GI Bleeding

GI Bleeding Definitions UGIB: parts proximal to ligament of Treitz Oesophagus, stomach or duodenum LGIB: from colon or rectum Small bowel bleeding: between ligament of Treitz and ileocecal valve Overt GIB: bleeding is visible as hematemesis, melena or hematochezia Epidemiology UGIB is the most common form for GI bleeding Small bowel bleeding is the least common form of GI bleeding Risk factors Any Bleeding UGIB NSAID use Antithrombic use H. pylori infection Antiplatelet or anticoagulant therapy or fibrinolytics? Renal failure History of prior GIB Especially in first year of haemodialysis Older age Causes UGIB LGIB Peptic ulcer Most common Esophagitis Diverticular bleeding Gastritis Colitis Duodenitis IBD Oesophageal cancer Proctitis Gastric cancer Rectal ulcers Oesophageal varices Haemorrhoids Mallory Weiss syndrome Colorectal varices Angioma Arteriovenous malformations Telangiectasia Lower abdominal trauma Hital hernia Anal fissures Trauma Merkel diverticulum Portal HTN gastroscopy Coagulopathies Clinical features Features of bleeding Hematemesis Melena Offensive odour Hematochezia Accompanying signs and features Features of shock Tachycardia HoTN AMS Syncope Signs of cirrhosis Abdominal pain Nausea and vomit Unintentional weight loss Constipation and/or pain on defecation Initial Investigations Medical history Focus exam and vitals Resting BP and HR Orthostatic HOTN Abdominal exam DRE Features of hypovolemia Features of portal HTN If more than 35 and have suspected or confirmed UGIB Baseline ECG -> assess for concomitant ACS Lab studies CBC -> normal or low Hb and Hct Platelets -> thrombocytopenia assessment BMP Increased BUN/Cr -> UGIB Lactate -> if initial reading more than 2.5 -> adverse outcomes Albumin Coagulation panel Group and hold Targeted investigations Diagnostic Approach to UGIB Hemodynamically unstable Initial study -> EDG -> for most within 24 hours It not possible -> mesenteric angiopathy Hemodynamically stable Initial study -> EDG If EDG not diagnostic: Colonoscopy after bowel prep CTA If above still not diagnostic -> approach to small bowel bleeding Diagnostic Approach to LGIB Hemodynamically unstable Initial study -> CTA If identify source of bleeding: Catheter angiography with angioembolisation Colonoscopy to attempt endoscopic Hemostasis Hemodynamically stable Initial study: nonemergency colonoscopy after bowel prep If urgently needed -> within 24 hours If high suspicion or cannot tolerate bowel prep -> CTA Targeted RBC scintigraphy ->if source of bleeding cannot be localised with colonoscopy or CTA Diagnostic Approach to Small Bowel Bleeding Repeat endoscopy If hemodynamically unstable CTA Video capsule endoscopy -> preferred in hemodynamically unstable patients with negative EGD and coloscopy As needed: Push endoscopy, double ballon enterscopy CT enterorrhaphy, targeted scintigraphy, Meckel scan DO NOT DELAT INTIAL MANAGEMENT FOR DIAGNOSTIC TESTS Initial Management Approach IV access For fluid resus and blood transfusion To large bore cannulas Consider central line if the above is not possible NPO If unstable ABCDE approach Intubation to protect airway if needed Immediate hemodynamic support and management of haemorrhagic shock IV resus with crystalloids Blood transfusions Anticoagulant reversible Urgent GIT, surgery and/or interventional radiology review Cease antithrombotic agents Haemostatic Control Endoscopic Hemostasis Preferred intervention for patients with ongoing bleeding or signs of recent bleeding on endoscopy Methods: Thermal coagulation Clip placement Band ligation Injection with epinephrine solution Topical sealants -> haemostatic sprays or powder Polypectomy Interventional radiology Consider in patients with rebleeding ongoing bleeding despite endoscopic Hemostasis or ongoing severe LGIB patients with hemodynamic instability to resus Techniques Angioembolisation Intra-arterial vasopressin Surgical Hemostasis Considered for patients who all therapeutic options have failed or have a refractory hemodynamic instability Techniques Surgical ligation of bleeding vessels Excision of susceptible mucosa Segmental bowel resection Complications Anaemia Most common Haemorrhagic shock Hepatic encephalopathy Aspiration pneumonia