Approach

to
GIT bleeding
Ben Jugmohan
19 November 2017
 Outline
• Introduction
• Definitions
• Differential diagnoses and Outcomes
• The 3 O’s
• Queries
• Summary
 Not covered
• Anatomy
• Physiology
• How to resuscitate
 Introduction
• Common problem in all settings
• Potentially fatal
• Frequently managed on an out-patient basis
• Prompt resuscitation, risk evaluation, provisional diagnosis and
further investigation
 Definitions

• Traditional
• Upper GI
• Lower GI
• Newer anatomical definitions
• Upper
• Mid
• Ampulla of Vater to ileo-caecal
valve
• Lower
 Definitions
• Overt
• Haematemesis, melaena
• haematochezia
• Occult
• Fe deficiency anaemia
• Positive stool occult blood
• Obscure
• No obvious cause after standard investigation
• Usually warrants investigation of the small bowel
 Differential Diagnosis – Upper GIB
• Peptic ulcer disease Most
• Gastroesophageal varices common
• Erosive esophagitis/gastritis/duodenitis
• Mallory Weiss tear
• Vascular ectasia
• Neoplasm
• Dieulafoy’s lesion Rare, but cannot
• Aortoenteric fistula afford to miss

• Hemobilia, hemosuccus pancreaticus

Outcome of Acute G I Bleeding
Influence of Diagnosis on Outcome
 Lower GI Bleed
• Differential Diagnosis
- Diverticulosis (# 1 cause) Large volume, painless
- Angioectasias
- Hemorrhoids
- Colitis (IBD, Infectious, Ischemic) Smaller volume, pain,
diarrhea
- Neoplasm
- Post-polypectomy
- Dieulafoy’s lesion
Overt GI Bleeding
 Approach to Overt GI bleeding
• Resuscitation
 Early Intensive Resuscitation
Reduces Mortality

Intervention: Faster correction of

hemodynamics, Hct and coags.
Time to endoscopy similar

(groups are essentially the same) Am J Gastroenterol

2004;99:619
 Early Intensive Resuscitation
Reduces Mortality
• Observation
group
– 5 MI
– 4 deaths
• Intense group
– 2 MI
– 1 death (sepsis)

Am J Gastroenterol
2004;99:619
 Initial Assessment
• Always remember to assess A,B,C’s
• Assess degree of hypovolemic shock

Class I Class II Class III Class IV

Blood loss (mL) 750 750-1500 1500-2000 >2000
Blood volume < 15% 15-30% 30-40% >40%
loss (%)
Heart rate <100 >100 >120 >140
SBP No change Orthostatic Reduced Very low,
change supine
Urine output >30 20-30 10-20 <10
(mL/hr)
Mental status Alert Anxious Aggressive/dro Confused/unco
wsy nscious
 Approach to Overt GI bleeding
• Resuscitation
• ? Transfusion
 Transfusion Strategies for Acute Upper
Gastrointestinal Bleeding
NEJM, January 2013

• 921 pts
• Liberal (9g/dl) vs restrictive (7g/dl)
• Haemodynamically stable
• 6 week survival, rebleeding rates, other adverse outcomes
• Better outcomes for restrictive strategey
 Approach to Overt GI bleeding
• Resuscitation
• ? Transfusion
• How and when to investigate ?
 Non-responder
• Transfer to theatre
• Senior personnel
• Endoscopy and all adjuncts
• Be prepared to operate
 Responder
• Upper GI
• Variceal
• Gastroscopy within 12 hours
• Non-variceal
• Gastroscopy within 24 hours
• Lower GI
• Gastroscopy within 24 hours
• Colonoscopy and/ or radiological imaging
 Approach to Overt GI bleeding
• Resuscitation
• ? Transfusion
• How and when to investigate ?
• Therapy
 Non-variceal UGIB
• PUD/ Gastritis/ MW
• PPI
• NPO
• ?NGT
• Bloods
• Stratify
• Endoscopy
• Re-stratify
 Rockall Scoring System
• Validated predictor of mortality in patients with UGIB
• 2 components: clinical + endoscopic

Variable 0 1 2 3

Age <60 60-79 ≥ 80

Shock No Tachy- Hypotension-

SBP ≥ 100 SBP ≥ 100 SBP <100
P<100 P>100
Comorbidity No major Cardiac Renal failure,
failure, CAD, liver failure,
other major malignancy

Gut 1996;38:316
Clinical Rockall Score – Mortality Rates
60%

50%

40%

30%

20%

10%

0%
0 1 2 3 4 5 6 7
 AIMS65
• Simple risk score that predicts in-hospital mortality, LOS, cost in
patients with acute UGIB

lbumin <3.0
NR > 1.5
ental status altered
ystolic BP <90
+ years old
Gastrointest Endosc 2011;74:1215
AIMS65

Gastrointest Endosc
2011;74:1215
 Blatchford Score

• Predicts need for

endoscopic
therapy
• Based on readily
available clinical
and lab data

Lancet
2000;356:1318
 Forrest Classification
Endoscopic Observation Rebleeding Chance %

