approachtogastrointestinalhemorrhage-130727122730-phpapp02

8/17/2019 approachtogastrointestinalhemorrhage-130727122730-phpapp02

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Approach to gastrointestinal

bleeding

Samir Haffar M.D.

Associated Professor of Gastroenterology


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Clinical Presentation of GI bleeding

• Hematemesis Vomiting of fresh or old blood

Proximal to Treitz ligament

Bright red blood = significant bleeding

Coffee ground emesis = no active bleeding

• Melena Passage of black & foul-smelling stools

Usuall u!!er source " ma be right colon

• Hematochezia Passage of bright red blood from rectum

#f brisk & significant $ U%# source

• Occult bleeeding Bleeding not a!!arent to !atient

a lead to ds!nea' (P & even #


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Assessing the severity of bleeding

First step

leeding se!erity "ital Signs lood loss #$%

inor )ormal * +,

oderate Postural

./rthostatic h!otension0

+, " 1,

assive 2hock

.3esting h!otension0

1, " 14


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ResuscitationProportional to bleeding se!erity

• 1 large-bore #V catheters5 )ormal saline " 3inger lactate

• /xgen b nasal cannula or facemask

•onitoring of vital signs & urine out!ut

• lood &ransfusion5 6t raised to 7lderl5 '( $

8oung5 )( * )+ $

P6T5 ), * )- $• Fresh frozen plasma platelet transfusion

#f transfusion of / 0( units of !acked red blood cells


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History

• 1lderly 9iverticula - (ngiods!lasia - Cancer

• 2oung Pe!tic ulcer " Varices " 7so!hagitis

• 3 '( years eckel diverticula

•Pre!ious bleeding Bleeding from similar causes

• Aortic surgery (ortoenteric fistula

• 4no5n li!er disease 7so!hageal or gastric varices

•

6SA7Ds • 8etching allor-:eiss tear

• 6on G7 sources 7s!eciall from naso!harnx


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Physical examination

• PH& 2!ider naevi " ca!ut medusa ;

• Acanthosis nigricans Underling cancer

•

Pigemnted lip lesions Peutz-


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Spider Naevi

Central arteriole

Blanch if occluded ith !inhead

S"9 Chest above ni!!le

>ace(rms

6ands

DD Childhood

Pregnanc

Chronic liver disease


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Direction of blood flo5 in anterior abdominal 5all

P" obstruction

2 2herlock & < 9oole? 9iseases of the @iver & Biliar 2stem " 1,,1?

7"9 obstruction


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Collateral circulation

Vein dilatation & tortuosit in abdominal all

of a cirrhotic !atient suffering from ascites & Aaundice


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Caput edusa

Portal hypertension

Seen much less fre:uently


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!cclusion of the I"C


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Gynecomastia in cirrhosis

2een in cirrhotic males

2!ironolactone is freuent cause

(bsent hair bod

(ssociated diminished libido

(ssociated testicular atro!h


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Palmar erythema

7xagereted red flushing of !alms

>ades on !ressure

Specially Thenar eminence

6!othenar eminence

Bases of fingers

DD Pregnanc

Throtoxicosis Bronchial carcinoma

%eneticall determined


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#hite nails

• Congenital

•

Cirrhosis5Present in most !atients

9ue to h!oalbuminemia


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Acanthosis nigricans

Pigmentation of (xilla

%roins

(ngles of mouth

6ands

Malignant disease %astric carcinoma

Pancreatic carcinomaBronchial carcinoma


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Hereditary telangiectasia

Rendu%!sler%#eber disease

Stomach&ongue


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Peut&%'eghers Syndrome


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Neuro(rmatosis

)von Rec*linghausen+s ,isease-

spots6eurofibromas


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Henoch%Scholein purpura

Age Pre!ubertal bos . m " ears0

Can occurs in adults

&etrad Pur!uric rash5 feet " buttocks " legs

Colick abdominal !ain - blood diarrhea(rthralgia

%lomerulone!hritis

Prognosis 2elf-limited

9omplications 3a!idl !rogressive renal failure

%# hemorrhage


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Henoch%Scholein Purpura

1?tenseor surfaces of legs

uttoc@s


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.hyphoid fever

8ose spots

>reuenc5 +, " D,

9uring second eek

7rthematous macules .1 " E mm0U!!er abdomen & anterior thorax

/ccur in small numbers

Blanch on !ressure@asts 1 " F das


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/aboratory evaluation

• Hematocrit a not reflect blood loss accuratel

• 1le!ated 6 )ot correlated to creatinine level

Breakdon of blood !roteins to ureaild reduction of %>3

• 7ron deficiency anemia

•Bo5 M9"

• Bo5 ferritin le!el


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Hematocrit values before 0 afterbleeding


