G I bleeding for Undergraduates Dr Shatdal Chaudhary

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UGI Bleeding for UG Medical Students

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Upper and Lower Gastrointestinal Bleeding:

Upper and Lower Gastrointestinal Bleeding Dr. Shatdal Chaudhary MD Assistant Professor Department of Internal Medicine, UCMS, Bhairahawa

G I Bleeding:

G I Bleeding Acute Vs Chronic Upper Vs Lower Bleeding above/below the ligament of Treitz

Acute U G I Bleeding:

Acute U G I Bleeding Introduction Most common gastrointestinal emergency Accounting for 50-120 admissions to hospital per 100 000 of the population each year in the U K. Higher among males, elderly

Causes of Upper GI Bleed (UGIB) :

Causes of Upper GI Bleed (UGIB) Peptic Ulcer Disease (60% cases of UGIB) Erosive Gastritis(10-20%) Esophagitis (10%) Esophageal and Gastric Varices (2-9%) Mallory-Weiss Syndrome(5%) Malignancy(2%) Others Stress ulcer, arteriovenous malformation, Aorto-duodenal Fistula, corrosive poisoning

Clinical Features::

Clinical Features: History: Usually presents with obvious complaints Hematemesis Melaena Hematochezia or may present with more subtle signs (hypotension, tachycardia, etc) H/o NSAIDs, Alcohol abuse, corrosive intake Weight loss/change in bowel habit (malignancy) Vomiting/retching followed by hematemesis (Mallory-Weiss) Hx aortic graft (possible aortocentric fistula)

Clinical Features: :

Clinical Features: Physical Exam Hypotension, tachycardia Skin: cool, clammy, jaundice, spider angioma and other stigmata of CLD Lymph node Abd: tenderness, masses, ascites, hepatosplenomegaly PR Exam: blood

Estimation of blood loss:

Estimation of blood loss

Investigations::

Investigations: Blood tests Blood Group Full blood count. Hb: may be normal or Low. Urea and electrolytes. may show evidence of renal failure. LFT. Prothrombin time & Coagulation Profile. Cross-matching of at least 2 units of blood.

PowerPoint Presentation:

UGI Endoscopy: Diagnostic as well as therapeutic should be carried out as early as possible after adequate resuscitation. A diagnosis will be achieved in 80% of cases. Patients who are found to have major endoscopic stigmata of recent haemorrhage can be treated endoscopically

PowerPoint Presentation:

Angiography: sometimes can localize, but requires brisk bleeding rate (0.5 to 2.0 ml/min) Technetium-labeled red cell scan: more sensitive than angiography

Forrest classification:

Forrest classification Acute hemorrhage Forrest I a (Spurting hemorrhage) Forrest I b (Oozing hemorrhage) Signs of recent hemorrhage Forrest II a (Visible vessel) Forrest II b (Adherent clot) Forrest II c (Hematin on ulcer base) Lesions without active bleeding Forrest III (Lesions without signs of recent hemorrhage or fibrin-covered ulcer base)

Treatment:

Treatment Primary ABCs Oxygen This should be given by facemask to all patients in shock. Close monitoring Immediate resuscitation, 2 wide bore IV cannula NG tube in all patients with significant bleeding Consider blood transfusion if no improvement after 2L of crystalloid or Hb < 10 gm/dL

PowerPoint Presentation:

Therapeutic Endoscopy Early treatment indicated when significant upper GI bleed Sclerotherapy or band ligation used to treat varices thermal modality 'heater probe‘ injection of dilute adrenaline (epinephrine) into the bleeding point application of metallic clips. Drug Therapy Intravenous proton pump inhibitor infusions reduce rebleeding Somatostatin and octreotide effective for reduction of acute variceal bleeding

PowerPoint Presentation:

Balloon Tamponade Sengstaken-Blakemore tube can control variceal hemorrhage in 40 – 80% patients Inflate gastric balloon first, the esophageal balloon if no improvement

PowerPoint Presentation:

Surgery – if all other interventions are ineffective endoscopic haemostasis fails to stop active bleeding rebleeding occurs on one occasion in an elderly or frail patient, or twice in younger, fit patients

Prognosis::

Prognosis: Mortality following a diagnosis of acute upper gastrointestinal bleeding is approximately 10%.

RISK FACTORS FOR DEATH IN PATIENTS WITH ACUTE U GI HAEMORRHAGE:

RISK FACTORS FOR DEATH IN PATIENTS WITH ACUTE U GI HAEMORRHAGE Factor Comments Increasing age: Risk increases over age 60 and especially in very elderly Comorbidity: Advanced malignancy; renal and hepatic failure Shock: Def as pulse > 100/min, BP < 100 Diagnosis: Varices and cancer have the worst prognosis Endoscopic findings: Active bleeding and a non- bleeding visible vessel at endoscopy Rebleeding Associated with 10-fold rise in mortality

Lower GI Bleeding:

Lower GI Bleeding Bleeding below the ligament of Treitz This may be due to haemorrhage from the small bowel colon or anal canal Incidence: 20 per 100,000 population

PowerPoint Presentation:

CAUSES OF LOWER GI BLEEDING Severe acute Diverticular disease Angiodysplasia Ischaemia Meckel's diverticulum Moderate, chronic/subacute Anal disease, e.g. fissure, haemorrhoids Inflammatory bowel disease Carcinoma Large polyps Angiodysplasia Radiation enteritis Solitary rectal ulcer

ETIOLOGY:

ETIOLOGY

Clinical Features:

Clinical Features OCCULT GI BLEEDING 'Occult' means that blood or its breakdown products are present in the stool but cannot be seen. Occult bleeding may reach 200 ml per day

Options to diagnose and control the bleeding:

Options to diagnose and control the bleeding Colonoscopy technetium-99m labeled RBC scan: requires 0.5-1 ml/min bleeding Mesenteric angiography: requires 1-1.5 ml/min bleeding Capsule Endoscopy Surgery

PowerPoint Presentation:

Colonscopy: diagnostic and therapeutic colonoscopy is necessary to exclude coexisting colorectal cancer. subjects who also have altered bowel habit and in all patients presenting at over 40 years of age,

Treatment:

Treatment Acute bleeding tends to be self limiting If bleeding persists perform endoscopy to exclude upper GI cause Therapeutic colonoscopy/Surgery Consider selective mesenteric embolisation if life threatening haemorrhage Proceed to laparotomy and consider on-table lavage an panendoscopy If right-sided angiodysplasia perform a right hemicolectomy If bleeding diverticular disease perform a sigmoid colectomy If source of colonic bleeding unclear perform a subtotal colectomy and end-ileostomy

The End:

The End

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