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Acute GI Bleeding

Louis Chaptini MD

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Forms of GI Bleeding Upper

Lower

Occult

Obscure

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Acute GI bleeding 300,000 hospitalizations/year

Mortality rate:

3.5%-7% with UGI bleed

3.6% with LGI bleed

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Historical Features Important in Assessing the Etiology of

Gastrointestinal Bleeding

Age

Prior bleedingPrevious 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

Acute GI bleeding

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Patient Assessment Determine the urgency

Signs of shock

Tachy, sometimes brady, hypotension..

Shock occurs if 40% of blood volume is lost

Orthostatic hypotension

Decrease 10mm in SBP, 20% loss of bloodvolume

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Management Large bore IV lines

Blood work

ht

Plt

Coag factors

Type and cross

(Liver enzymes)

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Management of UGI bleeidng

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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

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Resuscitation

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Location UGI bleeding is defined as bleeding

above the ________________

In the absence of hematemesis, whatelements indicate UGI bleeding?

________

________

________

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Location UGI bleeding is defined as bleeding

above the ligament of Treitz

In the absence of hematemesis, whatelements indicate UGI bleeding? Melena

High BUN Positive NG lavage

Hematochezia indicates LGI source

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Location How much blood do you need to have

melena? _______

Can melena be indicative of bleedingbelow the ligament of Treitz?

______

______

What is the significance of NG lavage?

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Location How much blood do you need to have

melena? 100-200 ml

Can melena be indicative of bleedingbelow the ligament of Treitz? Small bowel

Proximal colon What is the significance of NG lavage?

If bloodyUGIB, If not still can be UGIB

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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

Prognosis

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Causes Of these diagnoses, which one is the

most common cause of UGI bleed?

Dieulafoys

Mallory Weiss Tear

AVM

cancer

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Causes Of these diagnoses, which one is the

most common cause of UGI bleed?

Mallory Weiss Tear

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Causes Of these diagnoses, which one is the

most common cause of UGI bleed?

Duodenal Ulcer

GAVE

Gastritis

esophagitis

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Causes Of these diagnoses, which one is the

most common cause of UGI bleed?

Duodenal Ulcer

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Common Causes

Gastric ulcer

Duodenal ulcer

Esophageal varices

Mallory-Weiss tear

Causes of acute UGIB

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Less Frequent Causes

Dieulafoys lesions

Vascular ectasiaPortal hypertensive gastropathy

Gastric antral vascular ectasia

Gastric varices

Neoplasia

Esophagitis

Gastric erosions

Causes of acute UGIB

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Rare Causes

Esophageal ulcer

Erosive duodenitis

Aortoenteric fistula

Hemobilia

Pancreatic sourceCrohns disease

No lesion identified

Causes of acute UGIB

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Esophagitis 8 % of UGI Bleeding

Usually cause of occult bleeding unless

the disease is extensive or coagproblems

Treatment: antisecretory agents

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Case 33 y/o male admitted with DKA, started

vomiting blood.

What other elements in the history mighthelp?

What is the most likely diagnosis?

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Mallory Weiss Tear 5-10% of UGI Bleeding

Usually laceration of gastric mucosa

Mechanism: retching

Stops spontaneously in 80-90% of thecases

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Portal Hypertension Related causes

of bleeding

Several lesions:

Esophageal varices Gastric varices

Portal hypertensive gastropathy

10% of UGI bleeding

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Portal Hypertension Usually hemodynamic instability in

esophageal varices

v/s

Low volume occult bleeding in the caseof hypertensive gastropathy

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Ulcers Most common cause of UGI bleeding

Ulcers erode in the lateral wall of a

vessel

Ulcers located in high in the lessercurvature and in the posterior wall of

duodenal bulb are most likely to bleed(and rebleed)

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Predisposing factors for bleedingAcid

H.pylori

NSAID

Also, chronic pulmonary disease,cirrhosis, cardivascular andcerebrovascular diseases are associatedwith PUD

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Predisposing factors for bleeding Drugs other NSAIDs and ASA

Alendronate

Steroids (only with NSAIDs)

Ethanol (can potentiate the damagecaused by NSAID)

Anticoagulants (facilitate bleeding)

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Predisposing factors for bleeding ASA and NSAIDs

Decrease prostaglandins, platelet dysfunction

The risk of bleeding varies with individual NSAIDand is dose dependent

The risk of gastric ulceration is greater thanduodenal ulceration

Multiple cofactors contribute to NSAID risk Age Previous GI bleeding

Hx of PUD

Hx of heart disease

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Management of bleeding ulcers

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Gastric Erosions Gastritis is a histological diagnosis

Hemorrhagic gastritis and erosive gastritis are dg onEGD

Causes of subepithelial erosions NSAID

Stress related medical illness

Ethanol?

