Gastro 46 Acute Gastrointestinal Hemorrhage

  1. Enumerate causes of UGI bleed. What are different investigations to confirm the cause of bleeding and principles of management? [TU 2059]

    Enumerate the causes of UGI bleeding. [TU 2064/2, 61/4, 59/4]
    • Nonvariceal Bleeding - 80%
    • - Peptic ulcer disease - Gastric and duodenal ulcer
    • - Gastritis/Duodenitis
    • - Esophagitis
    • - Mallory-Weiss tear
    • - AV malformation - Dieulafoy lesions, Gastric antral vascular ectasia (GAVE)
    • - Malignancy
    • - Others - Aorto-enteric fistula, hemobilia, hemosuccus pancreaticus, Iatrogenic bleeding

    • Variceal Bleeding (20%)
    • - Gastro-esophageal varices
    • - Hypertensive portal gastropathy
    • - Isolated gastric varices

    Peptic ulcer disease and Variceal hemorrhage are the most common causes.
  2. Enumerate the common cause of lower GI bleeding. [TU 2057, 60/12]
    • Colonic bleeding - 95%
    • Diverticular disease
    • Anorectal disease (hemorrhoids, fissure, colorectal neoplasia)
    • Crohn’s disease
    • Ischemia
    • Neoplasia
    • Infectious colitis
    • Post-polypectomy
    • Inflammatory bowel disease
    • Angiodysplasia
    • Radiation colitis or proctitis
    • Other
    • Unknown

    • Small Bowel bleeding 5%
    • Angiodysplasias
    • Erosions or ulcers (potassium, NSAIDs)
    • Radiation
    • Crohn’s disease
    • Meckel’s diverticulum
    • Neoplasia
    • Aortoenteric fistula
  3. Timing of endoscopy in GI bleeding?
    For unstable patients – urgent endoscopy

    For stable patients with overt signs of bleeding – Early endoscopy, preferably within 12 hours of admission, with an attempt at control of bleeding is recommended. Urgent endoscopy is associated with reduced accuracy due to poor visualization and increased complications like aspiration, respiratory depression and GI perforation.
  4. What are the different investigations to confirm the cause of bleeding and principle of management? [TU 2059]
    Image Upload 1
  5. Prepare flow chart for the management of UGI bleeding. [TU 2064/12]
    Outline the plan of investigation preferably by flow chart. [TU 2064/3]

    Principles of surgical and non surgical management of upper GI bleeding . [TU 2062]
    Outline the plan of investigation preferably by flowchart. [TU 2061/12]

    Modern management of bleeding esophageal varices. [TU 2057] 

    Treatment of UGI bleeding secondary to portal hypertension?
    Treatment of UGI bleeding secondary to portal hypertension include - 

    1. Resuscitation

    2. Medical management - antibiotics, Octreotide, Vasopressin

    3. Endoscopic management - Nonoperative treatments are generally used as a first-line approach as these patients are high operative risks because of decompensated hepatic function.

    Endoscopic treatment (Sclerotherapy and band ligation) has become the mainstay of nonoperative treatment. Band ligation is modality of choice in the initial control of bleeding and is associated with fewer complications. Sclerotherapy, but not band ligation, may increase portal pressures.

    • 4. Other management -
    • - Balloon tamponade, which is infrequently used, can be lifesaving in patients with exsanguinating hemorrhage when other nonoperative methods are not successful.

    - TIPS has replaced operative shunts for managing acute variceal bleeding when pharmacotherapy and endoscopic treatment fail to control bleeding. As a result, emergency surgical intervention in most centers is reserved for selective patients who are not TIPS candidates.

    - Surgery - Esophageal transection with stapling device, portacaval shunt. In patients who are not actively bleeding at the time of surgery and in those in whom bleeding is temporarily controlled by pharmacotherapy or balloon tamponade, a more complex operation, such as the distal splenorenal shunt, may be appropriate

    Image Upload 2
  6. Prevention of Recurrent Variceal Hemorrhage?
    Pharmacotherapy - β-adrenergic blockade, PPI, sucralfate

    Endoscopic therapy - Band ligation. The combination of variceal ligation and pharmacotherapy with nonselective beta blockade is more effective than variceal ligation alone. Repeat EBL every 14 days until all the varices has been eradicated. 

    • Other management - Foe the patients who are medically non compliant
    • - TIPS for patients with poor liver reserve who are on the liver transplant list 
    • - Surgical decompression - those with good liver function who do not qualify for a transplant. The preferred elective shunt is a selective distal splenorenal shunt. 

