GASTROINTESTINAL GASTROINTESTINAL BLEEDINGBLEEDING

DR.IWAN KRISTIANDR.IWAN KRISTIANDEPT.OF.SURGERYDEPT.OF.SURGERYDR.SOETOMO HOSPITAL/ FACULTY DR.SOETOMO HOSPITAL/ FACULTY OFMEDICINE, AIRLANGGA UNIVERSITY OFMEDICINE, AIRLANGGA UNIVERSITY

IntroductionIntroduction

GI bleeding : 1-2 % of all hospitalization in USA GI bleeding : 1-2 % of all hospitalization in USA ( 300.000 / year )( 300.000 / year )

Overall mortality : 5 – 12 %Overall mortality : 5 – 12 % Upper GI bleeding : Upper GI bleeding : ± 10 %± 10 % Lower GI bleeding : < 5 %Lower GI bleeding : < 5 %

Upper GI bleeding : 100 cases / 100.000 populationUpper GI bleeding : 100 cases / 100.000 population Acid peptic disease 50 -75 %Acid peptic disease 50 -75 % 60 yrs : 35 – 45 %60 yrs : 35 – 45 %

Lower GI bleeding : 20-27 / 100.000 populationLower GI bleeding : 20-27 / 100.000 population 24 % of all GI bleeding24 % of all GI bleeding Male > femaleMale > female

Chung and Kim. Acute Gastrointestinal bleeding.2003

SEVERITY of bleedingSEVERITY of bleeding

Major bleedingMajor bleeding Acute blood loss causing hemodynamics of hypovolemiaAcute blood loss causing hemodynamics of hypovolemia Sudden passage of large amounts of bloody ,maroon,burgundy Sudden passage of large amounts of bloody ,maroon,burgundy

or melenic stool in the absence of hemodynamic compromise.or melenic stool in the absence of hemodynamic compromise. Hmt < 8 g% from base line or < 30 %.Hmt < 8 g% from base line or < 30 %. Tranfusion 4 -6 unit / 24 hours.Tranfusion 4 -6 unit / 24 hours.

Non major bleedingNon major bleeding A chemical test for blood in stool A chemical test for blood in stool The passage of hemodinamically insignificant amounts of either The passage of hemodinamically insignificant amounts of either

gross blood per rectum or melenagross blood per rectum or melena

Boley and Kaleya :Schackelford’s Surgery of the alimentary tract ,6 th ed

Occult GI bleeding :Occult GI bleeding : The most common form of GI bleedingThe most common form of GI bleeding Chronic or intermittent loss of small amount Chronic or intermittent loss of small amount

of blood of which the patients is unaware.of blood of which the patients is unaware. Manifestation : test + or iron deficiency Manifestation : test + or iron deficiency

anemiaanemia

Obscure GI bleeding :Obscure GI bleeding : Bleeding that persist or recurs without any Bleeding that persist or recurs without any

obvious source after endoscopic evaluationobvious source after endoscopic evaluation

Rockey.Current diagnosis & treatment in gastroenterology , 2 nd ed.2003

classificationclassification

Upper GI bleeding : between upper Upper GI bleeding : between upper oesophagus to lig.Treitzoesophagus to lig.Treitz GE variceal bleedingGE variceal bleeding Non variceal bleedingNon variceal bleeding

Lower GI bleeding : below lig.TreitzLower GI bleeding : below lig.Treitz Small bowel bleedingSmall bowel bleeding Colonic bleedingColonic bleeding

Sign and symptomSign and symptom

BleedingBleeding Hematemesis : vomiting fresh bloodHematemesis : vomiting fresh blood Melanemesis : vomiting “coffee-groundMelanemesis : vomiting “coffee-ground Melena : passage of black stool per rectumMelena : passage of black stool per rectum Hematochezia : passage of altered non Hematochezia : passage of altered non

black/maroon blood per rectumblack/maroon blood per rectum Rectal bleeding : passage of fresh blood per Rectal bleeding : passage of fresh blood per

rectumrectum

Sign And SymptomSign And Symptom

Systemic effect :Systemic effect : Shock or hypotensionShock or hypotension PallorPallor DizzinessDizziness WeaknessWeakness AnemiaAnemia

Basic element of the Basic element of the management of GI bleedingmanagement of GI bleeding

Causes of acute upper GI Causes of acute upper GI bleedingbleeding

Management of GI Management of GI bleedingbleeding

Prompt patient resuscitation and stabilizationPrompt patient resuscitation and stabilization Check vital sign.Check vital sign. Insert 2 large caliber peripheral catheter if neededInsert 2 large caliber peripheral catheter if needed Volume replacementVolume replacement Pass a large bore NGTPass a large bore NGT Perform rectal examinationPerform rectal examination Take historyTake history Insert ETT if neededInsert ETT if needed

Management contdManagement contd

Assessment of onset &severity of bleeding Assessment of onset &severity of bleeding serial exam : vital sign, Hmt,ECGserial exam : vital sign, Hmt,ECG

Determination of bleeding site, after the patient Determination of bleeding site, after the patient stabilized to guide the diagnostic work up. stabilized to guide the diagnostic work up.

Determination of the cause of bleedingDetermination of the cause of bleeding Medical historyMedical history Physical examinationPhysical examination

Management contdManagement contd

Control of active bleedingControl of active bleeding Medical : PPIMedical : PPI Endoscopy : injection ,banding,clippingEndoscopy : injection ,banding,clipping Angiography and embolizationAngiography and embolization surgerysurgery

Upper GI bleeding Upper GI bleeding managementmanagement

Lower GI bleedingLower GI bleeding

Aetology of lower GI Aetology of lower GI bleedingbleeding

Actual bleeding sites Actual bleeding sites in patients with in patients with hematosechiahematosechia Colon : 74 %Colon : 74 % UGI : 11 %UGI : 11 % Small bowel : 9 %Small bowel : 9 % No sites found : 6 %No sites found : 6 %

Freqency of colonic bleeding sites Freqency of colonic bleeding sites in patients with severe in patients with severe hematosechiahematosechia

Colonic diverticulosis : 42 %Colonic diverticulosis : 42 % Colorectal malignancy : 9%Colorectal malignancy : 9% Ischemic colitis : 9 %Ischemic colitis : 9 % Acute colitis, unknown cause : 9 %Acute colitis, unknown cause : 9 % Hemorrhoids : 5 %Hemorrhoids : 5 % Post polypectomy : 4 %Post polypectomy : 4 % Colonic angiodysplasia : 3 %Colonic angiodysplasia : 3 % Croh’s disease : 2 %Croh’s disease : 2 % Other : 10 %Other : 10 % Unkown : 11 %Unkown : 11 %

Longstreth GF .am J Gastroenterol 1997,92-419

Messmann H,Atlas of colonoscopy.2006

LOWER GI bleeding : LOWER GI bleeding : managementmanagement

Endoscopic clippingEndoscopic clipping

Third degree of hemorrhoid

LEFT LATERAL

LITHOTOMY

KNEE CHEST POSITION

Lower GI bleeding : surgical Lower GI bleeding : surgical managementmanagement