GI bleed Flashcards
Definition
Any bleeding from the GI tract - mouth to anus
divided in upper and lower by delineation of the ligament of treitz which is at the duodenojejunal flexure
Upper - esophageous, stomach, duodenum,
Lower - jejenum, ileum, colon, rectum, anal canal
Incidence
70-75% of acute gI bleed
48-160 per 100000
highest incidence in the elderly >65 and in MEN
Epidemiology
ALL GI BLEEDS
increases with increasing age
usually self limiting
20% have recurrent bleed - poorer prognosis
mortality - most common over 60
UPPER
5 x more common and more likely to cause shock, death, require blood transfusion and rebleed, less likely to stop spontaneously
UGIB Presentation
OVERT
- hematemesis
- melena
- hematochezia (10%) from MASSIVE upper GI bleed - bright red blood
OCCULT
- iron deficiency anemia
- positive fecal occult blood in stool
- visible bleeding with no source identified
UGIB Etiology
PEPTIC ULCER DISEASE (30-65%)
other causes
- esophagous - esophagitis, tumor, mallory weiss tears, esophageal varices (portal hypertension)
- gastric - erosions, gastritis /inflammation, cancer, angiodysplasia, AV malformations like Deilafouy lesion - abnormally large artery in the lining of the GI tract most commonly in the stomach
duodenum - ulcers/erosions, duodenitis, AV malformations like Deilafouy lesion, cancer NOT common
Rare causes of dudoneal bleed - hemobilia - bleeding from the biliary tract with blood passing down to the sphinchter of oddi , aorto- enteric fistula- aortic fistula made with duodenum
Role of H Pylori in PUD
H Pylori eradication and PPIs reduces the incidence of PUD and the complications associated
Mortality remains unchanged due to demographics, significant blood loss etc
Management UGIB
UNSTABLE
- fluid resuscitattion - bolus 1-1.5 L crystalloid
- Blood for Hb, renal function, GXM, coagulation
- request blood and blood products
- site u- cat - to assess resuciation
- place ng tube - coffee grounds
- administer supplemental oxygen as blood loss reduces o2 carrying capacity
STABLE (assuming PUD)
high dose iv proton pump inhibitors
endoscopy within 24 hours looking for stigmatata
THERAPEUTIC INTERVENTIONS w endoscopy
injections - vasoconstrictors adrenaline, vasopressin
ablation - thermal coagulation, argon plasma coagulation, fibrin sealant
mechanical methods - clips, bands used in variceal bleeding
after endoscopy (if it stops bleed then
- continue PPI to reduce risk of rebleeding
- do h pylori test
if endoscopy does not stop bleed
- surgery
- angiography with transcatheter embolization - alternative before surgery
forrest classification - appearance and likelihood of rebleed UGIB
for rebleeding %
1a spurting arterial hemmhorrhage 80-90
1b oozing hemmhorhage 10-30
2a non bleeding visible vessel 50-60
2b adherent clot 25-35
2c black spot on base 0-8
3 clean ulcer base 0-12
Indications for surgery UGIB
- failure of medical management
- failure to control bleed at endoscopy
- high risk stigmata on endoscopy
- rebleeding in hospital
LGIB Incidence
20% of all acute GIB
increases with age - MEN - 60-75
stops spontaneously in 80-85%
rebleed rate 10-20%
Etiology
CHRONIC
Hemmhorroids (most common overall)
diverticular disease
SEVERE ACUTE
Diverticular disease (most common acute )
Ischeamic colitis
Angiodysplasia
Colitis
AV malformations
Small bowel pathology like meckels diverticulum
MODERATE/CHRONIC/SUBACUTE anorectal disease IBD (chrons) Neoplasm (colon cancer or large polyps) radiation enteritis solitary rectal ulcer
LGIB definition
Bleeding distal to the Ligament of treitz
may be small bowel or colonic but most are colonic in origin (75%)
FRANK or OCCULT
LGIB management
Fluid resuscitation
take off bloods - CBC , renal, GXM,
request blood for transfusion
pass NG tube (is it upper or lower?) ng goes into stomach if there is bile and no blood you know there is no bleed in upper GI. ng tube stops at stomach
pass U cat to monitor resuscitation efforts
LGIB Investigations
STABLE
Colonoscopy within 12-48hrs
colonoscopy therapeutic and diagnostic - thermal coagulation or clips
source identified in up to 80%
high success rate 90-97%
Nuclear scintigraphy - tagging of red cells whch shows up when visualized in xray.bleeding can be slow and will show up- not very specific just shows where bleeding is
Angiography
done when colonoscopy is not feasible - high output bleed is needed
When is surgery needed in LGIB
- In an unstable patient where the source is not localized
- in persistent or recurrent bleeding
- if bleed cannot be localized then MUST do TOTAL COLECTOMY after using proctosigmoidoscopy to make sure rectum is not involved