    TIPS - 

    Shunt operations (e.g., nonselective, selective, partial)

    Liver transplantation
  7. Limitation of TIPS?
    Shunt stenosis or shunt thrombosis. Shunt stenosis secondary to neointimal hyperplasia, is more common than thrombosis .
  8. Sengstaken-Blakemore tube?
    • In cases in which pharmacologic or endoscopic therapies fail to control the hemorrhage, balloon tamponade can be successful in temporizing the hemorrhage.
    • Sengstaken-Blakemore tube consists of a gastric tube with esophageal and gastric balloons. The gastric balloon is inflated and tension is applied on the gastroesophageal junction. If this does not control the hemorrhage, the esophageal balloon is inflated as well, compressing the venous plexus between them.
    • The Minnesota tube includes a proximal esophageal lumen for aspirating swallowed secretions.
    • A related device with a larger gastric balloon capacity (about 500ml) is the Linton Nachlas tube, is used for controlling gastric varices. 

    • Inflate gastric balloon with 250 ml of air. 
    • Apply traction to tube by 1kg of weight. 
    • If bleeding does not stop, inflate esophageal balloon with 30mm Hg. 
    • If bleeding is still not in control, inflate the gastric balloon to 400ml  and esophageal balloon to 40 mm Hg.

    • Image Upload 3
    • Note two clamps, one secured with tape, to prevent inadvertent decompression of the gastric balloon.
  9. Management of non-variceal bleeding?
    Methods to control bleeding Peptic ulcer bleed

    • Endoscopic
    • Injection of vasoconstrictors
    • Sclerosing Agents
    • Thermocoagulation
    • Argon Plasma Coagulation (APC)
    • Clip placement - for spurting vessels 
    • Banding 
    • Combined approach - combination of thermal coagulation with epinephrine is better than epinephrine alone

    Angiographic endovascular embolization

    • Surgical
    • Duodenal ulcer - a) placed anteriorly - four quadrant suture ligation b) placed posteriorly - Three point U stitch for GDA and pancreatic branch ligation. Cut duodenum longitudinally, close transversely
    • For gastric ulcer - Gastrostomy and suture ligation

    Image Upload 4
  10. Indications of surgery in hemorrhage (UGI and LGI)?
    • Hemodynamic instability despite vigorous resuscitation (>6-unit transfusion)
    • Failure of endoscopic techniques to arrest hemorrhage
    • Recurrent hemorrhage after initial stabilization (with up to two attempts at obtaining endoscopic hemostasis)
    • Shock associated with recurrent hemorrhage
    • Continued slow bleeding with a transfusion requirement exceeding 3 units/day
  11. What is Mallory-Weiss tears?
    Mucosal and submucosal tears that occur near the gastroesophageal junction, in alcoholic patients after a period of intense retching and vomiting following binge drinking. Forceful contraction of the abdominal wall against an unrelaxed cardia, result in mucosal laceration of the cardia as a result of the increased intragastric pressure.

    • Treatment -
    • Supportive – mucosa heals within 72 hours
    • If not, other methods of management
  12. What are Dieulafoy lesion? [TU 2073]
    • Dieulafoy lesions are vascular malformations found primarily along the lesser curve of the stomach within 6 cm of the gastroesophageal junction, although they can occur elsewhere in the GI tract. They represent rupture of unusually large vessels (1 to 3 mm) found in the gastric submucosa. Erosion of the gastric mucosa overlying these vessels leads to hemorrhage. 
    • The mucosal defect is usually small (2 to 5 mm) and may be difficult to identify.
    • Given the large size of the underlying artery, bleeding from a Dieulafoy lesion can be massive Initial attempts at endoscopic control are often successful.

