GASTROINTESTINAL HEMORRHAGE :GASTROINTESTINAL HEMORRHAGE Roger P. Tatum, MD Assistant Professor, University of Washington Department of Surgery or, “What’s that smell…?”


GASTROINTESTINAL HEMORRHAGE :GASTROINTESTINAL HEMORRHAGE CASE #1 54 y/o male complains of fatigue and multiple dark, tarry stools for 2 days PMH: HTN, hypercholesterolemia; no surgical history; never had colonoscopy PEX: abdomen—soft, nontender, nondistended; rectal—no masses, heme+


GASTROINTESTINAL HEMORRHAGE Signs and Symptoms of GI Bleed :GASTROINTESTINAL HEMORRHAGE Signs and Symptoms of GI Bleed Hematemesis/ “coffee ground” emesis Melena—dark, tarry, foul-smelling stool Hematochezia—bright red blood per rectum Microcytic anemia Chronic fatigue—secondary to anemia Hypotension, tachycardia, mental status change—serious problem


GASTROINTESTINAL HEMORRHAGE Upper GI Bleed :GASTROINTESTINAL HEMORRHAGE Upper GI Bleed Bleeding from the foregut—mouth to ligament of Treitz Acute or chronic History is key element in workup


GASTROINTESTINAL HEMORRHAGE Upper GI Bleed—Acute Sources :GASTROINTESTINAL HEMORRHAGE Upper GI Bleed—Acute Sources Epistaxis (often overlooked) Oropharyngeal lesions Esophageal varices Mallory-Weiss syndrome Hemorrhagic gastritis Gastric or duodenal ulcer


GASTROINTESTINAL HEMORRHAGE Upper GI Bleed—Chronic Sources :GASTROINTESTINAL HEMORRHAGE Upper GI Bleed—Chronic Sources Esophageal Cancer Erosive esophagitis Paraesophageal hiatus hernia/Cameron lesions Gastric tumor Gastritis Gastric or duodenal ulcer


GASTROINTESTINAL HEMORRHAGE Upper GI Bleed—Workup :GASTROINTESTINAL HEMORRHAGE Upper GI Bleed—Workup History—as often, one of the most important elements: Hematemesis or “coffee grounds” most common in acute bleed Melena often presents later History of NSAID use—suggests gastritis or PUD Alcohol, cirrhosis—suggests varices or Mallory-Weiss GERD—in chronic bleed, esophagitis or Cameron lesions


GASTROINTESTINAL HEMORRHAGE Upper GI Bleed—Workup :GASTROINTESTINAL HEMORRHAGE Upper GI Bleed—Workup History—cont’d Antecedent pain—suggests ulcer or gastritis H/o recent trauma or major surgery—stress gastritis (Cushing’s ulcer, Curling’s ulcer)


GASTROINTESTINAL HEMORRHAGE Upper GI Bleed—Workup :GASTROINTESTINAL HEMORRHAGE Upper GI Bleed—Workup Physical Exam Not as helpful as history Abdominal tenderness uncommon Check nasopharynx, oropharynx


GASTROINTESTINAL HEMORRHAGE Upper GI Bleed—Workup :GASTROINTESTINAL HEMORRHAGE Upper GI Bleed—Workup Laboratory Hgb/Hct (remember, may not reflect true blood volume in patient with acute rapid bleed) PT/PTT—may need to correct coagulopathy Electrolytes—assess for dehydration, guide resuscitation Radiologic studies usually not initially helpful


GASTROINTESTINAL HEMORRHAGE Upper GI Bleed—Workup :GASTROINTESTINAL HEMORRHAGE Upper GI Bleed—Workup Nasogastric aspiration (acute bleed only) If completely negative, UGI source is not ruled out Can irrigate—if able to clear, then bleed may no longer be active Can be helpful in preparation for upper endoscopy


GASTROINTESTINAL HEMORRHAGE Upper GI Bleed—Workup :GASTROINTESTINAL HEMORRHAGE Upper GI Bleed—Workup Upper Endoscopy Most useful single diagnostic tool—90% success Nearly all sources of UGI bleeding may be identified Can be done (and often should) in ICU Often therapy delivered simultaneously


GASTROINTESTINAL HEMORRHAGE Acute Upper GI Bleed—Treatment :GASTROINTESTINAL HEMORRHAGE Acute Upper GI Bleed—Treatment RESUSCITATION! Patient should be transferred to ICU setting Ensure large bore IV access, may need central line Aggressive hydration Place Foley catheter to monitor hydration and efficacy of resuscitation Type and cross for 4U PRBCs Correct any coagulopathy Transfuse depending on Hgb/Hct and history of patient


