GI bleeding

Mackay Memorial Hospital

Department of Internal Medicine
Division of Gastroenterology
R4

97/6/22
 GI Bleeding
UGI bleeding

Peptic ulcer disease

Variceal bleeding

LGI bleeding
 UGI bleeding: 5 times more common than LGI
bleeding.
Men > Women
Elderly persons.
Despite ongoing advances, fundamental
principles are the same !!!!
immediate assessment and stabilization of
hemodynamic status
 Determine the source of bleeding
Stop active bleeding

Treat underlying abnormality

Prevent recurrent bleeding

hemodynamics Blood loss(% of Severity of
intravascular volume)
bleeding
normal < 10 minor

Orthostatic 10-20 moderate

hypotension or
tachycardia
shock 20-25 massive
 Resuscitation
In hemodynamically unstable
Set up two large-bore IV catheter
Colloid solution (NS or lactated Ringers)
To restore vital sign !!

ICU monitor is indicated

Central venous monitoring
F/U vital sign and urine output
History taking and physical examination
UGI or LGI ?
UGI peptic ulcer disease or portal
hypertension related (EV or GV)?
Differentiate LGI and UGI
Melena upper GI cause in 90%
Hematochezia upper GI cause in 10%
The intermediate patient
Take more time.
Re-examine,
Monitor vital signs,
Re-check CBC, BUN
 Transfusion ?
In hemodynamic unstable, any sign of poor

tissue oxygenation, continued bleeding,

persistent low Ht level(20-25%)
Maintain adequate perfusion

Target ?
Other Blood tests on the
bleeding patient
INR, PTT
coagulopathy anyone?
 There is no single value of
hemoglobin concentration that
justifies or requires transfusion;
an evaluation of the patients
clinical situation should also be a
factor in the decision.
Capital Health Guide to Blood Transfusion
Youve decided to give
blood
Options?
O neg immediately available
Type Specific 10 15 min.
Full Cross Match 30 60 min.
 What is in a unit of
packed cells?
250 mL volume
Contains citrate (anticoagulant), and
preservative.
1 unit packed cells will increase the Hb
concentration by approx. --? 0.5mg/dL
 Massive Transfusion
Greater than 1 blood volume( or 10 units )
transfused within 24 hours
May dilute platelets and clotting factors
Dilution coagulopathy

Monitor the patient for coagulopathy

Follow the resuscitation (CBC, INR, PTT)
Treatment of dilution
coagulopathy
Plasma /FFP 10 15 mL / kg
Usual adult dose 2 units.
5 8 mL / kg dose for warfarin
reversal
 Treatment of dilution
coagulopathy
Platelets
Keep the count greater than 50 ,000 in the
bleeding patient
1 unit should increase platelet count by
5 ,000 10, 000 / L
Dose: 6 pack
 Massive Transfusion
What else can go wrong?
Hypothermia
Potassium
Citrate toxicity (hypocalcemia)
Vomiting Blood
Hematemesis
Upper GI Bleeding
 Etiology
Peptic Ulcer 50 %
Gastritis 20%

Esophageal varices 10%

The rest: Tears, AVM, CA,etc 20%

More about bleeds.
80 % of Non variceal upper GI
bleeds will stop spontaneously

60 % of variceal bleeds will stop

spontaneously
What else can I do for GI bleeding,
before endoscopy
NG lavage
Drug
ABC
Patient and family Agree
( Sign permit first)
 Urgent Endoscopy ?
Initial evaluation: ?
,rebleeding
: vital sign (tachycardia, orthostatic
hypotension resting hypotension, shock),
, NG lavage
 NG lavage
15 20 % of upper GI bleeds have a
negative aspirate
Sensitivity 79%, Specificity 55%
Cuellar et al, Arch of Int Med Jul 1990

For endoscopic preparation

( not contraindicated in patients with varices)
Endoscopy
Diagnostic
Therapeutic

Prognostic
Endoscopic features and risk of
re-bleeding
Active bleeding
55 90%
 Endoscopic features and risk of re-
bleeding
Non bleeding visible vessel

40 50 %
 Endoscopic features and risk of re-
bleeding
Adherent clot

10 33%
Endoscopic features and risk of re-
bleeding
Flat spot

7 10 %
 Endoscopic features and risk of re-
bleeding
Clean base

3 5%
Variceal bleeding

Non-variceal bleeding
Drugs: Peptic ulcer bleeding

Manipulation of gastric pH
 Use of PPIs
Theory : raise gastric pH
Better platelet activity

Pepsinogen requires acid to become

activated to pepsin
Clots will form, clots not digested
 High Risk Patients
Elderly
Co Morbidity

More severe bleeding (hemo-dynamically

unstable, ongoing bleeding
Other helpful medication
somatostatin / octreotide
associated with a reduced risk of
continued bleeding and rebleeding in
PUD
When endoscopic / pharmacological treatment
fail
angiography to localize bleeder and
hemostasis
generally reserved for patient:
poor surgical candidates
control of bleeding in an unstable patient
awaiting surgery
 Surgery
Hemodynamic instability despite vigorous
resuscitation (more than a three unit
transfusion)
Recurrent hemorrhage after initial stabilization
(attempts at obtaining endoscopic hemostasis)
Shock associated with recurrent hemorrhage
Continued slow bleeding with a transfusion
requirement exceeding three units per day.
Variceal Bleeding
EGD finding:
F1-4
Ls-m-i
Cb / Cw
Red color sign
 After endoscopic treatment
Fail to achieve hemostasis or rebleeding

Balloon tamponade
Transjugular Intrahepatic Portosystemic Shunt

(TIPS)
Surgery for shunt
Balloon Tamponade
-Buy time
Available in MMH
S-B tube
 Esophageal Gastric
ballon ballon
SB tube

McCormick. British Journal of Hospital

Medicine. 43, Apr. 1990
 never exceed
45mmHg.

Volume 200ml

McCormick. British Journal of Hospital

Medicine. 43, Apr 1990
 Tamponade Tube
Sengstaken-Blakemore (S-B) tube
Radiographic confirmation of the gastric
balloons position -- 30cc air inflate the
gastric balloon
Insufflation of the esophageal balloon to
35mmHg
 Compression of varices for not excess 48
hours
Deflate the esophageal balloon for about
30 mins every 12 hours
Major complications -- aspiration and
esophageal perforation
Control hemorrhage >90%, but it is
temporary
 Bridging procedure buy time
Definite therapeutic management must be
performed.
Lower GI Bleeding

Hematochezia 90%
Melena 10%
 Etiology
Most blood passed per rectum is from
the upper GI tract.

Lower GI Bleeds
Diverticulosis, angiodysplasia, CA,
colitis, ischemia, hemorrhoids
 More about Lower GI
Bleeds
80% resolve spontaneously
25 % will rebleed

Usually painless

If painful, r/o mesenteric ischemia

Investigation of the lower
GI bleed

The usual suspects: CBC, BUN,

Creatinine, INR, PTT, T/S
 Investigation of the lower
GI bleed

Plain X-rays and abd. CT not much help

unless you clinically suspect perforation,
obstruction, ischemia (PAIN)
Diagnostic procedure
Endoscopy : 80% accuracy
Poor visibility with heavy bleeding

Angiography : 4080% accuracy

Requires heavy bleeding
Able to perform embolization or
vasopressin infusion
Diagnostic procedure

RBC scans
2590% accurate

Able to do with lower bleeding rates

What if the patient is
really bleeding?
Involve your consultants early.
Radiologist for angiography
Procto. If tumor or ischemic bowel