 75 – 80% of GI bleeding • annual hospitalization rate = 160/100,000 (US) • Mortality rate = 3.5 – 10% • Sex – M:F – 2:1 •  incidence with age • More likely to present with hemodynamic instability due to rich blood supply of UGI tract

  7. UGI BleedingCauses (Common) • Peptic Ulcer disease (20 - 50%) • Varices (5 - 20%) • AV Malformations (5%) • Mallory-Weiss tears (8 - 15%) • Tumours (5%) • Erosions (8 - 15%) • Dieulafoy’s lesions (1%)

  8. UGI BleedingCauses (Other) • Other (11%) • Gastric Antral Vascular Ectasia (GAVE) • AKA ‘Watermelon’ stomach • Portal hypertensive gastropathy • Hemobilia • Hemosuccus pancreatitis • Aortoenteric fistulas • Cameron’s lesions/ulcers

  9. UGI BleedingHow Do They Present? (1) • Hematemesis • Vomiting blood • Bright red blood, clots, ‘coffee ground’ emesis • Melena • Passage of black, tarry, foul-smelling stools • Digested blood • Appears with ≥ 50cc of bleeding from UGI tract • Things that mimick melena: • Iron pills - greenish • Bismuth subsalicylate (PeptolBismol™) - non-foul smelling

  10. UGI BleedingHow Do They Present? (2) •  Bowel movement frequency • Blood is cathartic and a great laxative • Rough indicator of rapidity of bleeding • Hemodynamic symptoms • Pre/Syncope • Orthostatic dizziness/lightheadedness • Chest pain, dyspnea

  11. UGI BleedingHow Do They Present? (3) • (Hematochezia - red blood per rectum) • Usually sign of LGI Bleeding, but can occur with rapid UGI bleeding (i.e. ≥ 1000cc) • patient usually hemodynamically unstable • Other symptoms • Dependent on cause • Abdominal pain, heartburn, dysphagia, nausea, vomiting

  12. Lower Gi Bleeding

  13. LGI Bleeding • 20 – 30% of gastrointestinal bleeding • Usually less hemodynamically significant, higher Hb level, less blood transfusion requirements than UGI bleeds • Increased incidence with age • Mean age at presentation: 63 – 77 • Mortality rate among hospitalized acute lower GI bleeds – 2 - 4%

  14. LGI BleedingCauses • Diverticulosis (25 - 65%) • Cancers/polyps (17%) • Colitis/ulcers (18%) • IBD, ischemic, vasculitis, infectious, radiation-induced, NSAID-induced • Unknown (16%) • Angiodysplasia(3 - 15%) • Other (8%) • Post-polypectomy, stercoral ulcers, aorto-colonic fistulas • Anorectal(24 - 64%) • Fissures, hemorrhoids

  15. LGI BleedingHow Do They Present? (1) • Red Blood per Rectum • Bright Red Blood Per Rectum (BRBPR) – left colonic? • Dark/maroon – right colonic/lower small bowel? • Stool •  frequency – blood is cathartic •  form – diarrhea • Location of blood • Surface/side of stool – perianal source? • Mixed in stool – R colonic? • (Melena)* • Usually sign of UGI bleeding, but can occur with distal small bowel, cecum or R-sided colonic bleeding source • Typically, hemodynamically stable with less rapid bleeding

  16. LGI BleedingHow Do They Present? (2) • Other Symptoms • Dependent on cause • Fecal urgency, tenesmus, incontinence • Abdominal pain/cramps • Fevers/chills • Weight loss

  17. GI Bleeding

  18. GI BleedingOther important historical items • Past medical history: • GI • Previous PUD/H. Pylori infection? • GI Malignancy? • Previous endoscopies • Previous polypectomy • Diverticulosis • IBD • Cirrhosis? • Varices? • Cardiac • CAD, angina, MI, CHF • Previous aortic aneurysms/grafts/vascular surgery? • Previous radiation therapy? • Bleeding episodes • Medications • Anti-platelet agents (i.e. ASA, Plavix), anticoagulants (i.e. warfarin, pradaxa) • NSAIDs • Habits – EtOH • Family history: • PUD, gastric cancer • Colonic polyps, cancer • IBD

