ugi bleed obie m. powell, m.d. joseph a. iocono, m.d. department of surgery university of kentucky

UGI BleedUGI Bleed

Obie M. Powell, M.D.Obie M. Powell, M.D.Joseph A. Iocono, M.D.Joseph A. Iocono, M.D.Department of SurgeryDepartment of SurgeryUniversity of KentuckyUniversity of Kentucky

Mr. MellennaMr. Mellenna

57 year-old white male with recent history of dark stools presents to the emergency room complaining of a two hour history of vomiting blood and feeling faint.

On presentation the patient is pale and lethargic complaining of abdominal pain.

HistoryHistory

What other points of the history do What other points of the history do you want to know?you want to know?

History, Mr. MellennaHistory, Mr. Mellenna

Characterization of Characterization of symptomssymptoms

Temporal sequenceTemporal sequenceAlleviating / Alleviating /

Exacerbating factors:Exacerbating factors:

Pertinent PMH, ROS, MEDS.

Relevant family hx.Associated signs and

symptoms

Consider the FollowingConsider the Following

Characterization of SymptomsCharacterization of Symptoms

Un-relenting nausea with associated burning Un-relenting nausea with associated burning epigastric discomfort epigastric discomfort

Pain is steady and rates it as a 5 on a scale of 1-Pain is steady and rates it as a 5 on a scale of 1-10.10.

Temporal SequenceTemporal SequenceDark stools off and on for approximately 6 months.Dark stools off and on for approximately 6 months.

Often has some mild epigastric pain to which he pays Often has some mild epigastric pain to which he pays little attention. This pain has been occurring for the little attention. This pain has been occurring for the same duration.same duration.

Today he has been feeling “light headed” for about 3-4 Today he has been feeling “light headed” for about 3-4 hours, and has been throwing up blood for 2 hours.hours, and has been throwing up blood for 2 hours.

Alleviating / Exacerbating FactorsAlleviating / Exacerbating Factors

Standing erect worsens his light headedness and laying Standing erect worsens his light headedness and laying down improves it.down improves it.

Nothing improves the pain or nauseaNothing improves the pain or nausea

In the past eating food sometimes relieved his In the past eating food sometimes relieved his

abdominal painabdominal pain.

PMHPMH

The patients past history is significant forThe patients past history is significant for

HTNHTN MI 3 years prior treated with angioplasty MI 3 years prior treated with angioplasty

and stenting.and stenting. COPDCOPD OsteoarthritisOsteoarthritis No prior abdominal surgeryNo prior abdominal surgery

PMHPMH

MedicationsMedications ASA - supposed to be on it but it bothers his ASA - supposed to be on it but it bothers his

stomachstomach Metoprolol 50mg po BIDMetoprolol 50mg po BID Simvastatin 10mg po dailySimvastatin 10mg po daily Ibuprofen 400mg po QID prn, none in past 2 Ibuprofen 400mg po QID prn, none in past 2

weeksweeks

NKDANKDA

Family/Social HistoryFamily/Social History

Family HistoryFamily History Non-contributoryNon-contributory

Social HistorySocial History MarriedMarried Computer programmerComputer programmer ETOH- 6 pack per weekETOH- 6 pack per week

ROSROS

As in HPI.As in HPI.

The patient denies chest pain, shortness of breath, The patient denies chest pain, shortness of breath, fever, chills, anorexia, and dysuriafever, chills, anorexia, and dysuria

ROS should emphasize further characterization of ROS should emphasize further characterization of the active disease process AND risk factors that may the active disease process AND risk factors that may complicate surgery complicate surgery such as active infection, active such as active infection, active CAD, poor exercise toleranceCAD, poor exercise tolerance

What is your Differential What is your Differential Diagnosis?Diagnosis?

Differential DiagnosisDifferential Diagnosis

Esophageal varicesEsophageal varicesGastric varicesGastric varicesErosive gastritisErosive gastritisMallory Weiss tearMallory Weiss tearReflux esophagitisReflux esophagitisGastric malignancyGastric malignancy

Vascular malformationsVascular malformationsNose bleedNose bleedAorto-enteric fistulaAorto-enteric fistulaGastric ulcer Gastric ulcer Duodenal ulcerDuodenal ulcer

Consider the followingConsider the following

Physical ExamPhysical Exam

What are you looking for?What are you looking for?


