7-gastroentestina lecture about GIT BLEEDING.pptx

GIT LECTURE 7

1. Gastrointestinal bleeding Dr jabbar jasim C.A.B.M

2. Gastrointestinal bleeding Gastrointestinal bleeding Upper lower Acute Chronic Acute Chronic

3. Acute upper GI bleeding ( proximal to the ligament of Treitz ), THIS IS THE MOST COMMON GASTROINTESTINAL EMERGENCY. Causes Peptic ulcer 35—50% Gastric erosions (alcohol, NSAID S ) 10—20% Esophagitis 10% Varices 2—9% Mallory Weiss tear Vascular malformations Gastric malignancy Aorto –duodenal fistula

4. Mallory Weiss tear The classic history is vomiting, retching, or coughing preceding hematemesis, especially in an alcoholic patient. Bleeding from these tears, which are usually on the gastric side of the gastroesophageal junction, stops spontaneously in 80–90% of patients and recurs in only 0–7%. Endoscopic therapy is indicated for actively bleeding Mallory-Weiss tears. Angiographic therapy with embolization and operative therapy with oversewing of the tear are rarely required.

5. Clinical presentation Haematemesis is red with clots when bleeding is profuse, or black ('coffee grounds') when less severe. Syncope may occur and is due to hypotension from intravascular volume depletion. Melaena is the passage of black, tarry offensive shiny sticky stools containing altered blood. Melena indicates that blood has been present in the GI tract for at least 14 h. Melaena is usually caused by bleeding from the upper gastrointestinal tract, although hemorrhage from the right side of the colon is occasionally responsible. A history of melena alone is suggestive but not pathognomonic of a bleeding source proximal to the ligament of Treitz. Severe acute upper gastrointestinal bleeding can sometimes cause maroon or bright red stool ( hematochasia ).

6. Management Intravenous access. Initial clinical assessment:- Assessment of circulatory status looking for vital signs & urine output{ tachycardia ,hypotension oligurea }. Evidence of liver disease { Jaundice, cutaneous stigmata, hepatosplenomegaly and ascites may be present in decompensated cirrhosis}. Identify comorbidity these may be worsened by acute bleeding and because they increase the hazards of endoscopy and surgical operations. ex heart failure ,CRF,CVA……… .

7. Risk scoring systems have been developed to stratify risk of needing endoscopic therapy or a poor outcome The advantage of the Blatchford score is that it may be used before endoscopy to predict the need for intervention to treat bleeding. Low scores (2 or less) are associated with a very low risk of adverse outcome. Modified Blatchford score: risk stratification in acute upper GI bleeding

8. 3 . Basic investigations Full blood count: looking for anemia . Urea and electrolytes : an elevated blood urea with normal creatinine concentration implies severe bleeding. Liver function tests {CLD}. Prothrombin time. Cross-matching of at least 2 units of blood . 4. Resuscitation :- IV crystalloid fluids or colloid should be given to raise the blood pressure, and blood should be transfused when the patient is actively bleeding with low blood pressure and tachycardia. Comorbidities should be managed as appropriate. Central venous pressure (CVP) monitoring is useful in severe bleeding, particularly in patients who have cardiac disease, to assist in defining the volume of fluid replacement and in identification of rebleeding . Chronic liver disease should receive broad-spectrum antibiotics.

9. 5. Oxygen :- should be given by facemask to all patients in shock. 6 . Endoscopy :- should be carried out after adequate resuscitation, ideally within24hours, and will yield a diagnosis in 80% of cases . It is of diagnostic & theraputic benefit (injection or banding therapy ). 7. Monitoring :- Patients should be closely observed, with hourly pulse, blood pressure and urine output measurements. 8. Surgery :- indicated when :- Endoscopic haemostasis fails to stop active bleeding. If rebleeding occurs on one occasion in an elderly or frail patient, or twice in a younger.

10. One-third of patients with active bleeding or a nonbleeding visible vessel have further bleeding that requires urgent surgery if they are treated conservatively. These patients clearly benefit from endoscopic therapy with bipolar electrocoagulation , heater probe, injection therapy (e.g., absolute alcohol, 1:10,000 epinephrine), and/or clips with reductions in bleeding, hospital stay, mortality rate, and costs. In contrast, patients with clean-based ulcers have rates of recurrent bleeding approaching zero. Patients without clean-based ulcers should usually remain in the hospital for 3 days, as most episodes of recurrent bleeding occur within 3 days.