  19. GI BleedingPhysical Exam (1) • Look for: • Hemodynamic instability • Intravascular depletion • Potential etiologies of bleeding • General: • Altered mentation, jaundice • Vitals • Hypotension • Tachycardia • Orthostatic changes •  in BP and/or  HR with position change from supine to standing • Suggests intravascular volume depletion of ≥ 2L • Head and Neck: • Conjunctival pallor • Scleral icterus • Dry mucous membranes, furrowed tongue,  JVP • Chest: •  skin turgor at sternal angle • Axilla: dry or moist • Abdomen: • Tenderness, masses, hepatosplenomegaly, stigmata of chronic liver disease • Digital rectal exam: • Red blood? Melena? • Hemorrhoids, fissures • Masses

  20. GI BleedingShock

  21. GI BleedingManagement (Overview) • ABC’s • Resuscitation • Focused History and Physical Exam • Upper vs. lower GI bleed • Investigations • Treatment

  22. GI BleedingInitial Management • ABC’s • Resuscitation • Intravenous (IV) access • Monitoring • Need for monitored area ? (i.e. ICU) • Cardiac, respiratory (i.e pulse oximetry) • Volume re-expansion • IV fluids • Keep patient NPO (nil per os) • Focused history and physical exam • Upper vs. lower GI Bleed

  23. GI BleedingInvestigations (1) • Bloodwork • Type and crossmatch - PRBC’s, blood products • Complete Blood Cell Count • Hemoglobin • MCV – mean corpuscular volume • MCV  Fe deficiency  chronic blood loss? • Platelets • Clotting ability • Electrolytes

  24. GI BleedingInvestigations (2) • Blood Urea Nitrogen (BUN), Creatinine • Intravascular dehydration   renal perfusion   BUN, Cr • UGI bleed  blood digestion in stomach/duodenum  protein absorption  urea nitrogen • [BUN x 10]: Cr > 1.5:1  May suggest UGI bleed • Liver enzymes and liver function tests • INR - Coagulation status (i.e. INR) • Liver disease (i.e. cirrhosis) • Albumin • INR • AST > ALT •  Platelets, MCV • (Nasogastric aspirate)

  25. GI BleedingInitial Treatment (1) • Fluid Management • IV crystalloids (i.e. normal saline); colloids (i.e. volume expanders) • Transfusion - Packed red blood cells • Reverse anti-coagulation •  INR - Vitamin K, fresh frozen plasma, prothrombin complex concentrate (i.e. Octaplex) •  Platelets – Platelets transfusion

  26. GI BleedingInitial Treatment (2) • Pharmacotherapy • UGI Bleeds: • IV Proton Pump Inhibitor • Mechanism: pH > 6  Promotes clot stability • acid/pepsin on lesion • platelet aggregation + fibrin formation • Empirically started to treat possible PUD until EGD performed • IV PPI before endoscopy: • Lau et al. (2007):  need for endoscopic therapy + accelerated healing of ulcers • Cochrane Meta-analysis (Sreedharan et al., 2010): • DOESN’T: mortality, rebleeding or progression to surgery • DOES: high risk stigmata, need for endoscopic therapy • IV PPI after endoscopic therapy: rebleeding, mortality • Dose: Pantoprazole 80mg IV bolus, then 8mg/h x 72 hours

  27. GI BleedingInitial Treatment (3) • IV Somatostatin (i.e. octreotide) • For possible varicealbleeds (i.e. patients with cirrhosis) – started empirically • Mechanism: splanchnic vasoconstriction   portal hypertension   bleeding • Prokinetics (20 – 120 minutes before) • i.e. metoclopramide (Maxeran) or IV erythromycin • To clear UGI tract of blood for better visualization • Meta-analysis (Barkun et al., 2010): need for repeat endoscopy • LGI Bleeds: No specific medications

  28. Urgent vs. Non-urgent Management Urgent Non-urgent Young, healthy, minimal bleeding • Hematemesis • Serious co-morbid illness • Malignancy, cirrhosis • Hemodynamic instability • Shock • SBP < 100mmHg • HR > 100bpm • (Orthostatic hypotension) • Hb < 80 • Transfusion requirement > 2u PRBC’s • Severe, ongoing bleeding

  29. GI BleedingEndoscopy • UGI Bleed – EGD • Timing: Within 24 hours of presentation • To: • Diagnose cause of bleeding (high sensitivity/specificity) • Stratify risk of rebleeding/adverse events • Potentially treat underlying pathology • LGI Bleed – Colonoscopy • Timing: Controversial • Severe bleeds: Within 8 – 24 hours • Generally, LGI bleeds less severe than UGI bleeds • Often, more difficult to identify source; therefore, mostly diagnostic rather than therapeutic • Unclear: EGD  Colonoscopy

