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GI Hemorrhage

GI Hemorrhage. November 14, 2014 David Hughes. Incidence. 1-2% of all hospital admissions Most common diagnosis of new ICU admits 5-12% mortality 40% for recurrent bleeders 85% stop sponateously Those with massive bleeding need urgent intervention

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GI Hemorrhage

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  1. GI Hemorrhage November 14, 2014 David Hughes

  2. Incidence • 1-2% of all hospital admissions • Most common diagnosis of new ICU admits • 5-12% mortality • 40% for recurrent bleeders • 85% stop sponateously • Those with massive bleeding need urgent intervention • Only 5-10% need operative intervention after endoscopic interventions

  3. Site • Upper • Esophageal • Stomach • Doudenum • Hepatic • Pancreatic • Lower • Small bowel • Colon • Anus

  4. Etiology • 85% are due to: • Peptic ulcer disease • Variceal hemorrhage • Colonic diverticulosis • Angiodysplasia

  5. Chain of events • Recognize severity • Establish access for resusitation • Resusitate • Identify source • Intervention

  6. Question #1 • JB a 30 y/o with hematemesis presents with orthostatic hypotension, clammy hands, but without tachycardia. How much blood has he lost? • >40% • 20-40% • 10-20% • <10%

  7. Question #1 • JB a 30 y/o with hematemesis presents with orthostatic hypotension, clammy hands, but without tachycardia. How much blood has he lost? b) 20-40%

  8. Upper GI hemorrhage • How do you know its upper? • 85% of all GI hemorrhage is upper • Hematemesis diagnostic • Don’t forget about nasal bleeding as possible source • Melena • Degradation of hemoglobin to hematin by acid • Bowel bacteria and digestive enzymes also contribute • Hematochezia • 10% of patients with very rapid UGI source

  9. Gastric varices

  10. Gastric varices Esophageal Varices

  11. Gastric varices Bleeding ulcers Esophageal Varices

  12. Gastritis

  13. Gastritis Dieulafoy’s lesion

  14. Mallory-weiss

  15. Watermelon stomach

  16. Upper GI hemorrhage • Etiology • Peptic ulcer disease - 50% • Varices – 10-20% • Gastritis – 10-25% • Mallory-weiss – 8-10% • Esophagitis – 3-5% • Malignancy – 3% • Dieulafoy’s lesion – 1-3% • Watermelon stomach – 1-2%

  17. Upper GI hemorrhage • Crampy abdominal pain common • Large caliber NGT • Coffee grounds or gross blood • No blood • Can be used for lavage prior to endoscopy • Upper endoscopy indications • Melena or hematochezia with hypotension • Hematemesis • NGT with guiac positive fluid • Should be completed in 24hrs for stable patients

  18. Peptic ulcer hemorrhage • Peptic ulcer disease • 20% of patients bleed at least once • Most lethal complication • Vessel is usually <1mm diameter • Causes • H. pylori 40-50% • NSAID’s 40-50% • Other (Z-E syndrome)

  19. Peptic ulcer hemorrhage • Predictors of mortality • Renal disease 29%  • Acute renal failure 63% • Liver disease 25%  • Jaundice 42% • Pulmonary disease 23%  • Respiratory failure 57% • Cardiac disease 13%  • Congestive heart failure 28%

  20. Peptic ulcer hemorrhage • Medical management • Anti-ulcer medication • H. pylori treatment • Stop NSAIDs • Follow up EGD for gastric ulcer in 6 weeks

  21. Peptic ulcer hemorrhage • Endoscopic interventions • Thermal coagulation • Injected agents • Success rate • 95% initailly • 80% will not rebleed • Repeat treatment after 1st rebleed salvages 50% • Increased risk of mortality

  22. Peptic ulcer hemorrhage • Surgical intervention • Only 10% of patients • Indications • Failure of endoscopy • Significant rebleeding after 1st endoscopy • Ongoing transfusion requirement • Need for >6 units over 24 hours • Earlier for elderly, multiple co-morbidities

  23. Peptic ulcer hemorrhage • Anti-secretory surgery?? • Indicated for NSAID pts who need to continued meds • H. pylori ulcer disease controversial • Only 0.2% of pts every require surgery for bleeding ulcer • Surgery pts had lower than average H. pylori positivity • Oversewing and antibiotics still leave 50% at high risk for rebleeding • Bottom line: still recommended but without definitive evidence

  24. Peptic ulcer hemorrhage • Doudenal ulcer • Expose ulcer with duodenotomy or duodenopyloromyotomy • Direct suture ligation, four quadrent ligation, ligation of gastroduodenal artery • Anti-secretory procedure • Truncal, parietal cell vagotomy • If unstable can use meds

