GASTROINTESTINAL TRACT BLEEDING By Dr. Wasfi M Salayta KHMC
Epidemiology • Upper GI bleeding: – Is defined as bleeding from a gastrointestinal source that is proximal to the ligament of Treitz. – It is more common than lower GI bleeding. – Annual incidence 149 -172/100, 000. – Increased in males and in older patients. – Over 50% of upper GI bleeds are due to erosive or ulcerative disease of the stomach or duodenum. – The mortality associated with GI bleeding remains significant at 5% to 11%. – The following factors increased the mortality rate in upper GI bleeding : • Age > 60. • Co morbid diseases especially pulmonary and hepatic diseases. • Physical findings consistent with cardiorespiratory or hemodynamic compromise. • Blood transfusion requirement greater than 5 units. • Requirement for surgery (patients requiring emergency surgery had increased mortality compared with those undergoing more elective surgery). • Recurrent bleeding after hospitalization. • Those who develop GI bleeding after hospitalization for other reasons.
Epidemiology • lower GI bleeding: – Is defined as bleeding distal to the ligament of Treitz. It can range in severity from trivial to massive. – LGIB accounts for approximately 20% of all major GI bleeds. – More commonly bleeding is from a colonic rather than a small bowel source. – Annual incidence 21 cases per 100, 000. – Increased in males and in older patients (mean age at presentation of 63 to 77 years). – 80 -90% of cases will stop bleeding spontaneously. – As many as 25% will re-bleed either during or after their hospital admission. – While most patients have a self-limited illness, the reported mortality ranges from 2 -4%. – Among all patients presenting with lower GI bleeding, diverticular disease is the most common cause, followed by, vascular anomaliesor ischemic colitis.
Etiology- Upper GI bleeding • Chronic Peptic ulcer disease : is the most common cause of upper GI bleeding , over 50% of cases – Duodenal ulcer 29%. – Gastric ulcer 16%. – Stomal ulcer 5% • Acute mucosal ulceration(Stress gastritis ) 1 -33% of the upper GI bleeding causes. Often multiple and not extend through muscularis mucosa. Diffuse and typically involve the gastric body and fundus. More frequently seen in the following conditions ( shock-sepsissurgery-trauma-burn-renal failure-respiratory failure-jaundice). – The pathogenesis is due to an imbalance between aggressive and protective mucosal factors. – Both H 2 -blocker and Antacid are effective in prevention. – –
Etiology- Upper GI bleeding • Mallory-Weiss tear: – A mucosal laceration of the gastric cardia or gastroesophageal junction. – Account for approximately 5% to 15% of all cases of upper GI bleeding and are relatively common in alcoholics. – The classic presentation is that of repeated retching, vomiting or coughing followed by hematemesis. – Up to 50% of patients do not give a history of antecedent retching or vomiting. – Only 10% present with hemodynamic compromise. – Bleeding is self-limited in 90% of cases • Esophagitis/esophageal ulcer (seen in HIATUS HERNIA )
Etiology- Upper GI bleeding • Esophageal/gastric varices. – The incidence of bleeding is approximately 10% to 15% per year, and in patients with large varices is 20% to 30%. – Bleeding due to varices is typically brisk and associated with hemodynamic compromise. – The mortality associated with the first variceal bleed ranges from 30% to 50%. – Treatment : • Endoscopic sclerotherapy and band ligation of varices are the mainstay of emergent therapy. • medical therapy for variceal hemorrhage has been extensively studied, the benefit of such therapy remains uncertain (vasopressin , More recently somatostatin and the somatostatin analogue, octreotide) • The Senkstaken-Blakemore tube remains an important therapeutic tool in patients with brisk esophageal or gastric variceal hemorrhage that cannot be controlled on initial endoscopy • Patients who continue to bleed or who have more than one rebleeding episode despite endoscopic and medical therapy should be considered for portal decompression. .
