Scribd Logo
Upload

Welcome to Scribd!

  • 108 views

    GI Hemorrhage: April 29, 2012 David Hughes

    Uploaded by

    Gendis Hendrarto
    1. Gastrointestinal hemorrhage accounts for 1-2% of hospital admissions and is a common cause of ICU admission. The mortality rate is 5-12% overall but rises to 40% for recurrent bleeders. 2. The majority (85%) of GI hemorrhage comes from the upper GI tract. Common causes are peptic ulcer disease, variceal hemorrhage, and colonic diverticulosis. 3. For a patient presenting with hematemesis and orthostatic hypotension but no tachycardia, the estimated blood loss is 20-40% based on clinical signs.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPTX, PDF, TXT or read online from Scribd

    GI Hemorrhage: April 29, 2012 David Hughes

    Uploaded by

    Gendis Hendrarto
    108 views50 pages
    1. Gastrointestinal hemorrhage accounts for 1-2% of hospital admissions and is a common cause of ICU admission. The mortality rate is 5-12% overall but rises to 40% for recurrent bleeders. 2. The majority (85%) of GI hemorrhage comes from the upper GI tract. Common causes are peptic ulcer disease, variceal hemorrhage, and colonic diverticulosis. 3. For a patient presenting with hematemesis and orthostatic hypotension but no tachycardia, the estimated blood loss is 20-40% based on clinical signs.

    Original Title

    GI Hemorrhage

    Copyright

    © Attribution Non-Commercial (BY-NC)

    Available Formats

    PPTX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    1. Gastrointestinal hemorrhage accounts for 1-2% of hospital admissions and is a common cause of ICU admission. The mortality rate is 5-12% overall but rises to 40% for recurrent bleeders. 2. The majority (85%) of GI hemorrhage comes from the upper GI tract. Common causes are peptic ulcer disease, variceal hemorrhage, and colonic diverticulosis. 3. For a patient presenting with hematemesis and orthostatic hypotension but no tachycardia, the estimated blood loss is 20-40% based on clinical signs.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    108 views50 pages

    GI Hemorrhage: April 29, 2012 David Hughes

    Uploaded by

    Gendis Hendrarto
    1. Gastrointestinal hemorrhage accounts for 1-2% of hospital admissions and is a common cause of ICU admission. The mortality rate is 5-12% overall but rises to 40% for recurrent bleeders. 2. The majority (85%) of GI hemorrhage comes from the upper GI tract. Common causes are peptic ulcer disease, variceal hemorrhage, and colonic diverticulosis. 3. For a patient presenting with hematemesis and orthostatic hypotension but no tachycardia, the estimated blood loss is 20-40% based on clinical signs.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    You are on page 1of 50

    GI Hemorrhage

    April 29, 2012 David Hughes

    Incidence

    1-2% of all hospital admissions

    Most common diagnosis of new ICU admits

    5-12% mortality

    40% for recurrent bleeders

    85% stop sponateously

    Those with massive bleeding need urgent intervention Only 5-10% need operative intervention after endoscopic interventions

    Site

    Upper

    Esophageal Stomach Doudenum Hepatic Pancreatic

    Lower

    Small bowel Colon Anus

    Etiology

    85% are due to:


    Peptic ulcer disease Variceal hemorrhage Colonic diverticulosis Angiodysplasia

    Chain of events
    1. 2. 3. 4. 5.

    Recognize severity Establish access for resusitation Resusitate Identify source Intervention

    Question #1

    JB a 30 y/o with hematemesis presents with orthostatic hypotension, clammy hands, but without tachycardia. How much blood has he lost?
    a) b)

    c)
    d)

    >40% 20-40% 10-20% <10%

    Question #1

    JB a 30 y/o with hematemesis presents with orthostatic hypotension, clammy hands, but without tachycardia. How much blood has he lost?
    b) 20-40%

    Upper GI hemorrhage

    How do you know its upper?


    85% of all GI hemorrhage is upper Hematemesis diagnostic

    Dont forget about nasal bleeding as possible source Degradation of hemoglobin to hematin by acid Bowel bacteria and digestive enzymes also contribute 10% of patients with very rapid UGI source

    Melena

    Hematochezia

    Gastric varices

    Gastric varices

    Esophageal Varices

    Gastric varices

    Bleeding ulcers

    Esophageal Varices

    Gastritis

    Gastritis

    Dieulafoys lesion

    Mallory-weiss

    Watermelon stomach

    Upper GI hemorrhage

    Etiology

    Peptic ulcer disease - 50% Varices 10-20% Gastritis 10-25% Mallory-weiss 8-10% Esophagitis 3-5% Malignancy 3% Dieulafoys lesion 1-3% Watermelon stomach 1-2%

    Upper GI hemorrhage

    Crampy abdominal pain common Large caliber NGT

    Coffee grounds or gross blood No blood Can be used for lavage prior to endoscopy Melena or hematochezia with hypotension Hematemesis NGT with guiac positive fluid Should be completed in 24hrs for stable patients

    Upper endoscopy indications

    Peptic ulcer hemorrhage

    Peptic ulcer disease


    20% of patients bleed at least once Most lethal complication Vessel is usually <1mm diameter Causes

    H. pylori 40-50% NSAIDs 40-50% Other (Z-E syndrome)

    Peptic ulcer hemorrhage

    Predictors of mortality

    Renal disease 29%

    Acute renal failure 63% Jaundice 42% Respiratory failure 57% Congestive heart failure 28%

    Liver disease 25%

    Pulmonary disease 23%

    Cardiac disease 13%

    Peptic ulcer hemorrhage

    Medical management

    Anti-ulcer medication H. pylori treatment Stop NSAIDs Follow up EGD for gastric ulcer in 6 weeks

    Peptic ulcer hemorrhage

    Endoscopic interventions

    Thermal coagulation Injected agents Success rate

    95% initailly 80% will not rebleed Repeat treatment after 1st rebleed salvages 50% Increased risk of mortality

    Peptic ulcer hemorrhage

    Surgical intervention

    Only 10% of patients Indications


    Failure of endoscopy Significant rebleeding after 1st endoscopy Ongoing transfusion requirement Need for >6 units over 24 hours Earlier for elderly, multiple co-morbidities

    Peptic ulcer hemorrhage

    Anti-secretory surgery??