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,iagnostic test in GI bleeding

• pper G7 endoscopy

• 9olonoscopy

• Small bo5el endoscopy

• 9apsule endoscopy double balloon enteroscopy

• arium radiograph

• 8adionuclide imaging

• Angiography

• Miscellaneous testsC abdominal S or 9&


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Causes of 1GI bleeding

9ommon

Pe!tic ulcer

Varices

allor-:eiss

Bess Fre:uent

9ieulafoGs lesion

Vascular ectasia

:atermelon stomach

%astric varices

)eo!lasia

7so!hagitis

8are

7so!hageal ulcer

7rosive duodenitis

6emobilia

CrohnGs disease

(orto-enteric fistula


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Predisposing factors to bleedingP1

• Acid ost !rominent factor

• 6elicobacter !lori

• )2(#9s

• Bi!hos!hnate alendronate

• Chronic !ulmonar disease

• Cirrhosis

• (nticoagulants

• 7thanol


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$leeding peptic ulcer

• ost freuent cause of U%# bleeding .+($0

• 7s!eciall high on gastric lesser curvature

or !ostero-inferior all of duodenal bulb

• ost ulcer bleeding is self-limited .-($0


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2orrest+s classi(cation for P1bleeding

Stage 9haracteristics 8ebleeding

# a


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2orrest+s classi(cation for P1bleeding

777 #clean base%77Eb #adherent clot%

77Ea #!isible !essel%7Eb #oozing%

77Ec #blac@ spot%

7Ea #arterial ;et %


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GI side e3ects of NSAI,s

Organ Side 1ffects

7so!hagus 7so!hagitis " Ulcer " 2tricture

2tomach & duodenum 2ube!ithelial hemorrhage " 7rosion " Ulcer

2mall #ntestine Ulcers " 2trictures " )2(#9 entero!ath

Colon )o !re-existing colonic disease5

Ulcerations " 2tricture " 9ia!hragm " Colitis

Pre-existing colonic disease5K Com!lications of diverticular disease

(ctivate #B9(no-rectum #nflammation " Ulcer " 2tricture

GI safety of non%selective


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Highest ris@ (za!ro!azone Tolmetin

Leto!rofenPiroxicam

GI safety of non%selectiveNSAI,s

88 of different 6SA7Ds could differ 0(Efold

Bo5est ris@ #bu!rofen M 9iclofenac

3isk at higher doses .N +?4 "1?E gOd0 com!arable to others NSAIDs

Br ed < +DD F+1 5 +4F " +4?

@onger half-time

Moderate ris@ #ndomethacin )a!roxen

2ulindac(s!irin


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Patients at increased ris* for NSAI,sC" toxicity

High risk Patients ith risk factors for CV disease often receive !ro!hlactic as!irin

(rbitraril defined as reuirement for lo-dose as!irin for !revention of serious CV events

Low risk )o risk factors


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Prevention of NSAI,%related ulcercomplications

)a!roxen ma have some cardio!rotective !ro!erties

Patients ith ulcer histor5 search for 6P & if !resent eradicated

(C% guidelines for !revention of )2(#9-related ulcer com!lications?

(m < %astroenterol 1,,D +,E5 J1H " JFH?

)2(#9 alone.least ulcerogenicat loest dose0

)2(#9Q

PP#Omiso!rostol

(lternative thera!or

Coxibs Q PP#Omiso!rostol

)a!roxenQ

PP#Omiso!rostol

)a!roxenQ

PP#Omiso!rostol

(void )2(#9s & coxibs

Use alternative thera!

High GI risk Moderate GI risk Low GI risk

Low CV risk

High CV

risk


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.reatment of bleeding P1

• Pharmacological PP# H, mg #V bolus

Hmg O hr O J1 hours #V infusion

• 1ndoscopic #nAection .e!ine!hrine +O+,?,,,0

ono!olar coagulationBi!olar coagulation

6eater !robe

6emocli!s(rgon !lasma coagulation

• Surgical :hen endosco!ic treatment fails


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Summary of therapy of bleedingP1

• Patients must be adeuatel resuscitated

• U%# endosco! is the !rimar diagnostic modalit

•

7ntubation if severe bleeding or altered mental status• 7ndosco!ic thera! indicated in high risk lesions

Combine 1 methods of endosco!ic treatment

• #V PP# should be used in high risk !atients

Cl i( i f h l


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Classi(cation of esophagealvarices

Grade 0Small

inimall elevated

veins above surface

((2@9 !ractice guidelines5 !revention & management of gastroeso!hageal varices?

6e!atolog 1,,J E 5 D11 " DFH?

