Acute GI Bleeding

Louis Chaptini MD

Forms of GI Bleeding

Upper Lower Occult Obscure

Acute GI bleeding

300,000 hospitalizations/year Mortality rate:

3.5%-7% with UGI bleed 3.6% with LGI bleed

Acute GI bleeding
Historical Features Important in Assessing the Etiology of Gastrointestinal Bleeding Age Prior bleeding Previous gastrointestinal disease Previous surgery Underlying medical disorder (especially liver disease) Nonsteroidal anti-inflammatory drugs/aspirin Abdominal pain Change in bowel habits Weight loss/anorexia History of oropharyngeal disease

Patient Assessment

Determine the urgency

Signs of shock

Tachy, sometimes brady, hypotension.. Shock occurs if 40% of blood volume is lost Decrease 10mm in SBP, 20% loss of blood volume

Orthostatic hypotension

Management

Large bore IV lines Blood work

ht Plt Coag factors Type and cross (Liver enzymes)

Management of UGI bleeidng

Resuscitation

The decision to transfuse should not depend on ht (it takes 24 to 48 hrs to equilibrate) Hematemesis, bloody NG lavage, hematochezia should be taken into consideration

Resuscitation

Location

UGI bleeding is defined as bleeding above the ________________ In the absence of hematemesis, what elements indicate UGI bleeding?

________ ________ ________

Location

UGI bleeding is defined as bleeding above the ligament of Treitz In the absence of hematemesis, what elements indicate UGI bleeding?

Melena High BUN Positive NG lavage

Hematochezia indicates LGI source

Location

How much blood do you need to have melena? _______ Can melena be indicative of bleeding below the ligament of Treitz?

______ ______

What is the significance of NG lavage?

Location

How much blood do you need to have melena? 100-200 ml Can melena be indicative of bleeding below the ligament of Treitz?

Small bowel Proximal colon If bloodyUGIB, If not still can be UGIB

What is the significance of NG lavage?

Prognosis
Adverse Prognostic Variables in Acute UGIB Increasing age Increasing number of comorbid conditions Cause of bleeding (variceal bleeding > others) Red blood in the emesis and/or stool Shock or hypotension on presentation Increasing numbers of units of blood transfused Active bleeding at the time of endoscopy Bleeding from large (>2.0 cm) ulcers Onset of bleeding in the hospital Emergency surgery

Causes

Of these diagnoses, which one is the most common cause of UGI bleed?

Dieulafoys Mallory Weiss Tear AVM cancer

Causes

Of these diagnoses, which one is the most common cause of UGI bleed?

Mallory Weiss Tear

Causes

Of these diagnoses, which one is the most common cause of UGI bleed?

Duodenal Ulcer GAVE Gastritis esophagitis

Causes

Of these diagnoses, which one is the most common cause of UGI bleed?

Duodenal Ulcer

Causes of acute UGIB

Common Causes Gastric ulcer Duodenal ulcer Esophageal varices

Mallory-Weiss tear

Causes of acute UGIB

Less Frequent Causes

Dieulafoys lesions Vascular ectasia Portal hypertensive gastropathy Gastric antral vascular ectasia Gastric varices Neoplasia Esophagitis Gastric erosions

Causes of acute UGIB

Rare Causes Esophageal ulcer Erosive duodenitis Aortoenteric fistula Hemobilia Pancreatic source Crohns disease

No lesion identified

Esophagitis

8 % of UGI Bleeding Usually cause of occult bleeding unless the disease is extensive or coag problems Treatment: antisecretory agents

Case

33 y/o male admitted with DKA, started vomiting blood.

What other elements in the history might help? What is the most likely diagnosis?

Mallory Weiss Tear

5-10% of UGI Bleeding Usually laceration of gastric mucosa Mechanism: retching Stops spontaneously in 80-90% of the cases

Portal Hypertension Related causes of bleeding

Several lesions:

Esophageal varices Gastric varices Portal hypertensive gastropathy

10% of UGI bleeding

Portal Hypertension

Usually hemodynamic instability in esophageal varices v/s Low volume occult bleeding in the case of hypertensive gastropathy

Ulcers

Most common cause of UGI bleeding Ulcers erode in the lateral wall of a vessel Ulcers located in high in the lesser curvature and in the posterior wall of duodenal bulb are most likely to bleed (and rebleed)

Predisposing factors for bleeding

Acid H.pylori NSAID Also, chronic pulmonary disease, cirrhosis, cardivascular and cerebrovascular diseases are associated with PUD

Predisposing factors for bleeding

Drugs other NSAIDs and ASA

Alendronate Steroids (only with NSAIDs) Ethanol (can potentiate the damage caused by NSAID) Anticoagulants (facilitate bleeding)

Predisposing factors for bleeding

ASA and NSAIDs

Decrease prostaglandins, platelet dysfunction The risk of bleeding varies with individual NSAID and is dose dependent The risk of gastric ulceration is greater than duodenal ulceration Multiple cofactors contribute to NSAID risk