What to look forWhat to look for Vital signsVital signs: instability, respiratory distress, beware : instability, respiratory distress, beware

of beta blockadeof beta blockade Overall appearanceOverall appearance: signs of anemia, dehydration: signs of anemia, dehydration Abdominal examAbdominal exam: probe for peritonitis: probe for peritonitis Rectal examRectal exam: : mandatorymandatory. Look for perianal causes . Look for perianal causes

of bleedingof bleeding.

Physical Exam, Physical Exam, Mr. Mr. Mellenna

Vital signs: Temp. 97.8, Pulse 90, BP 95/63 Vital signs: Temp. 97.8, Pulse 90, BP 95/63 Resp. 30 Resp. 30

Patient is alert and oriented. Pale skin and dry Patient is alert and oriented. Pale skin and dry mucous membranes.mucous membranes.

During your examination the patient has a large During your examination the patient has a large maroon bowel movementmaroon bowel movement


Head is atraumatic / Head is atraumatic / normocephalic, eyes sunken, normocephalic, eyes sunken, pale conjunctivapale conjunctiva

NeckNeck- - No lymphadenopathy, No lymphadenopathy, flat neck veins.flat neck veins.

OropharynxOropharynx - - dried blood, no dried blood, no active bleeding, dry mucus active bleeding, dry mucus membranes.membranes.

CV- CV- Regular rate and rhythm, no Regular rate and rhythm, no murmur, rubs, or gallopsmurmur, rubs, or gallops

Chest-Chest- Mild tachypnea, Mild tachypnea, respirations are clear bilaterally no respirations are clear bilaterally no rales, rhonchi, or wheezesrales, rhonchi, or wheezes

Abdomen is scaphoid, soft, Abdomen is scaphoid, soft, mildly tender in mid-mildly tender in mid-epigastrum. Bowel sounds are epigastrum. Bowel sounds are present and hyperactive.present and hyperactive.

Extremities show no clubbing, Extremities show no clubbing, cyanosis, or edema.cyanosis, or edema.

Rectal exam shows gross blood, Rectal exam shows gross blood, enlarged smooth prostate, no enlarged smooth prostate, no palpable masses, no palpable masses, no hemmorhoids or other peri-anal hemmorhoids or other peri-anal diseasedisease

Would you like to revise your initial differential diagnosis?

What Labs do you need ?What Labs do you need ?

Laboratory studies:Laboratory studies:What is necessary?What is necessary?

Type and CrossType and CrossCBC: Do you expect anemia?CBC: Do you expect anemia?CMP: evaluate for hepatic dysfunction and CMP: evaluate for hepatic dysfunction and

renal compromiserenal compromiseCoags: active hemorrhage can cause Coags: active hemorrhage can cause

coagulopathy and requires aggressive coagulopathy and requires aggressive replacementreplacement

ABG: probe for acidosisABG: probe for acidosis

Laboratory ValuesLaboratory Values

140 110

4.3 20

10.2

31.1144

10855

1.1

11

ABG:ABG: 7.23 | 28 | 80 | 18 | -5

PT:PT: 18 (1.5) PTT: 36

LFTs:LFTs: Normal

What do you think about the labs?

Laboratory Values DiscussionLaboratory Values Discussion

An elevated BUN to Creatinine ratio can be a sign of An elevated BUN to Creatinine ratio can be a sign of upper GI bleed due to the digestion of blood or upper GI bleed due to the digestion of blood or prerenal azotemia.prerenal azotemia.

A patient actively hemorrhaging will show a normal A patient actively hemorrhaging will show a normal Hgb/Hct prior to being resuscitated. Chronic bleeding Hgb/Hct prior to being resuscitated. Chronic bleeding presents with typical iron deficiency anemia.presents with typical iron deficiency anemia.

What would you do now?What would you do now?

Interventions to considerInterventions to consider

ABC’sABC’s Ensure adequate airway protection and adequate Ensure adequate airway protection and adequate

respirationsrespirations Start 2 large bore IV’s.Start 2 large bore IV’s. Fluid bolus either NS or LRFluid bolus either NS or LR

Foley CatheterFoley CatheterNG with gastric lavageNG with gastric lavageSTAT Upper endoscopySTAT Upper endoscopy

EndoscopyEndoscopy

Upon upper endoscopy the Upon upper endoscopy the esophagus appears normal.esophagus appears normal.