Etiology- Upper GI bleeding • Neoplasm – Gastric cancer – Esophageal cancer – Stromal tumor
Etiology- Upper GI bleeding • Vascular anomalies • An unusual cause of upper GI bleeding, accounting for only 5% of cases. . • Angiodysplasia, whether sporadic or secondary, is the most common vascular anomaly seen in the GI tract. – Angiodysplasia/ectasia • Are dilated, tortuous vessels in the mucosa and submucosa. • The pathophysiology unclear, but is felt to be due to intermittent obstruction of the submucosal veins because of the colonic wall tension, which is highest in the cecum. • May be sporadic, usually developing in the elderly. • May be found in association with a number of disorders including renal failure, cirrhosis, the CREST syndrome, radiation injury, von Willebrand’s disease, and aortic stenosis. • May occur anywhere in the GI tract, but are more com monly found in the colon(most common in the cecum and ascending colon ) , followed by the small intestine and the stomach. • These lesions usually lead to occult blood loss, but can also cause overt GI bleeding. • Usually apparent at endoscopy, at which time therapy with laser or thermal probes may be applied. • Bleeding that is refractory to endoscopic or medical therapy is an indication for surgical resection – Dieulafoy lesion • is characterized by an aberrantly large and tortuous submucosal artery that may erode through a small mucosal defect, resulting in massive hemorrhage • 75% to 95% occur in the proximal stomach, usually on the lesser curvature and within 6 cm of the gastroesophageal junction, although they have been reported to occur thoughout the GI tract • These lesions often respond to endoscopic therapy with injection of saline or 1: 10, 000 epinephrine and/or endoscopic application of thermal probes • Patients who do not respond to endoscopic therapy require surgical intervention • wide wedge resection of the artery and bleeding site is preferable to oversewing the artery in the area of the mucosal defect • Patients who are poor surgical candidates may respond to angiographic embolization – Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu) – Arteriovenous malformation
Etiology- Upper GI bleeding • Aortoduodenal erosion or fistula – Representing 80% of all aortoenteric fistulas. – It is estimated that 0. 4% to 4% of patients with aortic grafts develop an aortoenteric fistula. – Primary aortoduodenal fistulas associated with atherosclerotic aneurysms or trauma are much less common. – rarely is seen endoscopically – Angiography is seldom helpful unless a pseudoaneurysm is seen – CT visualization of an aneurysm with associated extraluminal gas is virtually diagnostic, this finding is also uncommon. – The diagnosis is usually made or confirmed on laparotomy. Surgical repair is the only therapeutic option.
Etiology- Upper GI bleeding • Hemobilia – Is usually associated with intraductal neoplasm, trauma, or iatrogenic injury such as percutaneous liver biopsy and cystic artery pseudoaneurysm. – Suggested by jaundice, right upper quadrant pain and gastrointestinal bleeding. – May be confirmed at endoscopy but often requires angiography. – Angiographic therapy is the treatment of choice, although occasionally surgical therapy is necessary • Hemosuccus pancreaticus (This is most commonly due to a pseudoaneurysm of the splenic artery in patients with a pancreatic pseudocyst or chronic pancreatitis but rarely may occur in patients with pancreatic duct malignancy • Non-GI source (epistaxis) • Factitious bleeding (ingestion of animal blood or human blood after auto-phlebotomy).
Etiology- lower GI bleeding • Anorectal causes : – Include hemorrhoids -anal fissure and rectal ulcer. – Bleeding from hemorrhoids and fissure is uncommonly associated with hemodynamic instability or large volume of blood loss. – While rectal ulcer can cause severe hemorrhage and hemodynamic instability – Possible causes of rectal ulcer are : • • • Radiation. Sexual transmitted disease. NSAIDs. Liver disease. Trauma.
Etiology- lower GI bleeding • Diverticular disease: – Contributes 20 -60% of the cases of LGIB. – In 75% of patients bleeding will stop spontaneously. – Rebleeding rate after first episode 25% and increase to 50% after two episodes. – 5% will have severe hemorrhage. – diverticular bleeding is distributed equally between the right and left sides of the colon. – Observation alone is generally recommended following the first episode of diverticular hemorrhage. However, following a second episode, the risk of subsequent episodes appears to approximate 50%, and thus elective resection has been recommended.