  25. Peptic ulcer hemorrhage • Gastric ulcer • 10% are maliganant • 30% will rebleed with simple ligation • Need Resection • Distal gastrectomy with Bilroth I or II • Subtotal gastrectomy for 10% high on lesser curve

  26. Variceal hemorrhage • Cirrhotics usually • 25% mortality for each bleeding episode • 75% will rebleed • 50% mortality with surgery • Based on Child’s class

  27. Somatostatin or vasopressin w/wo NTG

  28. TIPS Shunt procedures Sugiura procedure

  29. Other sources of UGI hemorrhage • Mucosal lesions • Gastritis, ischemia, stress ulceration • Key is prevention with acid supression • Surgery often requires resection and Roux-en-Y due to multiple bleeding sites • >50% mortality with surgery • Mallory-Weiss • 10% will have significant bleeding • 90% stop spontaneously • Surgery rare, but gastrotomy with oversewing effective • Dieulafoy’s • Wedge rxn after endoscopic marking • Aortoenteric fistula • 1% of AAA repair patients • Herald bleed preceeds exsangunation by hours to days • Endoscopy and if negative CT scan and if negative angiography • Surgery – graft removal and extraanatomic bypass

  30. LGI hemorrhage • Sites • Colon – 95-97% • Small bowel – 3-5% • Only 15% of massive GI bleeding • Finding the site • Intermittent bleeding common • Up to 42% have multiple sites

  31. Bleeding diverticulosis

  32. Colonic angiodysplasia Bleeding diverticulosis

  33. LGI hemorrhage • Etiology • Diverticulosis – 40-55% • Right sided lesions > left • 90% stop spontaneously • 10% rebleed in 1st year and 25% at 4 years • Angiodysplasia – 3-20% • Most common cause of SB bleeding in >50 y/o • >50% are in right colon • Neoplasia • Typically bleed slowly • Inflammatory conditions • 15% of UC patients, 1% of chron’s patients • Radiation, infectious, AIDS rarely • Vascular • Hemorrhoids • >50% have hemorrhoids, but only 2% of bleeding attributed to them • Others

  34. LGI hemorrhage • Evaluation • Same for UGI bleed • If unstable with hematochezia need EGD 1st • After stable • Rectal • Anoscopy for hemorrhoids

  35. LGI hemorrhage diagnostics • Colonoscopy • Within 12 hours in stable patients without large amounts of bleeding • Selective viseral angiography • Need >0.5 ml/min bleeding • 40-75% sensitive if bleeding at time of exam • Tagged RBC scan • Can detect bleeding at 0.1 ml/min • 85% sensitive if bleeding at time of exam • Not accurate in defining left vs right colon

  36. Meckel’s Diverticulum Cecal angiodysplasia with extravasation Small bowel ulceration due to NSAIDS

  37. LGI hemorrhage treatment • Endoscopy • Great for angiodysplasia and polypectomy sites • Angiographic • Selective embolization for poor surgical candidates • Can lead to ischemic sites requiring later resection • Surgery • Ongoing hemorrhage, >6 units or ongoing transfusion requirement • Site selection • Blind segmental will rebleed in 75% • Based on TRBC scan will rebleed in 35%

  38. GI hemorrhage from unknown source • Only 2-5% are not upper or lower • Average patient • 26 month duration of intermittent bleeding • 1-20 diagnostic tests • Average of 20 units transfused

  39. Localization of GIHOUS • CT scan • Tumors, inflammation, diverticuli • Enteroclysis • Ulcerations, inflammation • Only 10-20% yeild (SBFT is 0-6%) • Meckel’s scan • Initial test for patients <30 years old • Endoscopy • Push or pull endoscopy • Video capsule endoscopy • Intraoperative endoscopy – 70% successful

  40. Etiology of GIHOUS • Arteriovenous malformation 40 • Small bowel leiomyoma 11 • Small bowel adenocarcinoma 7 • Small bowel lymphoma 6 • Crohn’s disease 6 • “Watermelon” stomach 4 • Meckel’s diverticulum 4 • Small bowel leiomyosarcoma 3 • Metastatic colon carcinoma to small bowel 3 • Small bowel varices 3 • Small bowel melanoma 3 • Others 10 Szold A, Katz L, Lewis B: Surgical approach to occult gastrointestinal bleeding. Am J Surg 163:90–93, 1992.

  41. Treatment • Surgery • Without localization only for acute exsanguinating hemorrhage • Intraoperative endoscopy • Segmental resection

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