There is a large amount of clot in There is a large amount of clot in the stomach, irrigation reveals the stomach, irrigation reveals normal appearing mucosa normal appearing mucosa without signs of ulcer or without signs of ulcer or gastritis.gastritis.

On passing through the pylorus On passing through the pylorus copious gross blood is copious gross blood is encountered with a actively encountered with a actively bleeding ulcer on the posterior bleeding ulcer on the posterior wall of the duodenum.wall of the duodenum.

What would you do now?What would you do now?

Endoscopy

Attempt at injecting with epinepherine, and even direct pressure prove unsuccessful with continued brisk pulsatile bleeding.

Are there any particular endoscopic findings that suggest a higher risk of failed therapy or re-bleeding?

What would you do next?What would you do next?

Repeat Hct is 18Repeat Hct is 18

He is actively bleeding in EndoscopyHe is actively bleeding in Endoscopy

Surgery for Bleeding UlcersSurgery for Bleeding Ulcers

IndicationsIndicationsPre-operative preparationPre-operative preparationOperative approachOperative approachRelevant AnatomyRelevant AnatomyPotential complicationsPotential complications

Operative IndicationsOperative Indications

Duodenal ulcers located on the anterior wall Duodenal ulcers located on the anterior wall are prone to perforation and present as are prone to perforation and present as peritonitis and free air. Those on the posterior peritonitis and free air. Those on the posterior wall, which is the more common location, lead wall, which is the more common location, lead to bleeding.to bleeding.

The gastroduodenal artery passes just distal to The gastroduodenal artery passes just distal to the pylorus and posterior to the duodenum. If the pylorus and posterior to the duodenum. If it or one of it’s branches are in the ulcer crater it or one of it’s branches are in the ulcer crater they may erode and result in massive bleeding.they may erode and result in massive bleeding.

Operative Technique

Patients are explored through an upper midline incision.

An incision is made in the anterior duodenum through the pylorus and distal stomach.

The site of bleeding is identified. The bleeding can then usually be controlled by placing sutures in 3-4 quadrants around the ulcer base.

The gastroduodenal artery may be ligated if necessary

Operative TechniqueOperative Technique

Once bleeding has been controlled, the Once bleeding has been controlled, the horizontal opening through the pyloric channel horizontal opening through the pyloric channel is closed vertically resulting in a Heineke-is closed vertically resulting in a Heineke-Mikulicz pyloroplasty.Mikulicz pyloroplasty.

A truncal vagotomy is then added for long-term A truncal vagotomy is then added for long-term ulcer control. Specimens of both vagal trunks ulcer control. Specimens of both vagal trunks are sent to Pathology to document the vagotomyare sent to Pathology to document the vagotomy

Gastrointestinal Bleeding

Discussion

Gastrointestinal BleedingGastrointestinal Bleeding

Bleeding can arise anywhere along the GI tract. Bleeding can arise anywhere along the GI tract. Bleeding represents the initial symptom of Bleeding represents the initial symptom of gastrointestinal disease in 1/3 of all patients. gastrointestinal disease in 1/3 of all patients. The majority of bleeding will stop The majority of bleeding will stop spontaneously.spontaneously.


Hematemesis- Vomiting of blood. Can be either gross Hematemesis- Vomiting of blood. Can be either gross blood and blood clots representing rapid bleeding or blood and blood clots representing rapid bleeding or “coffee-ground” emesis signifying chronic bleeding. “coffee-ground” emesis signifying chronic bleeding. Hematemesis is the result of bleeding from the Hematemesis is the result of bleeding from the oropharynx to the ligament of Treitz.oropharynx to the ligament of Treitz.

Melena- Passage of black and tarry stool caused by Melena- Passage of black and tarry stool caused by digested blood.digested blood.


Melena is usually the result of severe upper GI Melena is usually the result of severe upper GI bleeding. Melena without hematemesis is bleeding. Melena without hematemesis is caused by severe bleeding distal to the ligament caused by severe bleeding distal to the ligament of Treitz.of Treitz.