Etiology- lower GI bleeding • Angiodysplasia: – Only about 15% of patients with vascular ectasia will develop gastrointestinal hemorrhage. – The incidence in most recent studies is only 3% compared to 15 -27% previously as cause of LGIB. • Colorectal neoplasm – Although colorectal cancer is most commonly associated with occult blood loss rather than overt bleeding, patients with rectosigmoid lesions may present with hematochezia. – CR-cancers are source of LGIB in 9 -13% of patients.
Etiology- lower GI bleeding • Ischemic colitis – Occurs in 9 -18% of patients. – Results from a sudden and often temporary reduction in mesenteric blood flow, typically caused by hypoperfusion, vasospasm, or occlusion. – The usual areas affected are the “watershed” areas of the colon: the splenic flexure and the rectosigmoid junction. – Patients tend to be elderly, often with significant atherosclerosis or cardiac disease. • Other colonic etiologies: – Inflammatory bowel disease: • Acute hemorrhage occurs 0. 9 -6% in CD and 1. 4 -4% in UC. • Bleeding occurred in both young and old patients and not related to disease duration. • Malignant lesion must be considered in patient with long standing history of IBD and LGIB. – – – Infectious colitis or enteritis : Radiation colitis/proctitis. Trauma, hematologic disorders and NSAIDs. Post polypectomy (occurs in 0. 3% to 6. 1% of polypectomies). Bleeding from CR-anastomosis (o. 5 -1. 8%).
Etiology- lower GI bleeding • Small bowel sources account for 3 -5% of all cases of LGIB: – Angiodysplasia is most common cause of small bowel hemorrhage (70 -80%). – small bowel diverticula, – Meckel’s diverticula, – neoplasia, – Crohn’s disease, – aorto-enteric fistulas.
Obscure Gastrointestinal Bleeding • Defined as recurrent acute or chronic GI bleeding for which no source has been found despite evaluation with EGD and colonoscopy with or without routine small bowel followthrough. • It accounts 1. 19 -9% of LGIB. • The most frequent causes are : – Small bowel tumors. – Angiodysplasia. – Ulcererosion. • The diagnosis needs more procedures than patients with upper GI and colonic bleeding include: – Capsule endoscopy. – Double balloon enteroscopy.
MANAGEMENT OF GI BLEEDING • Initial assessment, resuscitation and triage: – GI bleeding may have different clinical presentations • hematemesis or hematochezia with hemodynamic instability. • melena or rectal bleeding without hemodynamic compromise. • patients may have chronic GI bleeding with asymptomatic iron-deficiency anemia, or hemoccult-positive stool on screening for colorectal cancer. – Patients presenting to the emergency room with hemodynamic instability require rapid clinical assessment. • Intravenous access with at least two large-bore lines. • nasogastric tube placement, • determination of hematocrit and coagulation studies, and type and cross for blood products. • Patients with altered mental status should undergo endotracheal intubation for airway protection • . Emergent evaluation by a gastroenterologist should be requested. • The patient should be stabilized before proceeding to endoscopy.
MANAGEMENT OF GI BLEEDING – it is important to determine whether the bleeding is from an upper or lower GI source ( usually relatively straightforward ) • approximately 5%-10% of patients who present with hematochezia are bleeding from an upper GI source. • If there is uncertainty about the presence of an upper GI bleeding source, such as when the gastric aspirate is not bile-stained, patients with hematochezia and hemodynamic compromise should undergo upper endoscopy before evaluation of the lower GI tract. – Admission to the hospital is required for most patients presenting with GI bleeding • Those who present with frank hypotension or who have evidence for ongoing bleeding require monitoring in an intensive care unit and urgent endoscopic evaluation • Those who present with mild or no orthostasis, have no evidence for continued bleeding, but have had a significant drop in hematocrit are generally hospitalized on a medical/surgical floor. – young patients with self-limited GI bleeding who present without orthostasis or hemodynamic instability and who have no significant comorbid conditions may be managed as outpatients.