Ia Spurting Arterial bleed 80-90

Ib Oozing bleed 10-30
IIa Non-bleeding visible vessel 50-60
IIb Adherent clot 20-35
IIc Black hematin ulcer base 0-8
III Clean ulcer base 0-12
Stigmata of Recent Haemorrhage -
Prevalence
 Prognostic factors: endoscopic

Incidence of rebleeding by appearance

of ulcer at endoscopy
80%
% of patients rebleeding

60%

40% 55
43
20%
22
0% 5 10
Clean base Flat spot Adherent Nonbleeding Active
clot visible vessel bleeding

Laine & Peterson; 1994

 When is Endoscopic Therapy
Required?
• ~80% bleeds spontaneously resolve
• Endoscopic stigmata of recent hemorrhage

Stigmata Continued/rebleeding rate

Active bleeding 55-90%
major
Nonbleeding visible vessel 40-50%

Adherent clot Variable, depending on

underlying lesion: 0-35%

Flat pigmented spot 7-10%

Clean base < 5%

 Adherent Clot
• Role of endoscopic therapy of
ulcers with adherent clot is
controversial
• Clot removal usually attempted
• Underlying lesion can then be
assessed, treated if necessary
 Minor Stigmata

Flat pigmented spot Clean base

Low rebleeding risk – no endoscopic therapy

needed
 Variceal Bleeding
• Occurs in 1/3 of patients with cirrhosis
• 1/3 initial bleeding episodes are fatal
• Among survivors, 1/3 will rebleed within 6 weeks
• Only 1/3 will survive
1 year or more
 Treatment of Oesophageal Varices
• Options
• Pharmacological
• B-blockers, Nitrates
• Endoscopic
• Banding, injection sclerotherapy
• Categories
• Pre-primary
• never
• Primary
• Occasionally – single modality
• Secondary
• Always - dual
 Variceal Bleed – acute management
• Resuscitate
• Ideal hb 8 – 9
• Antibiotics – Rocephin or Norfloxacin
• Vasopressor – Terlipressin or Octreotide x 72 hours
• PPI
• Endoscopy within 12 hours
• Treat Liver failure if decompensated – lactulose, oral antibiotics
• Start beta-blockade once stable – Carvedilol > Propanolol
 Alternative/Rescue therapies
Sengstaken-Blakemore Tube
• Very effective for
immediate, temporary
control
• High complication rate –
aspiration, migration,
necrosis + perforation of
esophagus
• Use as bridge to TIPS
within 24 hours
• Airway protection
strongly recommended
 Alternative/Rescue therapies

Self-Expanding Metal Stent • Specially designed

covered metal stent
• Tamponades distal
esophageal varices
• Removable; does not
require airway
protection
• Very limited data

Gastrointest Endosc 2010;71:71

 Alternative/Rescue therapies
• TIPS – Transjugular Intrahepatic
Portosystemic Shunt
• Early placement of shunt
(within 24-72hrs) associated
with improved survival among
high-risk patients
• Preferred treatment for gastric
variceal bleeding (rule out
splenic vein thrombosis first)

Hepatology 2004;40:793 Fan, C. (Apr 25 2006). Vascular Interventions in the

Abdomen: New Devices and Applications. The DAVE
Hepatology 2008;48:Suppl:373A
Project. Retrieved Aug, 2, 2010, from
N Engl J Med. 2010 Jun 24;362:2370 http://daveproject.org/viewfilms.cfm?film_id=497
 Lower GI Bleed
• As for non-variceal upper GI bleed
• Gastroscopy within 24 hours
• Next step is debatable
• Traditional
• Out-patient colonoscopy
• Newer approach
• Early colonoscopy
 Urgent Colonoscopy – RCT#1
Definite bleeding source identified
more frequently (42% vs 22%)

But no significant difference in important

outcomes (but underpowered)

Am J Gastroenterol 2005;100:2395
 Urgent Colonoscopy – RCT#2
• 85 patients with serious hematochezia (hemodynamically significant,
Hgb drop > 1.5 g/dL, blood transfusion)
• EGD performed within 6 hours
• If EGD negative, randomized to urgent (<12 hr) or elective (36-60 hr)
colonoscopy
• Primary endpoint = further bleeding
• No evidence of improved outcomes

Am J Gastroenterol 2010;105:2636
 Radiographic Studies
Multi-Detector CT (CT angio)
• Readily available, can be
performed in ER within 10
minutes
• Can detect bleeding rate of 0.5
ml/min
• Can localize site of bleeding (must
be active) and provide info on
etiology
• Useful in the actively bleeding but
hemodynamically stable patient
Gastrointest Endosc 2010;72:402
 Occult bleeding

• Upper and lower endoscopy

• Treat as necessary
 Obscure Bleeding
• Imaging of the small bowel
• Capsule endoscopy
• Small bowel enteroscopy
Queries
Thank You

benjugmohan@gmail.com
076 371 5120