Hematochezia- Passage of maroon to red blood Hematochezia- Passage of maroon to red blood and blood clots.and blood clots.


As little as 50-60 mL of blood in the GI tract As little as 50-60 mL of blood in the GI tract produces melena. Melena can persist from 5-7 produces melena. Melena can persist from 5-7 days after a 2 unit bleed and stools can remain days after a 2 unit bleed and stools can remain occult positive up to 3 weeks.occult positive up to 3 weeks.

With upper GI blood loss blood urea nitrogen With upper GI blood loss blood urea nitrogen levels may be elevated to 30-50 mg/dL. A levels may be elevated to 30-50 mg/dL. A BUN: Creatinine ratio greater than 36:1 likely BUN: Creatinine ratio greater than 36:1 likely represents blood loss from an upper GI source.represents blood loss from an upper GI source.

Upper Gastrointestinal BleedingUpper Gastrointestinal Bleeding

Some dependency on socioeconomic factors. Some dependency on socioeconomic factors. Peptic ulcers are more common in suburban Peptic ulcers are more common in suburban hospitals, while gastritis and varices are more hospitals, while gastritis and varices are more common in urban centers. Patients 60 years old common in urban centers. Patients 60 years old and older represent ~ 60% of patients presenting and older represent ~ 60% of patients presenting with upper GI bleeding with a mortality rate of with upper GI bleeding with a mortality rate of 20-25%. For younger patients the mortality rate 20-25%. For younger patients the mortality rate drops to 4%.drops to 4%.


Although elective surgeries for duodenal ulcers Although elective surgeries for duodenal ulcers have dropped off significantly due to H2 have dropped off significantly due to H2 blockers and proton pump inhibitors, the blockers and proton pump inhibitors, the number of surgeries for bleeding duodenal number of surgeries for bleeding duodenal ulcers has remained stable. ulcers has remained stable.

Sudden cessation of H2 blockers or proton Sudden cessation of H2 blockers or proton pump inhibitors may result in a rebound pump inhibitors may result in a rebound increase in acid secretion resulting in GI increase in acid secretion resulting in GI bleeding.bleeding.


Nose bleeds-Nose bleeds- Rarely the cause of major Rarely the cause of major bleeding. It must be ruled out by a careful bleeding. It must be ruled out by a careful examination of the posterior pharynx to insure examination of the posterior pharynx to insure blood is not running down the esophagus, blood is not running down the esophagus, causing hematemesis .causing hematemesis .


EsophagitisEsophagitis- Hiatus hernia and reflux - Hiatus hernia and reflux esophagitis are not common causes of upper GI esophagitis are not common causes of upper GI bleeding. Reflux esophagitis is more likely to bleeding. Reflux esophagitis is more likely to result in chronic occult bleeding usually result in chronic occult bleeding usually associated with grade II-III esophagitis with associated with grade II-III esophagitis with friable mucosa. Significant bleeding in this area friable mucosa. Significant bleeding in this area is more commonly associated with para- is more commonly associated with para- esophageal hernias.esophageal hernias.


Varices-Varices- Bleeding esophageal and gastric Bleeding esophageal and gastric varices in the presence of liver disease account varices in the presence of liver disease account for about 10% of upper GI bleeds and are life for about 10% of upper GI bleeds and are life threatening situations associated with a high threatening situations associated with a high mortality rate. Alcoholism is the most common mortality rate. Alcoholism is the most common cause of portal hypertension but hepatitis B and cause of portal hypertension but hepatitis B and C are becoming common causes.C are becoming common causes.


VaricesVarices- In pediatric patients 95% of all upper GI - In pediatric patients 95% of all upper GI bleeds are caused by variceal hemorrhage, usually as a bleeds are caused by variceal hemorrhage, usually as a consequence of extra hepatic portal venous obstruction. consequence of extra hepatic portal venous obstruction. In patients with cirrhosis and portal hypertension In patients with cirrhosis and portal hypertension variceal hemorrhage accounts for 50-75% of all upper variceal hemorrhage accounts for 50-75% of all upper GI bleeds. Variceal hemorrhage is usually precipitated GI bleeds. Variceal hemorrhage is usually precipitated by ulceration of the varix secondary to reflux by ulceration of the varix secondary to reflux esophagitis or increased pressure within the varix. esophagitis or increased pressure within the varix.


