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GI Bleed

Adapted from source


GI Bleed
• Upper GI
• Lower GI
Upper GI
• Defined as bleeding that arises proximal to the
Ligament of Treitz
• 80% of acute bleeds
Upper GI Bleed Causes
• Peptic Ulcer 30-50%
• Mallory Weiss Tears 15-20%
• Gastritis / Duodenitis 10-15%
• Oesophagitis 5-10%
• Arteriovenous malformations
• Tumours 2%
• Others 5%
Upper GI Bleeding
• 80% are self-limited
• 20% with continuous bleeding – mortality is
about 20-40%
Upper GI Bleeding
History:
• Aspirin and other NSAIDS use
• Alcohol
• History of liver disease or variceal bleeding
• History of ulcers
• Weight loss
• Dysphagia
• Heartburn
• AAA or AAA graft – Concern wrt aortoenteric fistula
Haemodynamic Stability Assessment
Active bleeding:
• Ongoing haematemesis
• Bright red blood from NGT
• Haematochezia

Unstable:
• Shocked
• Hypotensive
• Anaemic
• Transfuse >2U PRBC
Upper GI Bleed Resuscitation
• Two large IVCs or CVL
• Crystalloid
• FBC, ELFT, Coag Profile, X-M
• Transfusion if Hb low or high risk patient (eg. IHD)
• Correction of coagulopathy (INR>1.5) or thrombocytopaenia (<50,000/µl)
• Intubation: if ongoing haematemesis, altered respiratory status or mental
state
• Gastroenterology / Surgical consult
• All patients with haemodynamic instability (Shock, orthostatic
hypotension, decrease in haemotocrit of at least 6% or transfusion
requirement over 2U of packed RBC) should be admitted to ICU
Other resuscitation considerations
• Octreotide: May decrease risk of bleeding from non
variceal sources (Decreases bleeding by decreasing
splanchnic blood flow and inhibiting gastric acid
secretion)
• Erythromycin: Given 30-90min prior to endoscopy
can clear gut of pooled blood / clot by acting as
motilin receptor agonist
• PPI infusion: Reduces rate of rebleeding from ulcers
Rockall Prognostic Scoring
System
Variable Score 0 Score 1 Score 2 Score 3

Age <60 60 - 79 >80  

Shock No shock Pulse >100 SBP < 100  

Renal failure, liver


CCF, IHD, major failure,
Comorbidity Nil major  
morbidity metastatic
cancer
Mallory-Weiss All other
Diagnosis GI malignancy  
Tear diagnoses
Blood, adherent
Evidence of
None   clot, spurting  
bleeding
vessel

A score less than 3 carries good prognosis but total score more than 8 carries high risk of mortality
Diagnostic Studies
• Endoscopy: Highly sensitive and specific for locating
and identifying bleeding lesions in upper GI tract
• Helpful to irrigate stomach prior to endoscopy to
remove residual blood and other gastric contents
• Despite irrigation, stomach can be obscured by blood
– difficult to establish diagnosis
• If bleeding stopped spontaneously, second-look
endoscopy may be required
Other Diagnostic Studies
• Angiography
• Radio-labelled red cell scan
• UGI barium studies are contraindicated in the
setting of UGI bleeding as they will interfere
with subsequent endoscopy, angiography or
surgery
Endoscopy
Perform early diagnostic endoscopy (<24 hours) with
risk classification by clinical and endoscopic criteria
to assist in:
• Safe and prompt discharge of patients low risk
• Improvement of outcomes for patients with high risk
• Reduction of resource utilisation for patients with
either low or high risk
Endoscopic Treatment
• Thermal coagulation: Coagulating bleeding artery at
ulcer base
• Endoclips: Ligation of bleeding vessel
• Injection can slow bleeding and allow endoclips or
thermal coagulation: Adrenaline (1:10000), <1ml
Alcohol 98%, saline (tamponade effect)
• Fibrin sealant
• Argon plasma coagulation
Refractory Bleeding
• Recurrent bleeding after two endoscopic trial of
haemostasis
• Angiographic haemostasis: High risks surgical
patients
• Surgery: Recurrent haemorrhage, continued slow
bleeding with ongoing transfusion requirements,
haemodynamically unstable despite resuscitation.
Procedure includes oversew of artery, antrectomy,
pyloroplasty, gastrojejunostomy
Peptic Ulcer

• Previously up to 50% of
UGI bleed
• Overall incidence
decreased
• Proportion of bleeds
associated with NSAIDS
increasing
• Mortality: 5-10%
Peptic Ulcer
• Causes: Decreased gastric/duodenal mucosal
defence associated with NSAIDS or aspirin, H. Pylori
infection or both

• Risk of rebleeding can be stratified during endoscopy


using Forrest Classification:
• Active arterial bleeding: 90%
• Non bleeding visible vessel: 50%
• Adherent clot: 30%
Mallory Weiss Tear

• Mucosal or submucosal lacerations


that occur at GOJ and usually extend
distally into hiatal hernia
• Presents with haematemesis / coffee
ground vomit after recent non bloody
vomitting
• At endoscopy usually a single tear
from GOJ distally into hiatal hernia
sac. Clean base with ooze or active
spurting
• Usually self limited and mild but can
be severe
Gastritis / Oesophagitis