GASTROINTESTINAL HEMORRHAGE Acute Upper GI Bleed—Treatment :GASTROINTESTINAL HEMORRHAGE Acute Upper GI Bleed—Treatment Endoscopic Can be therapeutic for many sources of UGI bleed Ulcer—can inject epinephrine or coagulate with heater probe in setting of “visible vessel” or “cherry red spot” Varices—banding or injection


GASTROINTESTINAL HEMORRHAGE Acute Upper GI Bleed—Treatment :GASTROINTESTINAL HEMORRHAGE Acute Upper GI Bleed—Treatment Angiography Typically reserved for failure of endoscopic treatment Localization of bleeding vessel Embolization with Gelfoam, coils Injection of vasopressin Can also aid localization of source when not evident by endoscopy


GASTROINTESTINAL HEMORRHAGE Acute Upper GI Bleed—Treatment :GASTROINTESTINAL HEMORRHAGE Acute Upper GI Bleed—Treatment Surgery—indications Failure of endoscopic control (usually after 2+ attempts) Transfusion requirement of 6 or more U PRBCs Hemodynamic instability despite resuscitation Usually for bleeding ulcers Occasionally for hemorrhagic gastritis, Mallory Weiss tears, varices (see next)


GASTROINTESTINAL HEMORRHAGE Acute Upper GI Bleed—Treatment :GASTROINTESTINAL HEMORRHAGE Acute Upper GI Bleed—Treatment Surgery—approach and strategy Preop localization is essential Typically, midline epigastric incision (celiotomy) For DU: duodenotomy, oversew vessel, vagotomy and pyloroplasty or antrectomy (particularly if patient already on anti-secretory therapy)


GASTROINTESTINAL HEMORRHAGE Acute Upper GI Bleed—Treatment :GASTROINTESTINAL HEMORRHAGE Acute Upper GI Bleed—Treatment


GASTROINTESTINAL HEMORRHAGE Acute Upper GI Bleed—Treatment :GASTROINTESTINAL HEMORRHAGE Acute Upper GI Bleed—Treatment Surgery—approach and strategy—cont’d Gastric ulcer—gastrotomy and oversew, wedge gastrectomy (depends on location), subtotal gastrectomy Mallory-Weiss tears—gastrotomy, oversew bleeding site


GASTROINTESTINAL HEMORRHAGE Acute Upper GI Bleed—Treatment :GASTROINTESTINAL HEMORRHAGE Acute Upper GI Bleed—Treatment A word on varices: Can start IV octreotide prior to endoscopy (increases success rate) Endoscopic therapy is treatment of choice, may need several treatments Use of the Sengstaken-Blakemore tube (includes football helmet) for severe, rapid hemorrhage—80-90% success, but 60% rebleed


GASTROINTESTINAL HEMORRHAGE Acute Upper GI Bleed—Treatment :GASTROINTESTINAL HEMORRHAGE Acute Upper GI Bleed—Treatment A word on varices—cont’d: Surgery rarely indicated—only with complete failure of above methods Emergency portacaval shunt or Esophageal division or devascularization


GASTROINTESTINAL HEMORRHAGE Chronic Upper GI Bleed—Treatment :GASTROINTESTINAL HEMORRHAGE Chronic Upper GI Bleed—Treatment Nearly always managed medically; Therefore, we will not discuss this (and you can’t make me…)


GASTROINTESTINAL HEMORRHAGE Lower GI Bleed--Presentation :GASTROINTESTINAL HEMORRHAGE Lower GI Bleed--Presentation Defined by bleeding source distal to ligament of Treitz Mean age of presentation 63-77 y/o Can present with melena or bright red blood per rectum with or without clots 20% presents as acute “massive” bleeding Often more difficult to localize than UGI bleed


GASTROINTESTINAL HEMORRHAGE Lower GI Bleed—Acute Sources :GASTROINTESTINAL HEMORRHAGE Lower GI Bleed—Acute Sources Diverticulosis Angiodysplasia (AVM)—more common in >65 Ischemic colitis Meckel’s diverticulum Infectious colitis (C. diff, E. coli, campylobacter) IBD (ulcerative colitis>Crohn’s disease) Malignancy (rare cause of acute bleed)


GASTROINTESTINAL HEMORRHAGE Lower GI Bleed—Chronic Sources :GASTROINTESTINAL HEMORRHAGE Lower GI Bleed—Chronic Sources Malignancy (most common chronic LGI source) Benign small or large bowel polyps Angiodysplasia IBD Hemorrhoids Anal fissure