VaricesVarices- In patients with liver disease bleeding - In patients with liver disease bleeding is precipitated by the inability of the liver to is precipitated by the inability of the liver to synthesize clotting factors. Initial therapy synthesize clotting factors. Initial therapy includes sclerotherapy, ligation and vasopressin. includes sclerotherapy, ligation and vasopressin. Ligation is as effective as sclerotherapy with Ligation is as effective as sclerotherapy with fewer complications. If unsuccessful shunting fewer complications. If unsuccessful shunting or transplant may be necessary. or transplant may be necessary.


Mucosal tear (Mallory-Weiss)Mucosal tear (Mallory-Weiss) Esophagogastric mucosal tear or Mallory-Weiss tear Esophagogastric mucosal tear or Mallory-Weiss tear

account for 5-10% of all upper GI bleeds. Mallory-Weiss account for 5-10% of all upper GI bleeds. Mallory-Weiss tears present in a classic pattern. Initially the patient has tears present in a classic pattern. Initially the patient has vomiting without blood. Continued emesis leads to pain vomiting without blood. Continued emesis leads to pain from the tear and eventually the patient develops from the tear and eventually the patient develops hematemesis. 90% of Mallory-Weiss bleeding resolves hematemesis. 90% of Mallory-Weiss bleeding resolves spontaneously and require no further therapy. spontaneously and require no further therapy.

If bleeding persists, endoscopic therapy with injection of If bleeding persists, endoscopic therapy with injection of vasoconstrictive agents, IV vasopressin or balloon vasoconstrictive agents, IV vasopressin or balloon tamponade with Sengstaken-Blakemoore tube may be tamponade with Sengstaken-Blakemoore tube may be necessary.necessary.


GastritisGastritis• Up to 1/3 of upper GI bleeds are caused by diffuse Up to 1/3 of upper GI bleeds are caused by diffuse

gastritis. Erosions are usually multiple and found gastritis. Erosions are usually multiple and found primarily in the fundus and body of the stomach. Chronic primarily in the fundus and body of the stomach. Chronic slow bleeds are most commonly associated with H. pylori, slow bleeds are most commonly associated with H. pylori, while more brisk bleeding is usually a result of ingested while more brisk bleeding is usually a result of ingested substances harmful to the gastric mucosa such as NSAIDs, substances harmful to the gastric mucosa such as NSAIDs, alcohol, steroids, or other drugs.alcohol, steroids, or other drugs.

• Treatment is with vasopressin, iced saline lavage, Treatment is with vasopressin, iced saline lavage, sucralfate, H2 blockers, and proton pump inhibitors. sucralfate, H2 blockers, and proton pump inhibitors. Bleeds refractory to these treatments may require Bleeds refractory to these treatments may require electrocautery, vagotomy and antrectomy or even total electrocautery, vagotomy and antrectomy or even total gastrectomy.gastrectomy.


Peptic ulcerPeptic ulcer• Most common cause of upper GI bleed, encompassing 1/2- Most common cause of upper GI bleed, encompassing 1/2-

2/3 of patients. Bleeding is presenting symptom in up to 2/3 of patients. Bleeding is presenting symptom in up to 10% of these patients. Duodenal bleed is four times more 10% of these patients. Duodenal bleed is four times more common than gastric ulcer bleed. Duodenal ulcers are common than gastric ulcer bleed. Duodenal ulcers are usually posterior and involve branches of the usually posterior and involve branches of the gastroduodenal artery.gastroduodenal artery.

• Benign gastric ulcers bleed more than malignant ulcers. Benign gastric ulcers bleed more than malignant ulcers. There will be significant bleeding in 10-15% of peptic There will be significant bleeding in 10-15% of peptic ulcers and surgical intervention is needed in 20% of these ulcers and surgical intervention is needed in 20% of these patientspatients


Stress ulcersStress ulcers• Stress ulcers refer to acute gastroduodenal lesions that Stress ulcers refer to acute gastroduodenal lesions that

arise after episodes of shock, sepsis, surgery, trauma, burns arise after episodes of shock, sepsis, surgery, trauma, burns ((Curling’s ulcerCurling’s ulcer), or intracrainial pathology or surgery ), or intracrainial pathology or surgery ((Cushing’s ulcerCushing’s ulcer). Specific risk factors associated with ). Specific risk factors associated with these ulcers are, multi system trauma, hypotension, these ulcers are, multi system trauma, hypotension, respiratory failure, sepsis, jaundice, recent surgery and respiratory failure, sepsis, jaundice, recent surgery and burns.burns.

