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GASTROINTESTINAL HEMORRHAGE. or, “What’s that smell…?”. Roger P. Tatum, MD Assistant Professor, University of Washington Department of Surgery. GASTROINTESTINAL HEMORRHAGE. CASE #1 54 y/o male complains of fatigue and multiple dark, tarry stools for 2 days

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gastrointestinal hemorrhage

GASTROINTESTINAL HEMORRHAGE

or, “What’s that smell…?”

Roger P. Tatum, MD

Assistant Professor,

University of Washington Department of Surgery

gastrointestinal hemorrhage2
GASTROINTESTINAL HEMORRHAGE

CASE #1

  • 54 y/o male complains of fatigue and multiple dark, tarry stools for 2 days
  • PMH: HTN, hypercholesterolemia; no surgical history; never had colonoscopy
  • PEX: abdomen—soft, nontender, nondistended; rectal—no masses, heme+
gastrointestinal hemorrhage signs and symptoms of gi bleed
GASTROINTESTINAL HEMORRHAGESigns and Symptoms of GI Bleed
  • Hematemesis/ “coffee ground” emesis
  • Melena—dark, tarry, foul-smelling stool
  • Hematochezia—bright red blood per rectum
  • Microcytic anemia
  • Chronic fatigue—secondary to anemia
  • Hypotension, tachycardia, mental status change—serious problem
gastrointestinal hemorrhage upper gi bleed
GASTROINTESTINAL HEMORRHAGEUpper GI Bleed
  • Bleeding from the foregut—mouth to ligament of Treitz
  • Acute or chronic
  • History is key element in workup
gastrointestinal hemorrhage upper gi bleed acute sources
GASTROINTESTINAL HEMORRHAGEUpper GI Bleed—Acute Sources
  • Epistaxis (often overlooked)
  • Oropharyngeal lesions
  • Esophageal varices
  • Mallory-Weiss syndrome
  • Hemorrhagic gastritis
  • Gastric or duodenal ulcer
gastrointestinal hemorrhage upper gi bleed chronic sources
GASTROINTESTINAL HEMORRHAGEUpper GI Bleed—Chronic Sources
  • Esophageal Cancer
  • Erosive esophagitis
  • Paraesophageal hiatus hernia/Cameron lesions
  • Gastric tumor
  • Gastritis
  • Gastric or duodenal ulcer
gastrointestinal hemorrhage upper gi bleed workup
GASTROINTESTINAL HEMORRHAGEUpper GI Bleed—Workup
  • History—as often, one of the most important elements:
    • Hematemesis or “coffee grounds” most common in acute bleed
    • Melena often presents later
    • History of NSAID use—suggests gastritis or PUD
    • Alcohol, cirrhosis—suggests varices or Mallory-Weiss
    • GERD—in chronic bleed, esophagitis or Cameron lesions
gastrointestinal hemorrhage upper gi bleed workup8
GASTROINTESTINAL HEMORRHAGEUpper GI Bleed—Workup
  • History—cont’d
    • Antecedent pain—suggests ulcer or gastritis
    • H/o recent trauma or major surgery—stress gastritis (Cushing’s ulcer, Curling’s ulcer)
gastrointestinal hemorrhage upper gi bleed workup9
GASTROINTESTINAL HEMORRHAGEUpper GI Bleed—Workup
  • Physical Exam
    • Not as helpful as history
    • Abdominal tenderness uncommon
    • Check nasopharynx, oropharynx
gastrointestinal hemorrhage upper gi bleed workup10
GASTROINTESTINAL HEMORRHAGEUpper GI Bleed—Workup
  • Laboratory
    • Hgb/Hct (remember, may not reflect true blood volume in patient with acute rapid bleed)
    • PT/PTT—may need to correct coagulopathy
    • Electrolytes—assess for dehydration, guide resuscitation
    • Radiologic studies usually not initially helpful
gastrointestinal hemorrhage upper gi bleed workup11
GASTROINTESTINAL HEMORRHAGEUpper GI Bleed—Workup
  • Nasogastric aspiration (acute bleed only)
    • If completely negative, UGI source is not ruled out
    • Can irrigate—if able to clear, then bleed may no longer be active
    • Can be helpful in preparation for upper endoscopy
gastrointestinal hemorrhage upper gi bleed workup12
GASTROINTESTINAL HEMORRHAGEUpper GI Bleed—Workup
  • Upper Endoscopy
    • Most useful single diagnostic tool—90% success
    • Nearly all sources of UGI bleeding may be identified
    • Can be done (and often should) in ICU
    • Often therapy delivered simultaneously
gastrointestinal hemorrhage acute upper gi bleed treatment
GASTROINTESTINAL HEMORRHAGEAcute Upper GI Bleed—Treatment
  • RESUSCITATION!
    • Patient should be transferred to ICU setting
    • Ensure large bore IV access, may need central line
    • Aggressive hydration