GASTROINTESTINAL HEMORRHAGE Lower GI Bleed—Workup :GASTROINTESTINAL HEMORRHAGE Lower GI Bleed—Workup History Character and quantity of blood History of HTN, CAD, PVD (ischemic colitis) History of IBD Anticoagulation or coagulopathy


GASTROINTESTINAL HEMORRHAGE Lower GI Bleed—Workup :GASTROINTESTINAL HEMORRHAGE Lower GI Bleed—Workup Exam Look for abdominal masses Listen for bruits Rectal—masses, characterize blood, look for anal pathology such as hemorrhoids, fissures


GASTROINTESTINAL HEMORRHAGE Lower GI Bleed—Workup :GASTROINTESTINAL HEMORRHAGE Lower GI Bleed—Workup Laboratory (look familiar?) Hgb/Hct (remember, may not reflect true blood volume in patient with acute rapid bleed) PT/PTT—may need to correct coagulopathy Electrolytes—assess for dehydration, guide resuscitation Radiologic studies—CT may show thickening of bowel in case of mesenteric ischemia; diverticulosis usually easily identified


GASTROINTESTINAL HEMORRHAGE Lower GI Bleed—Workup :GASTROINTESTINAL HEMORRHAGE Lower GI Bleed—Workup Rule out Upper GI bleed source! Follow initial steps in algorithm for UGI bleed Patient may need EGD for differentiation


GASTROINTESTINAL HEMORRHAGE Lower GI Bleed—Workup :GASTROINTESTINAL HEMORRHAGE Lower GI Bleed—Workup Colonoscopy Often 1st maneuver Visualization difficult secondary to invariably poor prep


GASTROINTESTINAL HEMORRHAGE Lower GI Bleed—Workup :GASTROINTESTINAL HEMORRHAGE Lower GI Bleed—Workup Tagged RBC scan (nuclear medicine) 99mTc-pertechnaetate-labeled RBCs, IV injection Demonstrates bleeding source when rate of bleed=0.1-0.5ml/minute Allows repeated evaluation over course of 24 hours May not exactly localize source—may not be able to differentiate colon from small bowel Typically not used alone for localization


GASTROINTESTINAL HEMORRHAGE Lower GI Bleed—Workup :GASTROINTESTINAL HEMORRHAGE Lower GI Bleed—Workup Angiography Better for specific localization Sensitive for bleeding rate 0.5-1.5ml/minute Often requires large amount of contrast (beware renal insufficiency) Can be therapeutic (embolization, vasopressin)


GASTROINTESTINAL HEMORRHAGE Lower GI Bleed—Workup :GASTROINTESTINAL HEMORRHAGE Lower GI Bleed—Workup Provocative Angiography When bleeding is recurrent and suspected to be from colonic source, can inject heparin and/or tPA Treatment then delivered immediately when bleeding discovered May require urgent trip to OR if angiographic therapy fails


GASTROINTESTINAL HEMORRHAGE Lower GI Bleed—Workup :GASTROINTESTINAL HEMORRHAGE Lower GI Bleed—Workup Capsule Endoscopy When unable to localize intermittent bleed via above methods, may be effective in defining source May be the only way to identify small bowel source


GASTROINTESTINAL HEMORRHAGE Acute Lower GI Bleed—Treatment :GASTROINTESTINAL HEMORRHAGE Acute Lower GI Bleed—Treatment RESUSCITATION! (once again, in case you forgot) Patient should be transferred to ICU setting Ensure large bore IV access, may need central line Aggressive hydration Place Foley catheter to monitor hydration and efficacy of resuscitation Type and cross for 4U PRBCs Correct any coagulopathy Transfuse depending on Hgb/Hct and history of patient


GASTROINTESTINAL HEMORRHAGE Acute Lower GI Bleed—Treatment :GASTROINTESTINAL HEMORRHAGE Acute Lower GI Bleed—Treatment Colonoscopy Often unsuccessful due to difficulties in localization May be effective in situations such as sclerosis of AVM


GASTROINTESTINAL HEMORRHAGE Acute Lower GI Bleed—Treatment :GASTROINTESTINAL HEMORRHAGE Acute Lower GI Bleed—Treatment Angiography As in UGI bleed, embolization with coils or gelfoam, vasopressin injection 5-10% risk of bowel infarction


GASTROINTESTINAL HEMORRHAGE Acute Lower GI Bleed—Treatment :GASTROINTESTINAL HEMORRHAGE Acute Lower GI Bleed—Treatment Surgery Typically, segmental resection of small bowel or colon (NOT enterotomy and repair) Usually very dependent on preoperative localization In cases where localization not possible, can do on-table push enteroscopy to look past ligament of Treitz