    Indicated for NSAID pts who need to continued meds H. pylori ulcer disease controversial

    Only 0.2% of pts every require surgery for bleeding ulcer Surgery pts had lower than average H. pylori positivity Oversewing and antibiotics still leave 50% at high risk for rebleeding

    Bottom line: still recommended but without definitive evidence

    Peptic ulcer hemorrhage

    Doudenal ulcer

    Expose ulcer with duodenotomy or duodenopyloromyotomy Direct suture ligation, four quadrent ligation, ligation of gastroduodenal artery Anti-secretory procedure Truncal, parietal cell vagotomy If unstable can use meds

    Peptic ulcer hemorrhage

    Gastric ulcer

    10% are maliganant 30% will rebleed with simple ligation

    Need Resection

    Distal gastrectomy with Bilroth I or II Subtotal gastrectomy for 10% high on lesser curve

    Variceal hemorrhage

    Cirrhotics usually

    25% mortality for each bleeding episode 75% will rebleed 50% mortality with surgery

    Based on Childs class

    Somatostatin or vasopressin w/wo NTG

    TIPS

    Shunt procedures

    Sugiura procedure

    Other sources of UGI hemorrhage

    Mucosal lesions

    Gastritis, ischemia, stress ulceration Key is prevention with acid supression Surgery often requires resection and Roux-en-Y due to multiple bleeding sites >50% mortality with surgery

    Mallory-Weiss

    10% will have significant bleeding 90% stop spontaneously Surgery rare, but gastrotomy with oversewing effective
    Wedge rxn after endoscopic marking 1% of AAA repair patients Herald bleed preceeds exsangunation by hours to days Endoscopy and if negative CT scan and if negative angiography Surgery graft removal and extraanatomic bypass

    Dieulafoys

    Aortoenteric fistula

    LGI hemorrhage

    Sites

    Colon 95-97% Small bowel 3-5%

    Only 15% of massive GI bleeding Finding the site

    Intermittent bleeding common Up to 42% have multiple sites

    Bleeding diverticulosis

    Colonic angiodysplasia Bleeding diverticulosis

    LGI hemorrhage

    Etiology

    Diverticulosis 40-55%

    Right sided lesions > left 90% stop spontaneously 10% rebleed in 1st year and 25% at 4 years Most common cause of SB bleeding in >50 y/o >50% are in right colon Typically bleed slowly 15% of UC patients, 1% of chrons patients Radiation, infectious, AIDS rarely

    Angiodysplasia 3-20%

    Neoplasia

    Inflammatory conditions Vascular Hemorrhoids

    >50% have hemorrhoids, but only 2% of bleeding attributed to them

    Others

    LGI hemorrhage

    Evaluation

    Same for UGI bleed

    If unstable with hematochezia need EGD 1st Rectal Anoscopy for hemorrhoids

    After stable

    LGI hemorrhage diagnostics

    Colonoscopy

    Within 12 hours in stable patients without large amounts of bleeding Need >0.5 ml/min bleeding 40-75% sensitive if bleeding at time of exam

    Selective viseral angiography


    Tagged RBC scan

    Can detect bleeding at 0.1 ml/min 85% sensitive if bleeding at time of exam Not accurate in defining left vs right colon

    Meckels Diverticulum

    Cecal angiodysplasia with extravasation

    Small bowel ulceration due to NSAIDS

    LGI hemorrhage treatment


    Endoscopy

    Great for angiodysplasia and polypectomy sites

    Angiographic

    Selective embolization for poor surgical candidates Can lead to ischemic sites requiring later resection

    Surgery

    Ongoing hemorrhage, >6 units or ongoing transfusion requirement Site selection Blind segmental will rebleed in 75% Based on TRBC scan will rebleed in 35%

    GI hemorrhage from unknown source


    Only 2-5% are not upper or lower Average patient

    26 month duration of intermittent bleeding 1-20 diagnostic tests Average of 20 units transfused

    Localization of GIHOUS

    CT scan

    Tumors, inflammation, diverticuli

    Enteroclysis

    Ulcerations, inflammation Only 10-20% yeild (SBFT is 0-6%)

    Meckels scan

    Initial test for patients <30 years old

    Endoscopy

    Push or pull endoscopy Video capsule endoscopy Intraoperative endoscopy 70% successful

    Etiology of GIHOUS

    Arteriovenous malformation 40 Small bowel leiomyoma 11 Small bowel adenocarcinoma 7 Small bowel lymphoma 6 Crohns disease 6 Watermelon stomach 4 Meckels diverticulum 4 Small bowel leiomyosarcoma 3 Metastatic colon carcinoma to small bowel 3 Small bowel varices 3 Small bowel melanoma 3 Others 10

    Szold A, Katz L, Lewis B: Surgical approach to occult gastrointestinal bleeding. Am J Surg 163:9093, 1992.

    Treatment

    Surgery

    Without localization only for acute exsanguinating hemorrhage Intraoperative endoscopy Segmental resection

    You might also like