    • Place Foley catheter to monitor hydration and efficacy of resuscitation
    • Type and cross for 4U PRBCs
    • Correct any coagulopathy
    • Transfuse depending on Hgb/Hct and history of patient
gastrointestinal hemorrhage acute upper gi bleed treatment14
GASTROINTESTINAL HEMORRHAGEAcute Upper GI Bleed—Treatment
  • Endoscopic
    • Can be therapeutic for many sources of UGI bleed
    • Ulcer—can inject epinephrine or coagulate with heater probe in setting of “visible vessel” or “cherry red spot”
    • Varices—banding or injection
gastrointestinal hemorrhage acute upper gi bleed treatment15
GASTROINTESTINAL HEMORRHAGEAcute Upper GI Bleed—Treatment
  • Angiography
    • Typically reserved for failure of endoscopic treatment
    • Localization of bleeding vessel
    • Embolization with Gelfoam, coils
    • Injection of vasopressin
    • Can also aid localization of source when not evident by endoscopy
gastrointestinal hemorrhage acute upper gi bleed treatment16
GASTROINTESTINAL HEMORRHAGEAcute Upper GI Bleed—Treatment
  • Surgery—indications
    • Failure of endoscopic control (usually after 2+ attempts)
    • Transfusion requirement of 6 or more U PRBCs
    • Hemodynamic instability despite resuscitation
    • Usually for bleeding ulcers
    • Occasionally for hemorrhagic gastritis, Mallory Weiss tears, varices (see next)
gastrointestinal hemorrhage acute upper gi bleed treatment17
GASTROINTESTINAL HEMORRHAGEAcute Upper GI Bleed—Treatment
  • Surgery—approach and strategy
    • Preop localization is essential
    • Typically, midline epigastric incision (celiotomy)
    • For DU: duodenotomy, oversew vessel, vagotomy and pyloroplasty or antrectomy (particularly if patient already on anti-secretory therapy)
gastrointestinal hemorrhage acute upper gi bleed treatment19
GASTROINTESTINAL HEMORRHAGEAcute Upper GI Bleed—Treatment
  • Surgery—approach and strategy—cont’d
    • Gastric ulcer—gastrotomy and oversew, wedge gastrectomy (depends on location), subtotal gastrectomy
    • Mallory-Weiss tears—gastrotomy, oversew bleeding site
gastrointestinal hemorrhage acute upper gi bleed treatment20
GASTROINTESTINAL HEMORRHAGEAcute Upper GI Bleed—Treatment
  • A word on varices:
    • Can start IV octreotide prior to endoscopy (increases success rate)
    • Endoscopic therapy is treatment of choice, may need several treatments
    • Use of the Sengstaken-Blakemore tube (includes football helmet) for severe, rapid hemorrhage—80-90% success, but 60% rebleed
gastrointestinal hemorrhage acute upper gi bleed treatment21
GASTROINTESTINAL HEMORRHAGEAcute Upper GI Bleed—Treatment
  • A word on varices—cont’d:
    • Surgery rarely indicated—only with complete failure of above methods
    • Emergency portacaval shunt or
    • Esophageal division or devascularization
gastrointestinal hemorrhage chronic upper gi bleed treatment
GASTROINTESTINAL HEMORRHAGEChronic Upper GI Bleed—Treatment
  • Nearly always managed medically;
  • Therefore, we will not discuss this (and you can’t make me…)
gastrointestinal hemorrhage lower gi bleed presentation
GASTROINTESTINAL HEMORRHAGELower GI Bleed--Presentation
  • Defined by bleeding source distal to ligament of Treitz
  • Mean age of presentation 63-77 y/o
  • Can present with melena or bright red blood per rectum with or without clots
  • 20% presents as acute “massive” bleeding
  • Often more difficult to localize than UGI bleed
gastrointestinal hemorrhage lower gi bleed acute sources
GASTROINTESTINAL HEMORRHAGELower GI Bleed—Acute Sources
  • Diverticulosis
  • Angiodysplasia (AVM)—more common in >65
  • Ischemic colitis
  • Meckel’s diverticulum
  • Infectious colitis (C. diff, E. coli, campylobacter)
  • IBD (ulcerative colitis>Crohn’s disease)
  • Malignancy (rare cause of acute bleed)
gastrointestinal hemorrhage lower gi bleed chronic sources
GASTROINTESTINAL HEMORRHAGELower GI Bleed—Chronic Sources
  • Malignancy (most common chronic LGI source)
  • Benign small or large bowel polyps
  • Angiodysplasia
  • IBD
  • Hemorrhoids
  • Anal fissure
gastrointestinal hemorrhage lower gi bleed workup
GASTROINTESTINAL HEMORRHAGE Lower GI Bleed—Workup
  • History