• It is believed that stress ulceration is the result of bile It is believed that stress ulceration is the result of bile reflux damage to the gastric protective barrier combined reflux damage to the gastric protective barrier combined with decreased gastric blood flow secondary to splanchnic with decreased gastric blood flow secondary to splanchnic vasoconstriction. Sepsis, coagulopathy, and activation of vasoconstriction. Sepsis, coagulopathy, and activation of cytokines may also play a role in the formation of stress cytokines may also play a role in the formation of stress ulcers. ulcers.


Other causesOther causes• Miscellaneous causes may contribute up to 18% of upper Miscellaneous causes may contribute up to 18% of upper

GI bleeds. GI bleeds. Gastric neoplasmsGastric neoplasms both malignant and benign both malignant and benign can cause bleeding which is usually mild and chronic. can cause bleeding which is usually mild and chronic. Dieulafoy’s vascular malformationsDieulafoy’s vascular malformations are dilated arterial are dilated arterial lesions usually amendable to endoscopic injection. lesions usually amendable to endoscopic injection.

• Aorto-enteric fistulasAorto-enteric fistulas can present as a herald bleed can present as a herald bleed followed by a massive bleed in patients with prior aortic followed by a massive bleed in patients with prior aortic reconstructions. reconstructions. HematobiliaHematobilia can be found in patients can be found in patients following hepatic injuries or manipulations.following hepatic injuries or manipulations.


ManagementManagement- Complete history with inquiries of - Complete history with inquiries of peptic ulcer disease, alcohol use, cirrhosis, heart burn, peptic ulcer disease, alcohol use, cirrhosis, heart burn, reflux, and medications. Exam looking for signs of reflux, and medications. Exam looking for signs of cirrhosis including spider angiomata, palmer cirrhosis including spider angiomata, palmer erythema, prominent abdominal veins, caput medusa, erythema, prominent abdominal veins, caput medusa, and ascites. Examine mucous membranes for and ascites. Examine mucous membranes for melanin spots associated with Puetz-Jeghers melanin spots associated with Puetz-Jeghers syndrome. Perform rectal exam and check for occult syndrome. Perform rectal exam and check for occult blood in the stool.blood in the stool.


ManagementManagement- Fluid resuscitation, foley, naso-- Fluid resuscitation, foley, naso-gastric tube, gastric lavage and arterial line.gastric tube, gastric lavage and arterial line.

LabsLabs- Complete blood count with platelets, - Complete blood count with platelets, comprehensive metabolic panel with liver comprehensive metabolic panel with liver functions, and coagulation studies. Cross functions, and coagulation studies. Cross match for blood transfusion. match for blood transfusion.


Studies/Treatment :Studies/Treatment :• EGD with sclerotherapy or electrocautery, EGD with sclerotherapy or electrocautery,

tagged red blood cell scan, arteriography with tagged red blood cell scan, arteriography with embolization. embolization.

• If esophageal bleeding does not respond to If esophageal bleeding does not respond to sclerotherapy, ligation, or intravenous sclerotherapy, ligation, or intravenous vasopressin, Sengstaken-Blakemoore tube vasopressin, Sengstaken-Blakemoore tube should be used.should be used.


TIPS- for portal hypertensionTIPS- for portal hypertension• Trans jugular intrahepatic porto-systemic shunt. Trans jugular intrahepatic porto-systemic shunt.

Used for bleeding secondary to portal hypertension. Used for bleeding secondary to portal hypertension. Associated with in hospital mortality rate of 35-56%. Associated with in hospital mortality rate of 35-56%. Encephalopathy rate is the same as for patients who Encephalopathy rate is the same as for patients who undergo porto-caval shunts. Stenosis or occlusion of undergo porto-caval shunts. Stenosis or occlusion of TIPS is up to 50% at one year.TIPS is up to 50% at one year.

