Causes of gastro intestinal bleedingBleed.ppt

Causes of gastro intestinal bleeding

1. Acute Gastrointestinal
Bleeding

2. GI Bleeding
•Clinical Presentation
•Acute Upper GI Bleed
•Acute Lower GI Bleed

3. Case Presentation
•CC: Melena
•HPI: 54 yo man taking ibuprofen 200 mg
po tid for the past 2 wks b/o acute LBP
after lifting presents with 2 day h/o
melena
•PMHx: neg All: NKDA SHx/FHx: neg
•Vitals: BP 105/75 P 90
•PE: normal

4. Clinical Presentation
Hematemesis: bloody vomitus (bright red or
coffee-grounds)
Melena: black, tarry, foul-smelling stool
Hematochezia: bright red or maroon blood
per rectum
Occult: positive guaiac test
Symptoms of anemia: angina, dyspnea, or
lightheadedness

5. Patient Assessment
•Hemodynamic status
•Localization of bleeding source
•CBC, PT, and T & C
•Risk factors
–Prior h/o PUD or bleeding
–Cirrhosis
–Coagulopathy
–ASA or NSAID’s

6. Resuscitation
•2 large bore peripheral IV’s
•Normal saline or LR
•Packed RBCs
•Correct coagulopathy

7. Location of Bleeding
•Upper
–Proximal to Ligament of Treitz
–Melena (100-200 cc of blood)
–Azotemia
–Nasogatric aspirate
•Lower
–Distal to Ligament of Treitz
–Hematochezia

8. Acute UGIB
Demographics
•10,000 - 20,000 deaths annually
•Mortality stable at 10%
•80% self-limited
•Continued or recurrent bleeding -
mortality 30-40%

9. •Cause of bleeding
•Severity of initial bleed
•Age of the patient
•Comorbid conditions
•Onset of bleeding during
hospitalization
Acute UGIB
Prognostic Indicators

10. NASOGASTRIC
ASPIRATE
STOOL
COLOR
MORTALITY RATE
(%)
Clear Red, brown, or black 10
Coffee Grounds Brown or black 10
Red 20
Red Blood Black 10
Brown 20
Red 30

Acute UGIB
Prognostic Indicators
Tedesco et al. ASGE Bleeding Survey. Gastro Endo. 1981.

11. Acute UGIB
Differential Diagnosis

12. •Peptic ulcer disease
–Gastric ulcer
–Duodenal ulcer
•Mallory-Weiss tear
•Portal hypertension
–Esophagogastric
varices
–Gastropathy
•Esophagitis
•Dieulafoy’s lesion
•Vascular anomalies
•Hemobilia
•Hemorrhagic
gastropathy
•Aortoenteric fistula
•Neoplasms
–Gastric cancer
–Kaposi’s sarcoma
Acute UGIB
Differential Diagnosis

13. DIAGNOSES % OF TOTAL
Duodenal ulcer 24
Gastric erosions 23
Gastric ulcer 21
Varices 10
Mallory-Weiss tear 7
Esophagitis 6
Acute UGIB
Final Diagnoses of the Cause in 2225 Patients
Tedesco et al. ASGE Bleeding Survey. Gastro Endo. 1981.

14. DIAGNOSES % OF TOTAL
Peptic ulcer 55
Varices 14
Angioma 6
Mallory-Weiss tear 5
Erosions 4
Tumor 4


Acute UGIB
Causes in CURE Hemostasis Studies (n=948)
Savides et al. Endoscopy 1996;28:244-8.

15. Acute UGIB
CORI Database
University, VA, & private
practices
20 months (12/99-7/01)
7822 EGDs for UGIB
BoonpongmaneeS. et al. Gastrointest Endosc 2004;59:788-94.

16. Endoscopic Appearance
of Ulcers

17. Prognostic Features at Endoscopy
in Acute Ulcer Bleeding
Laine and Peterson New Eng J Med 1994;331:717-27.

18. •Thermal
–Bipolar probe
–Monopolar probe
–Argon plasma
coagulator
–Heater probe
•Mechanical
–Hemoclips
–Band ligation
•Injection
–Epinephrine
–Alcohol
–Ethanolamine
–Polidocal
Endoscopic Therapy of PUD

19. Endoscopic Therapy of PUD
Laine and Peterson New Eng J Med 1994;331:717-27.

20. Adjuvant Medical Therapy
of PUD
•Acid suppression (intragastric pH > 4)
–Histamine 2 Receptor Antagonists (H2RAs)
•Ranitidine (Zantac)
•Famotidine (Pepcid)
–Proton Pump Inhibitors (PPIs)
•Pantoprazole (Protonix)
•Lansoprazole (Prevacid)
•Esomeprazole (Nexium)

21. Bleeding PUD: IV H2RAs
Meta-Analysis
•Duodenal ulcer: no
benefit
•Gastric ulcer: mild
benefit
–Mortality
•ARR 3%; NNT 33
–Surgery
•ARR 7%; NNT 14
–Rebleeding
•ARR 7%; NNT 14
•Caveats
–Tolerance develops
within 24 hrs
–More potent acid
suppression
available
Levine JE et al. Aliment Pharmacol Ther 2002;16:1137-42.