In stress related med illness ranitidine has beenshown to be effective

Ethanol as a cause of gastric erosions is controversial

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Duodenitis Risk factors similar to PUD

Rare cause of acute bleeding

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Neoplasms Usually are associated with occult

bleeding

The most frequent in the case of UGIBis gastric adenocarcinoma

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Dieulafoys lesionAbnormally 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

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Case 67 y/o male with renal failure and hx of

recurrent gi bleed, on estrogen for

prevention of bleeding, presents forhematemesis.

Whats your diagnosis?

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Vascular lesionsVascular ectasia

Seen in CREST, Ehler Danlos, von

willebrand disease, renal failure, cirrhosis Usually cause occult bleeding or LGI

bleeding

Hormonal therapy controversialAVM

rare

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Case Patient with hx of epistaxis, presents for

hematemesis. His mother had the same

problem. On exam he has telangiectasiaon his skin.

Whats your diagnosis?

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Vascular lesions HHT (osler-rendu-weber disease)

Autosomal dominant disease characterized

by telangiectasia of the skin, mucousmembranes and GI tract

Epistaxis most common manifestation ofthe disease

Estrogen and progesterone showed mixedresults

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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 hypertgastropathy

TRT: endoscopy, ethinyl estradiol

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Acute Lower GI Bleeding Important historical information

Age

HIV

NSAID

Abd pain

Radiation Change in bowel habits

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Management of LGI Bleeding

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Colonoscopy Urgent colonoscopy (after prep)

Probably the best diagnostic test

Frequently leads to diagnosis

Possibility of treatment

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Tagged RBC scintigraphy and

Angiograohy RBC scan

Controversial

Detects bleeding of ________ ml/min ?helpful before surgery

Angiography

_______ ml/minAccurate localization

Complications: arterial thrombosis

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Tagged RBC scintigraphy and

Angiograohy RBC scan

Controversial

Detects bleeding of 0.1 to 0.5 ml/min ?helpful before surgery

Angiography

0.5 to 1 ml/minAccurate localization

Complications: arterial thrombosis

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Causes Of these diagnoses, which one is the

most common cause of LGI bleed?

IBD Hemorrhoids

AVM

Radiation colitis

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Causes Of these diagnoses, which one is the

most common cause of LGI bleed?

AVM

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Causes Of these diagnoses, which one is the

most common cause of LGI bleed?

Rectal ulcer Diverticulosis

Neoplasia

Rectal varices

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Causes Of these diagnoses, which one is the

most common cause of LGI bleed?

Diverticulosis

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Causes

Common causes

Diverticula

Vascular ectasia

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CausesUncommon causes

Neoplasia (including postpolypectomy)

Inflammatory bowel disease

Colitis

Ischemic

Radiation

UnspecifiedHemorrhoids

Small bowel source

Upper gastrointestinal source

No lesion identified

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Causes

Rare causes

Dieulafoys lesionsColonic ulcerations

Rectal varices

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Diverticulosis

Acute painless hematochezia

In 10 to 40% the bleeding recurs

Surgery should be considered ifrecurrence occurs

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Vascular ectasia

Common cause of acute, chronic andoccult 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)

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Neoplasia

Uncommon cause of acute bleeding

History of intermittent hematochezia,

change in caliber of stools, evidence ofchronic bleeding suggest this diagnosis

Post polypectomy bleeding can occur upto 3 weeks after polypectomy

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Hemorrhoids

Extremely common

5 to 10% of LGI bleeding

Usually history of blood o the toilettissue, not mixed with stools, straining

Even when present, work-up with

colonoscopy should be pursuedespecially in elderly patients

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Meckels diverticulum

Terminal 100cm of ileum

Gastric mucosa secreting acid and

causing ulceration of adjacent mucosa Usually in children and young adults

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Colitis

IBD Most common

Infectious colitis Salmonella, Shigella, E.Coli, C.Diff

Radiation

Ischemia Sudden, crampy abdominal pain with

bleeding

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Take home message

Acute GI bleeding is a life threatening condition thatneeds 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 commoncauses of UGIB

Diverticulosis and vascular ectasia are the mostcommon causes in LGIB