Grade )Medium

Tortuous veins occu!ing

* +OF of eso!hageal lumen

Grade 'Barge

/ccu!ing N +OF of

eso!hageal lumen


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Classi(cation of gastric varices

8amada T et all? 8amadaGs textbook of gastroenterolog?Blackell Publishing' :est 2ussex' UL' 4th edition' 1,,D?

GastroEOesophageal "arices

T!e # (long lesser curve

T!e ## To gastric fundus

7solated Gastric "arices

T!e # >undal T!e ## 7cto!ic


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Predictive factors for ris* ofbleeding

6orth 7talian 1ndoscopic 9lub 7nde?

• "ariceal size Best !redictor of bleeding

• Se!erity of li!er disease 7x!ressed b Child-Pugh

• 8ed signs /n the varices

)#7C? ) 7ngl < ed +DHH F+D 5 DHF " DHD?


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Child%Pugh score

Categor+ 1 F

Bilirubin .mgOdl0 * 1 1 - F N F

(lbumin .gOl0 N F4 1H " F4 * 1H

(scites (bsent ild- oderate 2evere

7nce!halo!ath , # " ## ### " #V

#)3 * +?J.J,0

+?J " 1?F.E, " J,0

N 1?F.* E,0

9lass AC + * 9lass C , * 9lass 9C 0( * 0+


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Score ' month mortalityR E, +,,

F, " FD HF

1, " 1D J

+, " +D 1J

* +, E

Interpretation of 5/, score

The maximum score given for 7@9 is E,

(ll values N E, are given a score of E,

?unos?orgOresourcesOeldPeldCalculator

.reatment of acute variceal


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.reatment of acute varicealbleeding

8ecommendations E 0• Best a!!roach is combined use of5

- Pharmacological agent started from admission &

- 1ndoscopic procedure• &erlipressin somatostatin !referable if available

/ctreotide' vaso!ressin Q nitroglcerin ma be used

• 9rug thera! maintained for at least J- h + day thera! recommended to !revent earl rebleeding



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8ecommendations E )• leeding 1"

Band ligation is the endosco!ic treatment of choice

2clerothera! ma be used

• leeding G"

/bturation ith cyanoacrylate

•

&7PS 3escue !rocedure if medical & endosco!ic tt fails

Bleeding from %V ma reuire earlier decision for T#P2



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• Shunt surgery

esocaval graft shunts or traditional !ortacaval shunts

ma be an alternative to T#P2 in Child ( !atients

• lood transfusion

9one cautiousl using !acked red cells .6t5 14 " 1H 0

Plasma ex!anders to maintain hemodnamic stabilit

• Prophyla?is of infection

%iven to all !atients .norfloxacin E,, mg O+1 hours0


8ecommendations E '


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5sophageal varices

7ndosco!ic vie of

eso!hageal varices

Varix endosco!icall

ligated ith a band


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.IPS

. 6 l I t h ti


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.rans6ugular IntrahepaticPortosystemic Shunt

&echni:ue etallic stent beteen branch of PV &6V

Under sedation ith local anesthesia

U2 guidance essential during the !rocedure Time of !rocedure5 + " 1 hours

9ifficult .skilled interventional radiologist0

7ndications Control of bleeding from 7V or %V edical & endosco!ic tt given before T#P2

8esults Bleeding control D,

Mortality * +


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General results of surgical shunts

leeding Prevented or at least decreasedVarices disa!!ear in " +1 months

9omplications Post-o!erative Aaundice

#ncrease cardiac out!ut & failure

Hepatic encephalopathy a be transient

Chronic changes in F, " E,

#ncrease ith the size of shunt

ore common in older !atients

Mortality + $ in good-risk !atients

+( $ in !oor-risk !atients


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Side%to side porto%caval shunt


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,istal spleno%renal shunt

Veins feeding varices ligated5 coronar-rt gastric-rt gastroe!i!loic

2!leen is !reserved


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,istal spleno%renal shunt

ortalit similar to non-selective shunts

Hepatic encephalopathy similar to nonEselecti!e shunts

Better results in non-alcoholic !atients & in gastric varices

9oes not interfere ith subseuent liver trans!lant

Technicall difficult .feer surgeons illing to !erform it0


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Portal gastropathy

MosaicEli@e mucosal pattern

Sna@eEs@in appearance

5ndoscopic images of PH. gastropathy


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p g g p y

6e5 7talian 1ndoscopic 9lub

• MosaicEli@e mucosal pattern .snake-skin a!!earance0

• 8ed point lesions

2mall .*+ mm0' red' flat' !oint-like marks

• 9herryEred spots@arge .N1 mm0' round' red-colored' !rotruding lesions

• lac@*bro5n spots

#rregular black & bron flat s!ots not fading u!on ashing

ight re!resent intramucosal hemorrhage

Primignani et al? %astroenterolog 1,,, ++D 5 +H+ " +HJ?


