GI bleedingMackay Memorial Hospital Department of Internal MedicineDivision of GastroenterologyR4

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GI BleedingUGI bleedingPeptic ulcer diseaseVariceal bleedingLGI bleeding

UGI bleeding: 5 times more common than LGI bleeding. Men > Women Elderly persons.Despite ongoing advances, fundamental principles are the same !!!! immediate assessment and stabilization of hemodynamic status

Determine the source of bleedingStop active bleedingTreat underlying abnormalityPrevent recurrent bleeding

ResuscitationIn hemodynamically unstableSet up two large-bore IV catheterColloid solution (NS or lactated Ringers) To restore vital sign !!ICU monitor is indicatedCentral venous monitoringF/U vital sign and urine output

History taking and physical examinationUGI or LGI ?UGI peptic ulcer disease or portal hypertension related (EV or GV)?

Differentiate LGI and UGIMelena upper GI cause in 90%Hematochezia upper GI cause in 10%

The intermediate patientTake more time.Re-examine,Monitor vital signs,Re-check CBC, BUN

Transfusion ?In hemodynamic unstable, any sign of poor tissue oxygenation, continued bleeding, persistent low Ht level(20-25%)Maintain adequate perfusionTarget ?

Other Blood tests on the bleeding patientINR, PTT coagulopathy anyone?

There is no single value of hemoglobin concentration that justifies or requires transfusion; an evaluation of the patients clinical situation should also be a factor in the decision.Capital Health Guide to Blood Transfusion

Youve decided to give bloodOptions?

O neg Type Specific Full Cross Match immediately available 10 15 min. 30 60 min.

What is in a unit of packed cells?250 mL volumeContains citrate (anticoagulant), and preservative.1 unit packed cells will increase the Hb concentration by approx. --?0.5mg/dL

Massive TransfusionGreater than 1 blood volume( or 10 units ) transfused within 24 hoursMay dilute platelets and clotting factors

Dilution coagulopathyMonitor the patient for coagulopathyFollow the resuscitation (CBC, INR, PTT)

Treatment of dilution coagulopathyPlasma /FFP 10 15 mL / kgUsual adult dose 2 units.5 8 mL / kg dose for warfarin reversal

Treatment of dilution coagulopathyPlateletsKeep the count greater than 50 ,000 in the bleeding patient1 unit should increase platelet count by 5 ,000 10, 000 / LDose: 6 pack

Massive TransfusionWhat else can go wrong?HypothermiaPotassiumCitrate toxicity (hypocalcemia)

Vomiting BloodHematemesisUpper GI Bleeding

EtiologyPeptic Ulcer 50 %Gastritis 20%Esophageal varices 10%The rest: Tears, AVM, CA,etc 20%

More about bleeds.80 % of Non variceal upper GI bleeds will stop spontaneously 60 % of variceal bleeds will stop spontaneously

What else can I do for GI bleeding, before endoscopyNG lavageDrugABCPatient and family Agree( Sign permit first)

Urgent Endoscopy ?Initial evaluation: ?,rebleeding : vital sign (tachycardia, orthostatic hypotension resting hypotension, shock), , NG lavage

NG lavage 15 20 % of upper GI bleeds have a negative aspirate Sensitivity 79%, Specificity 55%Cuellar et al, Arch of Int Med Jul 1990

For endoscopic preparation( not contraindicated in patients with varices)

EndoscopyDiagnosticTherapeuticPrognostic

Endoscopic features and risk of re-bleedingActive bleeding55 90%

Endoscopic features and risk of re-bleedingNon bleeding visible vessel40 50 %

Endoscopic features and risk of re-bleedingAdherent clot10 33%

Endoscopic features and risk of re-bleedingFlat spot7 10 %

Endoscopic features and risk of re-bleedingClean base3 5%

Variceal bleeding

Non-variceal bleeding

Drugs: Peptic ulcer bleedingManipulation of gastric pH

Use of PPIsTheory : raise gastric pHBetter platelet activityPepsinogen requires acid to become activated to pepsinClots will form, clots not digested

High Risk PatientsElderlyCo MorbidityMore severe bleeding (hemo-dynamically unstable, ongoing bleeding

Other helpful medication

somatostatin / octreotide associated with a reduced risk of continued bleeding and rebleeding in PUD

When endoscopic / pharmacological treatment fail angiography to localize bleeder and hemostasisgenerally reserved for patient: poor surgical candidates control of bleeding in an unstable patient awaiting surgery

SurgeryHemodynamic instability despite vigorous resuscitation (more than a three unit transfusion) Recurrent hemorrhage after initial stabilization (attempts at obtaining endoscopic hemostasis) Shock associated with recurrent hemorrhage Continued slow bleeding with a transfusion requirement exceeding three units per day.

Variceal BleedingEGD finding:F1-4Ls-m-iCb / CwRed color sign

Pharmacological treatment:

Drug of choice: control bleeding and reduce mortality rate Glypressin (Terlipressin) 1 amp iv stat and q6h.Sandostatin no evidence 2 amp iv drip stat and 12 amp in 500 c.c. D5W run 24 hoursPitressin: -- Seldom used in recently years

After endoscopic treatmentFail to achieve hemostasis or rebleeding

Balloon tamponadeTransjugular Intrahepatic Portosystemic Shunt (TIPS)Surgery for shunt

Balloon Tamponade-Buy timeAvailable in MMHS-B tube

McCormick. British Journal of Hospital Medicine. 43, Apr. 1990SB tubeGastric ballonEsophageal ballon

McCormick. British Journal of Hospital Medicine. 43, Apr 1990never exceed 45mmHg. Volume 200ml

Tamponade Tube Sengstaken-Blakemore (S-B) tube Radiographic confirmation of the gastric balloons position -- 30cc air inflate the gastric balloon Insufflation of the esophageal balloon to 35mmHg

Compression of varices for not excess 48 hoursDeflate the esophageal balloon for about 30 mins every 12 hoursMajor complications -- aspiration and esophageal perforation Control hemorrhage >90%, but it is temporary

Bridging procedure buy time Definite therapeutic management must be performed.

Lower GI BleedingHematochezia 90%Melena 10%

EtiologyMost blood passed per rectum is from the upper GI tract.

Lower GI BleedsDiverticulosis, angiodysplasia, CA, colitis, ischemia, hemorrhoids

More about Lower GI Bleeds80% resolve spontaneously25 % will rebleedUsually painlessIf painful, r/o mesenteric ischemia

Investigation of the lower GI bleedThe usual suspects: CBC, BUN, Creatinine, INR, PTT, T/S

Investigation of the lower GI bleedPlain X-rays and abd. CT not much help unless you clinically suspect perforation, obstruction, ischemia (PAIN)

Diagnostic procedureEndoscopy : 80% accuracyPoor visibility with heavy bleedingAngiography : 4080% accuracy Requires heavy bleeding Able to perform embolization or vasopressin infusion

Diagnostic procedureRBC scans 2590% accurateAble to do with lower bleeding rates

What if the patient is really bleeding?Involve your consultants early. Radiologist for angiographyProcto. If tumor or ischemic bowel