MANAGEMENT OF GI BLEEDING • Diagnosis : – History and physical : • During the initial stabilization and evaluation, a complete history and physical should be performed • History. : – Patients with upper GI bleeding should be questioned about » Peptic ulcer disease » liver disease, » malignancy, » abdominal surgery » bleeding disorder, » weight loss, » alcohol, » aspirin or non-steroidal antiinflammatory drug (NSAID) use. » A history of antecedent retching suggests a Mallory-Weiss tear – Patients with suspected lower GI bleeding should also be asked about » hemorrhoids, » associated diarrhea, » change in bowel habits, » personal or family history of inflammatory bowel disease, » A history of radiation therapy. » A family history of GI disorders, malignancy or bleeding disorders should also be obtained. : :
MANAGEMENT OF GI BLEEDING • Physical examination – Orthostatic blood pressure and pulse even if the patient appears stable. – cutaneous stigmata of liver disease – splenomegaly or ascites, abdominal tenderness, an abdominal mass or lymphadenopathy – cutaneous or mucocutaneous manifestations of systemic disorders associated with GI bleeding – ENT EXAMINATION, RECTAL EXAMINATION.
MANAGEMENT OF GI BLEEDING – Diagnostic studies: • Upper GI endoscopy: – the preferred diagnostic modality in patients with upper GI bleeding – advantages of endoscopy include: » the ability to obtain biopsies for an accurate histologic diagnosis, » Determine the risk of rebleeding. » Provide endoscopic therapy. – Patients with severe upper GI bleeding should have an upper endoscopy, or esophagogastroduodenoscopy (EGD), performed as soon as they are stable. – Patients in whom endoscopy cannot be performed due to torrential bleeding should be considered for laparotomy, with or without prior mesenteric angiography
MANAGEMENT OF GI BLEEDING • Sigmoidoscopy and colonoscopy – Patients with bright red hematochezia and minimal blood loss can undergo initial evaluation with anoscopy and flexible sigmoidoscopy, unless the patient is age 50 or older(a full colonoscopy is generally recommended to rule out a colonic neoplasm) – Those with dark hematochezia or bright red blood per rectum and evidence for significant blood loss should undergo full colonoscopy – Active, brisk bleeding and continued hemodynamic instability despite ongoing resuscitation is an indication for emergency angiography rather than colonoscopy. » Since lower GI bleeding can originate anywhere in the small bowel or colon, angiography is also preferable to laparotomy in the setting of such bleeding. » Surgery is generally reserved for patients whose bleeding site is identified by angiography but who are inappropriate for, or fail, angiographic therapy
MANAGEMENT OF GI BLEEDING • Angiography: – bleeding rate of 0. 5 m. L/min is necessary in order for angiography to be positive – helpful in the patient with massive GI bleeding from either an upper or lower source – reveals a bleeding site in up to 75% of patients with massive upper GI bleeding – success rate in LGIB 60 -90% rebleeding rate 0 -33% and significant ischemia 7%
MANAGEMENT OF GI BLEEDING • Radionuclide scanning : – Red blood cells obtained by venipuncture are labeled with technetium 99 m (99 m. Tc) and reinjected into the patient. – red blood cell scans detect lower rates of bleeding (0. 1 cc/min) – Since prolonged or repeated scanning is possible, bleeding can be detected even if it is intermittent or too slow to be detected on angiography. – If the red blood cell scan is negative, the angiogram is very unlikely to demonstrate active bleeding – Helpful in some patients with recurrent lower GI bleeding in whom all other diagnostic studies are negative. – is particularly helpful in the setting of bleeding from a Meckel’s diverticulum • Multidetector row CT: – Blood flow can be detected at the rate of 0. 3 mlmin – Considered positive when vascular contrast material is extravasated into bowel lumen. • Capsule endoscopy +double balloon enteroscopy for obscure GI bleeding.
Surgery - Indications in upper GI bleeding • Age >60 years. • Massive bleeding. • Continued bleeding more than 4 units of blood transfused. • Endoscopic stigmata. – Vessel in base of ulcer. – Arterial spurter. – Adherent clot. • Rebleeding within hours or days. • Unique and shortage of blood.
Surgery - Indications in lower GI bleeding • The majority of patients with LGIB will stop spontaneously and never require surgery • approximately 10 -25% of patients will require operative intervention • The indications for surgery include: • 1. Continued or recurrent hemorrhage despite nonoperative attempts. • 2. Transfusion requirement >6 units within 24 hours. • 3. hemodynamic instability patients who have massive ongoing bleeding and are unresponsive to initial resuscitation.
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