    • Character and quantity of blood
    • History of HTN, CAD, PVD (ischemic colitis)
    • History of IBD
    • Anticoagulation or coagulopathy
gastrointestinal hemorrhage lower gi bleed workup27
GASTROINTESTINAL HEMORRHAGE Lower GI Bleed—Workup
  • Exam
    • Look for abdominal masses
    • Listen for bruits
    • Rectal—masses, characterize blood, look for anal pathology such as hemorrhoids, fissures
gastrointestinal hemorrhage lower gi bleed workup28
GASTROINTESTINAL HEMORRHAGELower GI Bleed—Workup
  • Laboratory (look familiar?)
    • Hgb/Hct (remember, may not reflect true blood volume in patient with acute rapid bleed)
    • PT/PTT—may need to correct coagulopathy
    • Electrolytes—assess for dehydration, guide resuscitation
    • Radiologic studies—CT may show thickening of bowel in case of mesenteric ischemia; diverticulosis usually easily identified
gastrointestinal hemorrhage lower gi bleed workup29
GASTROINTESTINAL HEMORRHAGELower GI Bleed—Workup
  • Rule out Upper GI bleed source!
    • Follow initial steps in algorithm for UGI bleed
    • Patient may need EGD for differentiation
gastrointestinal hemorrhage lower gi bleed workup30
GASTROINTESTINAL HEMORRHAGELower GI Bleed—Workup
  • Colonoscopy
    • Often 1st maneuver
    • Visualization difficult secondary to invariably poor prep
gastrointestinal hemorrhage lower gi bleed workup31
GASTROINTESTINAL HEMORRHAGELower GI Bleed—Workup
  • Tagged RBC scan (nuclear medicine)
    • 99mTc-pertechnaetate-labeled RBCs, IV injection
    • Demonstrates bleeding source when rate of bleed=0.1-0.5ml/minute
    • Allows repeated evaluation over course of 24 hours
    • May not exactly localize source—may not be able to differentiate colon from small bowel
    • Typically not used alone for localization
gastrointestinal hemorrhage lower gi bleed workup32
GASTROINTESTINAL HEMORRHAGELower GI Bleed—Workup
  • Angiography
    • Better for specific localization
    • Sensitive for bleeding rate 0.5-1.5ml/minute
    • Often requires large amount of contrast (beware renal insufficiency)
    • Can be therapeutic (embolization, vasopressin)
gastrointestinal hemorrhage lower gi bleed workup33
GASTROINTESTINAL HEMORRHAGELower GI Bleed—Workup
  • Provocative Angiography
    • When bleeding is recurrent and suspected to be from colonic source, can inject heparin and/or tPA
    • Treatment then delivered immediately when bleeding discovered
    • May require urgent trip to OR if angiographic therapy fails
gastrointestinal hemorrhage lower gi bleed workup34
GASTROINTESTINAL HEMORRHAGELower GI Bleed—Workup
  • Capsule Endoscopy
    • When unable to localize intermittent bleed via above methods, may be effective in defining source
    • May be the only way to identify small bowel source
gastrointestinal hemorrhage acute lower gi bleed treatment
GASTROINTESTINAL HEMORRHAGEAcute Lower GI Bleed—Treatment
  • RESUSCITATION! (once again, in case you forgot)
    • Patient should be transferred to ICU setting
    • Ensure large bore IV access, may need central line
    • Aggressive hydration
    • Place Foley catheter to monitor hydration and efficacy of resuscitation
    • Type and cross for 4U PRBCs
    • Correct any coagulopathy
    • Transfuse depending on Hgb/Hct and history of patient
gastrointestinal hemorrhage acute lower gi bleed treatment36
GASTROINTESTINAL HEMORRHAGEAcute Lower GI Bleed—Treatment
  • Colonoscopy
    • Often unsuccessful due to difficulties in localization
    • May be effective in situations such as sclerosis of AVM
gastrointestinal hemorrhage acute lower gi bleed treatment37
GASTROINTESTINAL HEMORRHAGEAcute Lower GI Bleed—Treatment
  • Angiography
    • As in UGI bleed, embolization with coils or gelfoam, vasopressin injection
    • 5-10% risk of bowel infarction
gastrointestinal hemorrhage acute lower gi bleed treatment38
GASTROINTESTINAL HEMORRHAGEAcute Lower GI Bleed—Treatment
  • Surgery
    • Typically, segmental resection of small bowel or colon (NOT enterotomy and repair)
    • Usually very dependent on preoperative localization
    • In cases where localization not possible, can do on-table push enteroscopy to look past ligament of Treitz