  30. Upper vs. Lower EndoscopyPresumed Upper GI Bleed Hematemesis EGD

  31. Upper vs. Lower EndoscopyPresumed Lower GI Bleed

  32. Upper vs. Lower EndoscopyMassive Rectal Bleeding

  33. Upper vs. Lower EndoscopyOccult Bleeding • Occult bleeding • Stool testing positive for occult blood • Unexplained Fe deficiency anemia

  34. GI BleedingEndoscopic Hemostasis (1) • Injection • i.e. Vasoconstrictors (i.e. epinephrine), saline, sclerosants, tissue adhesives • Creates submucosal cushion of fluid which tamponades site +/- vasoconstriction • Thermal therapy • i.e. Mono/bipolar electrocoagulation, Argon Plasma Coagulation (APC), Laser Photocoagulation • Cauterizes vessel closed

  35. GI BleedingEndoscopic Hemostasis (2) • Mechanical therapy • i.e. Hemoclips, rubber bands • Closes and tamponadesvessel • Animation • http://www.youtube.com/watch?v=59uO-8UVC2A • Hemospray • New therapy • Nano particle spray

  36. UGI BleedingPeptic Ulcer Disease (1) • Most commonly due to NSAIDS, H. Pylori • 75 – 80% stop spontaneously • Ulcer appearance indicates risk of rebleedingand determines whether therapy required • Forrest Classification

  37. UGI BleedingPeptic Ulcer Disease (2) • Endoscopic intervention: • Risk of rebleeding • Need for surgery • Mortality

  38. UGI BleedingVarices • Often unstable UGI bleeds • Esophageal – Options: • Ligated with rubber bands (band ligation) • Injection with sclerosants • Gastric – Options: • Injected with ‘glue’ (cyanoacrylate) • Band Ligation • If endoscopy unsuccessful: • Transjugular intrahepatic portosystemic shunt (TIPS) • Liver transplant

  39. LGI BleedingDiverticular Bleeding • Complicates 3 – 15% with colonic diverticulae • Pathophysiology: • Trauma of vasa recta at neck or dome of diverticulum • Presentation: • Painless hematochezia • Treatment: • 75 - 80% resolve spontaneously • Recurrence within 4 years • 25 – 40% • Endoscopic hemostasis • If site can be identified • < 30d rebleeding: Uncommon • Angiography (85% effective) • < 30d rebleeding: 22% • Surgical resection

  40. LGI BleedingAngiodysplasia • Increases with age • Pathophysiology • Degenerative changes • Chronic, intermittent obstruction of submucosal vessels • Presentation • Usually asymptomatic • Overt or occult bleeding • Usually in right colon • Treatment • Iron replacement • Cauterization if bleeding or Fe deficiency anemia • (Estrogen/progesterone)

  41. GI BleedingOther Options (1) • If endoscopy fails to identify source or fails to stop the bleeding • Mesenteric angiography • Performed by interventional radiology • Catheter introduced through femoral artery, passed to celiac trunk, SMA, IMA + branches to: • Diagnose bleeding site • Requires blood loss of ≥ 0.5-1mL/min • Low sensitivity (47%) but high specificity (100%) • Perform therapy • Feeding arteries can be embolized with microscopic gel foam, microcoilsor EtOH particles • Success rate: 52 – 94% • http://www.youtube.com/watch?v=jvi2WwvXIew • Complications (17%): Nephrotoxicity, bowel infarction, hematomas

  42. GI BleedingOther Options (2) • RBC scan • Patient infused with technetium tagged RBC’s to locate site of bleeding • Disadvantages: • Not therapeutic • Only localizes bleeding to generalized area of abdomen • Requires blood loss ≥ 0.1mL/min • Higher sensitivity; lower specificity • Surgery • Intraoperative enteroscopy • Oversew, resection

  43. Summary (1) Upper GI Bleed Lower GI Bleed Dark/bright red blood per rectum (hematochezia) Longer course Tend to be more hemodynamically stable • Hematemesis • Melena • Hemodynamic instability • Elevated BUN x 10: Cr

  44. Summary (2) • PUD is most common cause of UGIB bleeding • Diverticular disease is the most common cause of significant LGIB • Approach includes • ABC’s • Resuscitation • History and Physical Exam • Initial Investigations • Initial Treatment • Endoscopy • Radiology • Surgery • IV PPI’s are started empirically if UGIB is suspected • Endoscopy is the primary diagnostic and therapeutic tool for GI bleeds

  45. Questions?

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