    • Treatment –
    • Application of thermal or sclerosant therapy is effective in 80%  to 100% of cases.
    • In cases that fail endoscopic therapy, angiographic coil embolization can be successful.
    • If these approaches are unsuccessful, surgical intervention may be necessary. A gastrostomy is performed, and attempts are made at identifying the bleeding source. The lesion can then be oversewn. In cases in which the bleeding point is not identified, a partial gastrectomy may be necessary
  13. Gastric antral vascular ectasia?
    GAVE is also known as watermelon stomach is characterized by a collection of dilated venules appearing as linear red streaks converging on the antrum in longitudinal fashion, giving it the appearance of a watermelon.
  14. Discuss the investigations needed to diagnose lower GI bleeding? [TU 2057, 60/12]
    • Lower GI bleeding typically is manifested with hematochezia that can range from bright red blood to old clots.
    • Compared with endoscopy in upper GI bleeding, no diagnostic modality is as sensitive or specific in making an accurate diagnosis in lower GI bleeding.
    • Once resuscitation has been initiated, the first step in the workup is to rule out anorectal bleeding with a digital rectal examination and anoscopy or sigmoidoscopy.
    • With significant bleeding, it is also important to eliminate an upper GI source. An NG aspirate that contains bile and no blood effectively rules out upper tract bleeding.
    • When emergent surgery for life-threatening hemorrhage is being contemplated, preoperative or intraoperative EGD is usually appropriate.
    • Colonoscopy is the mainstay - allows both visualization of the pathologic process and therapeutic intervention. The usual adjuncts to colonoscopy include tagged RBC scan and angiography.
    • For obscure bleeding - Repeated Upper and lower GI endoscopy, RBC scan, Small bowel endoscopy (push endoscopy), Video capsule endoscopy, CT enterography, Intraoperative endoscopy
  15. What is Obscure bleeding?
    • Obscure - bleeding that persists or recurs after an initial negative evaluation with EGD and colonoscopy. It is of two types (obscure means you don’t find the source of bleeding)
    • Obscure-occult - iron deficiency anemia or guaiac-positive stools without visible bleeding. (occult means you cannot see)
    • Obscure-overt – recurrent or persistent visible bleeding (overt means that can be seen by nacked eyes)
  16. Guaiac test?
    To differentiate malena from black stool due to Iron intake. Guaiac test is positive in Malena.,
  17. Diagnosis of Obscure bleed?
    • Repeated endoscopy
    • RBC scan
    • CT angiography
    • Small bowel enteroclysis and  enterography - can identify gross lesions such as small bowel tumors and inflammatory conditions such as Crohn’s disease.
    • Small bowel endoscopy (push endoscopy) – 50-70 cm distal to ligament of treitz
    • Video capsule endoscopy – Offers no interventional capability
    • Intraoperative endoscopy
  18. What is RBC scan?
    • Radionuclide scanning with technetium Tc 99m (99mTc-labeled RBC) is the most sensitive but least accurate method for localization of GI bleeding.
    • With this technique, the patient’s own RBCsare labeled and reinjected.
    • The labeled blood is extravasated into the GI tract lumen, creating a focus that can be detected scintigraphically. 
    • Can detect bleeding as slow as 0.1 mL/min and is reported to be more than 90% sensitive
    • Spatial resolution is low, and blood may move proximally or distally.
    • It is not usually employed as a definitive study before surgery but instead as a guide to the utility of angiography; if the RBC scan is negative or only positive after several hours, angiography is unlikely to be revealing. Such an approach avoids the significant morbidity of angiography.
    • CT angiography can detect hemorrhage in the range of 0.5 to 1.0 mL/min and is generally employed only in the diagnosis of ongoing hemorrhage
  19. Benefits of CT angiography?
    • Spatial localization
    • Can be used for embolization
  20. Capsule endoscopy? [TU 69]
    • Capsule endoscopy uses a small capsule with a video camera,which is swallowed and acquires video images as it passes throughthe GI tract.
    • This modality permits visualization of the entire GI tract but offers no interventional capability and is also time consuming because someone has to watch the video to identify the bleeding source.
    • This procedure is usually well tolerated, although it is contraindicated in patients with obstruction or a motility disorder.
    • Capsule endoscopy is frequently used in the patient who is hemodynamically stable but continues to bleed.

    • Indications
    • -  to evaluate suspected small bowel bleeding in adults
    • - to evaluate patients with suspected Crohn disease
    • - assess mucosal healing
    • - detect small bowel tumors.
    • - detect small bowel injury associated with the use of NSAIDS. 

    • Contraindications
    • ●Dementia (in patients who cannot cooperate with swallowing of the capsule or who may inadvertently damage the equipment).
    • ●Gastroparesis (the capsule can be placed in the duodenum by endoscopy to avoid this problem).
    • ●An esophageal stricture or swallowing disorders that could prevent passage of the capsule (eg, Zenker's diverticulum) (the capsule can be placed in the duodenum by endoscopy to avoid this problem).
    • ●Partial or intermittent small bowel obstruction (unless a surgeon is involved, the patient understands the risks, and the patient has been cleared for surgery).
    • ●Those patients who are inoperable or refuse surgery.

    • Disadvantage
    • - Does not permit tissue samplingor therapeutic intervention

    • This technique has reported success rates as high as 90% in identifying small bowel disease.
    • However, in a large national review of capsule endoscopy in obscure GI bleeding, the test failed to identify a source of bleeding in 30% to 40% of both obscure-occultand obscure-overt cases.
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Gastro 46 Acute Gastrointestinal Hemorrhage