11. high-dose constant-infusion IV proton pump inhibitor (PPI) (e.g., omeprazole 80-mg bolus and 8-mg/h infusion), designed to sustain intragastric pH > 6 and enhance clot stability, decreases further bleeding (but not mortality), in patients with high-risk ulcers (active bleeding, nonbleeding visible vessel, adherent clot), even after appropriate endoscopic therapy. Dose of PPI therapy in UGI bleeding Give 72-hr proton pump inhibitor IV infusion for bleeding peptic ulcer

12. Lower gastrointestinal bleeding It can be cassified into :- Severe acute lower gastrointestinal bleeding. Moderate, chronic/ subacute bleeding.

13. Severe acute bleeding Diverticular disease. Angiodysplasia . Ischaemia . Meckel's diverticulum . Inflammatory bowel disease (rarely)

14. Anal disease, e.g. fissure, haemorrhoids . Inflammatory bowel disease . Carcinoma. Large polyps . Angiodysplasia. Radiation enteritis. Solitary rectal ulcer. Moderate, chronic/subacute

15. Severe acute lower GI bleeding 1) Diverticular disease is the most common cause and is often due to erosion of an artery within the mouth of a diverticulum. Bleeding almost always stops spontaneously, but if it does not, the diseased segment of colon should be resected after confirmation of the site by angiography or colonoscopy. 2) Angiodysplasia is a disease of the elderly in which vascular malformations develop in the proximal colon. Bleeding can be acute and profuse; it usually stops spontaneously but commonly recurs.

16. 3) Ischaemia due to occlusion of the inferior mesenteric artery can present with abdominal colic and rectal bleeding. It should be considered in patients (particularly the elderly) who have evidence of generalised atherosclerosis. The diagnosis is made at colonoscopy. Resection is required only in the presence of peritonitis 4) Meckel's diverticulum with ectopic gastric epithelium may ulcerate and erode into a major artery. The diagnosis should be considered in children or adolescents who present with profuse or recurrent lower gastrointestinal bleeding. A Meckel's 99mTc-pertechnate scan is sometimes positive but the diagnosis is commonly made only by laparotomy, at which time the diverticulum is excised. Diagnosis is often difficult , Colonoscopy may reveal characteristic vascular spots, and in the acute phase visceral angiography can show bleeding into the intestinal lumen and an abnormal large, draining vein. In some patients, diagnosis is only achieved by laparotomy with on-table colonoscopy. The treatment of choice is endoscopic thermal ablation, but resection of the affected bowel may be required if bleeding continues

17. Subacute or chronic lower gastrointestinal bleeding Hemorrhoids or anal fissure is common at all ages . Haemorrhoidal bleeding is bright red and occurs during or after defecation. Diagnosis by Proctoscopy , but in subjects who also have altered bowel habit and in all patients presenting at over 40 years of age , colonoscopy is necessary to exclude coexisting colorectal cancer. 2) Anal fissure should be suspected when fresh rectal bleeding and anal pain occur during defecation.

18. Obscure major gastrointestinal bleeding Definition : it is a major gastrointestinal bleeding, when upper endoscopy and colonoscopy fail to reveal a diagnosis. The bleeding may be clinically evident or occult in nature, and it may be caused by common conditions such as an arteriovenous malformation or uncommon ones such as Dieulafoy's lesion or Meckel's diverticulum.

19. Diagnosis &treatment Urgent mesenteric angiography is indicated when severe life-threatening bleeding continues. This will usually identify the site if the bleeding rate exceeds 1 mL/min and embolisation can often stop the bleeding ( diagnostic & therapeutic ). If angiography is negative or bleeding is less severe, push or double balloon enteroscopy can visualise the small intestine and treat the bleeding source. Wireless capsule endoscopy is often used to define a source of bleeding prior to enteroscopy . laparotomy with on-table endoscopy is indicated if all above are failed

20. Occult gastrointestinal bleeding Definition : blood or its breakdown products are present in the stool but cannot be seen by the naked eye, may reach 200 mL per day. The most important is colorectal cancer, particularly carcinoma of the caecum which may have no gastrointestinal symptoms. Testing the stool for the presence of blood is unnecessary and should not influence whether or not the gastrointestinal tract is imaged because bleeding from tumours is often intermittent and a negative faecal occult blood,(FOB) test does not exclude important gastrointestinal disease. The only value of FOB testing is as a means of screening for colonic disease in asymptomatic populations.

21. Evaluation of a positive test for fecal occult blood generally should begin with colonoscopy, particularly in patients >40 years. If evaluation of the colon is negative, may perform upper endoscopy only if iron-deficiency anemia or upper GI symptoms are present, while others recommend upper endoscopy in all patients since up to 25–40% of these patients may have some abnormality noted on upper endoscopy. If standard endoscopic tests are unrevealing, enteroscopy , video capsule endoscopy, and/or enteroclysis may be considered in patients with iron-deficiency anemia .

22. Thanks