Age Previous GI bleeding Hx of PUD Hx of heart disease

Management of bleeding ulcers

Gastric Erosions

Gastritis is a histological diagnosis Hemorrhagic gastritis and erosive gastritis are dg on EGD Causes of subepithelial erosions NSAID Stress related medical illness Ethanol? In stress related med illness ranitidine has been shown to be effective Ethanol as a cause of gastric erosions is controversial

Duodenitis

Risk factors similar to PUD Rare cause of acute bleeding

Neoplasms

Usually are associated with occult bleeding The most frequent in the case of UGIB is gastric adenocarcinoma

Dieulafoys lesion

Abnormally large artery approaching the mucosa 6% of cases of UGI Bleeding Usually in proximal portion of stomach, 6cm from the GE junction EUS may be used for detection

Case

67 y/o male with renal failure and hx of recurrent gi bleed, on estrogen for prevention of bleeding, presents for hematemesis.

Whats your diagnosis?

Vascular lesions

Vascular ectasia

Seen in CREST, Ehler Danlos, von willebrand disease, renal failure, cirrhosis Usually cause occult bleeding or LGI bleeding Hormonal therapy controversial rare

AVM

Case

Patient with hx of epistaxis, presents for hematemesis. His mother had the same problem. On exam he has telangiectasia on his skin.

Whats your diagnosis?

Vascular lesions

HHT (osler-rendu-weber disease)

Autosomal dominant disease characterized by telangiectasia of the skin, mucous membranes and GI tract Epistaxis most common manifestation of the disease Estrogen and progesterone showed mixed results

Vascular lesions

Hemangiomas

Usually upper small intestine Blue rubber nevus

Hemangiomas in skin, gi tract and other viscera

Gastric vascular ectasia

Aggregates of red spots, when linear in the antrum GAVE (water melon stomach) Difficult to differentiate from portal hypert gastropathy TRT: endoscopy, ethinyl estradiol

Acute Lower GI Bleeding

Important historical information

Age HIV NSAID Abd pain Radiation Change in bowel habits

Management of LGI Bleeding

Colonoscopy

Urgent colonoscopy (after prep)

Probably the best diagnostic test Frequently leads to diagnosis Possibility of treatment

Tagged RBC scintigraphy and Angiograohy

RBC scan

Controversial Detects bleeding of ________ ml/min ?helpful before surgery _______ ml/min Accurate localization Complications: arterial thrombosis

Angiography

Tagged RBC scintigraphy and Angiograohy

RBC scan

Controversial Detects bleeding of 0.1 to 0.5 ml/min ?helpful before surgery 0.5 to 1 ml/min Accurate localization Complications: arterial thrombosis

Angiography

Causes

Of these diagnoses, which one is the most common cause of LGI bleed?

IBD Hemorrhoids AVM Radiation colitis

Causes

Of these diagnoses, which one is the most common cause of LGI bleed?

AVM

Causes

Of these diagnoses, which one is the most common cause of LGI bleed?

Rectal ulcer Diverticulosis Neoplasia Rectal varices

Causes

Of these diagnoses, which one is the most common cause of LGI bleed?

Diverticulosis

Causes
Common causes Diverticula Vascular ectasia

Causes
Uncommon causes Neoplasia (including postpolypectomy) Inflammatory bowel disease Colitis Ischemic Radiation Unspecified Hemorrhoids Small bowel source Upper gastrointestinal source No lesion identified

Causes
Rare causes Dieulafoys lesions Colonic ulcerations Rectal varices

Diverticulosis

Acute painless hematochezia In 10 to 40% the bleeding recurs Surgery should be considered if recurrence occurs

Vascular ectasia

Common cause of acute, chronic and occult LGI bleeding Most common in R colon Common in renal failure patients Association with aortic valve disease is questionable Trt: therapeutic endoscopy (risk of perforation)

Neoplasia

Uncommon cause of acute bleeding History of intermittent hematochezia, change in caliber of stools, evidence of chronic bleeding suggest this diagnosis Post polypectomy bleeding can occur up to 3 weeks after polypectomy

Hemorrhoids

Extremely common 5 to 10% of LGI bleeding Usually history of blood o the toilet tissue, not mixed with stools, straining Even when present, work-up with colonoscopy should be pursued especially in elderly patients

Meckels diverticulum

Terminal 100cm of ileum Gastric mucosa secreting acid and causing ulceration of adjacent mucosa Usually in children and young adults

Colitis

IBD

Most common Salmonella, Shigella, E.Coli, C.Diff

Infectious colitis

Radiation Ischemia

Sudden, crampy abdominal pain with bleeding

Take home message

Acute GI bleeding is a life threatening condition that needs immediate care History is key in determining the diagnosis and initiating treatment before endoscopy Emergent EGD is diagnostic and therapeutic in the setting of UGI bleed Colonoscopy is probably the best test for LGI bleed Ulcers, MWT and varices are the most common causes of UGIB Diverticulosis and vascular ectasia are the most common causes in LGIB