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allory%#eiss syndrome

8etrofle?ed !ie5

+E 0( $ of G7 bleeding

T!icall in gastric mucosa

2to! s!ontaneousl in H,-D,

)ot bleeding5 discharge !rom!tl

(ctive bleeding5 inAection " banding


63/99


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/A classi(cation system of


65/99

/ne .or more0 mucosal break continuous beteen to!s of N

1 mucosal folds' but hich involves * J4 of circumference

yesophagitis

Grade 9

/A classi(cation system of


66/99

/ne .or more0 mucosal break that involves at least

J4 of the eso!hageal circumference

yesophagitis

Grade D


67/99

$arrett+s esophagus

7ndosco!ic vie of distal eso!hagus from a !atient ith %739

Tongue of BarrettGs mucosa .b0 & 2chatzkiGs ring.s0 .arro0


68/99

5sophageal candidiasis

ulti!le small hite !laues of Candida seen on background

of abnormall reddened eso!hageal mucosa

Herpes Simplex in the


69/99

Herpes Simplex in theesophagus

(!!earance not diagnostic of 62V infection

#t could be due to drug-induced lesion .L su!!lement0

Presence of vesicles in mucosa virtuall diagnostic of 62V

2mall volcano-like ulcers due to 62V


70/99


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Cancer of gastroesophageal 6unction

@arge malignant mass at %7 Aunction


72/99

#atermelon stomach

%astrointest 7ndosc 1,,4 + 5 F+ - FF?


73/99

Ampulloma

1ndoscopic !ie5


74/99

Hemobilia

Blood clot !rotruding

from the am!ullaCorres!onding 73CP


75/99

Causes of lo4er GI bleeding

9ommon

9iverticula

Vascular ectasia

Bess Fre:uent

)eo!lasia

#B9

Colitis5 ischemia " radiation

6emorrhoids

2mall boel source

U%# source

8are

9ieulafoGs lesion

Colonic ulceration

3ectal varices


76/99

,iverticular disease of the colon

:ide-mouthed o!enings to diverticula are !resent

The ere seen throughout the sigmoid colon in this !atient

ucosal telangiectasia of the


77/99

ucosal telangiectasia of thecolon

The !atient !resented ith hematochezia

The lesion as subseuentl cauterized endosco!icall


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.elangiectasia

Telangiectasia in duodenum in

!atient ith microctic anemia

Treatment ith AP9

.(rgon Plasma Coagulation0


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5ndoscopic polypectomy

2nare !assed through endosco!e

& !ositioned around !ol! .P0

Cauter a!!lied & !ol! resected

leaving clean mucosal defect


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1lcerative colitis

Colonic mucosa in a !atient ith idio!athic ulcerative colitis'

shoing a friable mucosa' extensive ulceration' and exudates?


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Crohn+s disease of the ileum


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Crohn s disease of the ileum

@uminal narroing

ucosal ulceration

2e!aration of barium-filled loo!s .thickening of boel all0

Small bo5el follo5Ethrough in ileal Crohn+s disease

NSAI,s%induced colitis


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NSAI,s%induced colitis

7ndosco!icall nons!ecific findings6istologicall nons!ecific

995 infections' #B9' ischemia' vasculitis


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Rectal ,ieulafoy+s lesion

%astrointest 7ndosc 1,,E , 5 JD?

7ndosco!ic a!!earance 9uring ligation (fter ligation

Classi(cation of hemorrhoids


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Classi(cation of hemorrhoids

Degree Description

First degree ProAect a short a into anal canal /nl sm!tom is bleeding

Second degree Prola!se during defecation 3educe s!ontaneousl

&hird degree ust be reduced manuall

Fourth degree #rreducible


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Prolapse of 8 mains hemorrhoidal


90/99

ppiles

Preferences for treatment of


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hemorrhoids

Degree or Grade &reatment

+ 2clerosing inAections#nfrared coagulation

1 #nfrared coagulation3ubber band ligation

F 3ubber band ligation

E 6emorrhoidectom

S l i i 6 ti


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Sclerosing in6ection

I f d h t l ti


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Infrared photocoagulation


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Rubber band ligation


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Anal (ssure


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Anal (ssure

ec*el+s divertculum


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ec*el s divertculum

#soto!e scan ith TcDDm

Approach to lo4er GI bleeding


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Approach to lo4er GI bleeding

• @ess common than U%# bleeding

• Usuall less hemodnamical significant

•ost common cause of severe bleeding5 di!erticula

• ost common cause of minor bleeding5 hemorrhoids

• Controversial best diagnostic a!!roach if severe5

Urgent colonosco! " 3BC scintigra!h " angiogra!h


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&han@ 2ou

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