Lower Gastrointestinal BleedingLower Gastrointestinal Bleeding

Small Bowel- Small Bowel- Small bowel accounts for 10-15% of Small bowel accounts for 10-15% of all lower GI bleeds. Usually a diagnosis of exclusion. all lower GI bleeds. Usually a diagnosis of exclusion. Seeing blood exiting the ileo-cecal valve accounts for Seeing blood exiting the ileo-cecal valve accounts for 10% of diagnoses. Causes include, Meckel’s 10% of diagnoses. Causes include, Meckel’s diverticulum, Crohn’s disease, intussusception, diverticulum, Crohn’s disease, intussusception, neoplasm, vascular malformations, intestinal varices, neoplasm, vascular malformations, intestinal varices, blood dyscrasias, non-Meckel’s diverticulum, blood dyscrasias, non-Meckel’s diverticulum, mesenteric thrombosis, drug reactions, enteric mesenteric thrombosis, drug reactions, enteric infections, and polyps.infections, and polyps.


ColonColon- Most often related to polyps or - Most often related to polyps or neoplastic disease (occult). Right sided lesions neoplastic disease (occult). Right sided lesions usually present through anemia and guaiac usually present through anemia and guaiac positive stools. Larger bleeds can arise from positive stools. Larger bleeds can arise from diverticuli or angiodysplastic lesions on either diverticuli or angiodysplastic lesions on either the right or left side. the right or left side.


Angiodysplastic lesionsAngiodysplastic lesions have the following have the following characteristics. They are not congenital or neoplastic characteristics. They are not congenital or neoplastic but degenerative. They are not associated with other but degenerative. They are not associated with other vascular lesions. They increase with age. They are vascular lesions. They increase with age. They are usually small < 5mm. They can be diagnosed by usually small < 5mm. They can be diagnosed by colonoscopy. 80% of angiodysplastic bleeds will stop colonoscopy. 80% of angiodysplastic bleeds will stop spontaneously and 50% will re- bleed within 3 years.spontaneously and 50% will re- bleed within 3 years.

Ulcerative colitis-Ulcerative colitis- Usually cause chronic bloody Usually cause chronic bloody diarrhea, but massive bleeds can occurdiarrhea, but massive bleeds can occur


Management- Complete H&P. Fluid Management- Complete H&P. Fluid resuscitation, foley, naso-gastric tube, gastric resuscitation, foley, naso-gastric tube, gastric lavage and arterial line.lavage and arterial line.

Labs- Complete blood count with platelets, Labs- Complete blood count with platelets, comprehensive metabolic panel with liver comprehensive metabolic panel with liver functions, and coagulation studies. Cross functions, and coagulation studies. Cross match for blood transfusion.match for blood transfusion.


Studies/Treatment:Studies/Treatment:• Normalize coagulation. Colonoscopy, tagged Normalize coagulation. Colonoscopy, tagged

red blood cell scan 91% sensitive and 100% red blood cell scan 91% sensitive and 100% specific. Angiography with or without coil specific. Angiography with or without coil embolization.embolization.

• Local resection of defined bleeds, otherwise if Local resection of defined bleeds, otherwise if bleeding continues and no source can be bleeding continues and no source can be identified within the colon, total colectomy is identified within the colon, total colectomy is indicated.indicated.

Rectal and Anal BleedingRectal and Anal Bleeding

Fresh red blood on the exterior of stool usually Fresh red blood on the exterior of stool usually represents hemorrhoids, fissures, or proctitis. represents hemorrhoids, fissures, or proctitis. Bleeding that drops into the toilet water is most Bleeding that drops into the toilet water is most likely the result of fissures or hemorrhoids. All likely the result of fissures or hemorrhoids. All rectal bleeding should be fully investigated with rectal bleeding should be fully investigated with full H&P, anoscopy / proctoscopy and if full H&P, anoscopy / proctoscopy and if necessary exam under anesthesia.necessary exam under anesthesia.

QUESTIONS ??????QUESTIONS ??????

Acknowledgment The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATIONASSOCIATION FOR SURGICAL EDUCATION

In order to improve our educational materials wewelcome your comments/ suggestions at:

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ugi bleed obie m. powell, m.d. joseph a. iocono, m.d. department of surgery university of kentucky

Documents

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prior abdominal surgery

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peritonitis abdominal

dehydration abdominal

physical exam head