22. 472 patients required no
endoscopic treatment
27 patients not included:
comorbid or no consent
120 patients received IV
omeprazole 80 mg bolus
then 8 mg/hr for 72 hours
120 patients received placebo
267 received endoscopic treatment
739 patients admitted with GI bleeding
Lau et al. New Eng J Med 2000;343:310-316.
Adjuvant Medical Therapy of
PUD

23. Adjuvant Medical
Therapy of PUD
Lau et al. New Eng J Med 2000;343:310-316.

24. Bleeding PUD: PO/IV PPIs
Meta-Analysis
•Reduction in:
–RebleedingNNT* 4-17
–SurgeryNNT* 6-25
•No change in mortality
•PPIs add to endoscopic
therapy but do not
supplant endoscopic
therapy
* Estimates from pooled ORs
Leontiadis, GI et al. BMJ 2005;330:568-75.

25. Mallory-Weiss Tear

26. Esophageal Varices

27. Variceal Band Ligation

28. Variceal Band Ligation

29. •Vasopressin/Glypressin
•Nonselective vasoconstrictor
•50% efficacy in controlling bleeding
•25% vasospastic side effects
•Octreotide
•Cyclic octapeptide analog of
somatostatin
•Longer acting than somatostatin
•Equivalent to sclerotherapy and
improves endoscopic results
MEDICAL THERAPY
Acute Variceal Bleeding

30. TIPS
IVC
Portal Vein
Splenic Vein
Coronary Vein

31. Aortoduodenal Fistula
Aorta
Duodenum
Graft
Fistula

32. Acute Bleeding
Changes Before and After 2 Liter Bleed
0
1
2
3
4
5
6
Before During 24-72 Hrs
V
O
L
U
M
E

(

L

)
Plasma RBC
27%
45%
45%

33. Acute UGIB
Surgery
•Recurrent bleeding despite
endoscopic therapy
•> 6-8 units pRBCs

34. Case Presentation
•CC: Hematochezia
•HPI: 74 yo woman presents with 6 hour
history of painless maroon blood per rectum
•PMHx: CAD, Chol, AFib, CABG, L-CEA
•Meds: ASA, coumadin, digoxin, lovastatin
•Vitals: BP 105/75 P 90
•PE: irreg rhythm, maroon blood on DRE

35. Acute LGIB
Differential Diagnosis

36. •Diverticulosis
•Colitis
–IBD (UC>>CD)
–Ischemia
–Infection
•Vascular anomalies
•Neoplasia
•Anorectal
–Hemorrhoids
–Fissure
•Dieulafoy’s lesion
•Varices
–Small bowel
–Rectal
•Aortoenteric fistula
•Kaposi’s sarcoma
•UPPER GI BLEED
Acute LGIB
Differential Diagnosis

37. DIAGNOSES % OF TOTAL
Diverticulosis 40
Vascular anomalies 30
Colitis 21
Neoplasia 14
Anorectal 10
Upper GI sites 10
Acute LGIB
Diagnoses in pts with hemodynamic compromise.
Zuccaro. ASGE Clinical Update. 1999.

38. Diverticulosis

39. Diverticular Bleeding

40. Urgent Colonoscopy for the Diagnosis
and Treatment of Severe Diverticular
Hemorrhage
•121 pts with severe
bleeding (>4 hrs
after hospitalization)
•1
st
73 pts: no
colonoscopic tx
•Last 48 pts eligible
for colonoscopic tx
•Colonoscopy w/in 6-
12 hrs

41. Urgent Colonoscopy for the Diagnosis and
Treatment of Severe Diverticular
Hemorrhage
Jensen DM, et al. New Eng J Med 2000:342:78-82.

42. Hemorrhoids

43. Bleeding AVM

44. Radiation Proctitis

45. •Incidence 0.3 - 3.0 %
•EtiologyIncomplete obliteration of the
vitelline duct.
•Pathology50% ileal, 50% gastric,
pancreatic, colonic mucosa
•Complications
–Painless bleeding (children, currant jelly)
–Intussusception
Acute LGIB
Meckel’s Diverticulum

46. Study
Yield
%
Comments
Colonoscopy 69-80 Therapeutic
Arteriography 40-78
1 ml/min,
risks
Tagged RBC Scan 20-72 Localization


Acute LGIB
Evaluation
Zuccaro. ASGE Clinical Update. 1999.

47. •Resuscitation
•UGI source
•Most bleeding ceases
•Colonscopy - early
•No role for barium studies
•5% Mortality
Acute LGIB
Key Points