• Multiple superficial erosions


• May present as malaena or
haematemesis
• Diagnosed at endoscopy but
endoscopic treatment has no
role unless there is a focal
ulcer with active bleeding or
recent bleeding
• Treat with PPI
Tumours

• Ulcerated mass
• Endoscopic management
may allow time for formal
treatment strategies such
as resection
• If endoscopy
unsuccessful,
angiographic strategies
can be used
Dieulafoy’s Lesion

• Dilated aberrant submucosal vessel which


erodes overlying epithelium in the absence
of an ulcer
• Usually located in upper stomach along
lesser curvature but can be found in
oesophagus and duodenum
• Etiology unknown. Possibly congenital
• Treatment: Combination of adrenaline
injection and bipolar coagulation
• Other options: Band ligation, haemoclips
Case 1 (UGI Bleed)
• 45 year old female
• Two days of malaena and one episode of small
to moderate amount of haematemesis.
Otherwise well. Haemodynamicall stable. Hb
134.
• When endoscopy?
Case 2 (UGI Bleed)
• 84 year old male.
• Large amount of haematemesis, malaena,
dizziness. Has HTN and otherwise well.
Haemodynamically unstable: PR 110, BP
85/50. Hb 43.
• When endoscopy?
Lower GI Bleed
Causes:
• Anatomic (Diverticulosis)
• Vascular (Angiodysplasia, Ischaemic,
radiation-induced)
• Inflammatory (Infectious, idiopathic)
• Neoplastic
Lower GI Bleed
Incidence:
• Diverticulosis: 5-42%
• Ischaemia: 6-18%
• Anorectal (Haemorrhoids, anal fissures): 6-16%
• Neoplasia: 3-11%
• Unknown: 6-23%
• Angiodysplasia
• Postpolypectomy
• Inflammatory bowel disease
• Radiation colitis
• Small bowel / upper GI bleed
• Other causes
Lower GI Bleed
• Bright red blood or blood clots per rectum
• Blood from left colon is typically bright red
• Blood from right colon is maroon and may be mixed
with stool
• Rapid transit of blood from right colon may be bright
red
• Malaena suggest UGI though bleeding from caecum
can be similar
Stratification Of Risks
• Low risk: Young and otherwise well with self-
limited PR bleeding can be reviewed in OPD
• High risk: Haemodynamic instability, serious
comorbid disease, multiple transfusions or
evidence of acute abdomen
Lower GI Bleed Resuscitation
• Two large IVCs or CVL
• Crystalloid
• FBC, ELFT, Coag Profile, X-M
• Transfusion if Hb low or high risk patient (eg. IHD)
• Correction of coagulopathy (INR>1.5) or thrombocytopaenia
(<50,000/µl)
• Gastroenterology / Surgical consult
• All patients with haemodynamic instability (Shock, orthostatic
hypotension, decrease in haemotocrit of at least 6% or
transfusion requirement over 2U of packed RBC) should be
admitted to ICU
Colonoscopy
• Advantage: Potential to precisely localise bleeding
points, obtain specimens and potential therapeutic
intervention
• Disadvantage: Poor visualisation in unprepared colon
and risks of sedation in acutely bleeding patient
• Timing depends on patient’s clinical condition
Radionuclide Imaging
• Detects bleeding at a rate of 0.1-0.5ml/min:
More sensitive than angiography
• Major disadvantage: Localise bleeding to
general area of abdomen. Poor localisation
occurs as blood can move in peristaltic or
antiperistaltic direction
CTA Abdomen
• Sensitivity of 90% and specificity of 99%
• Limitations: Potential artifacts obscuring
contrast extravasation and requires active
bleeding
Angiography
• Requires active blood loss of 1-1.5mls/min
• 100% specific but sensitivity is variable according to
the pattern of bleeding
• Advantage: Does not require bowel prep and
anatomic localisation is accurate
• Embolisation can be performed but there is up to
20% risk of bowel infarction
Other Considerations:
• Barium studies have no role in lower GI bleed
• Rarely, patient with exsanguinating lower GI
bleed may need immediate surgery
Warnings

Patients with minimal PR bleeding in the


following categories should undergo
additional testing regardless of age
Warnings
• History of malaena, dark red blood per rectum or
postural vital sign abnormalities should be
evaluated for upper gastrointestinal tract
pathology first
• Even if a lower GI tract source is possible, these
patients are more likely to have proximal rather
than distal colonic lesions and should undergo
colonoscopy after upper GI tract investigations.
Warnings
• Patients with symptoms suggestive of
malignancy such as anaemia, or change in
frequency, consistency of stools, should
have a colonoscopy.
Warnings
• Family history suggesting familial
polyposis or hereditary nonpolyposis colon
cancer syndromes who present with
bleeding per rectum should have
colonoscopy
Warnings
• Patients with minimal PR bleeding who did
not to require initial colonoscopy or
sigmoidoscopy and then develop new
constitutional symptoms or a change in
bowel habits should undergo colonoscopy

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