gastro- intestinal bleeding. gib 1-2% of acute hospital admissions. 5% mortality. 90% cease...
TRANSCRIPT
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GASTRO-INTESTINAL BLEEDING
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GIB
• 1-2% of acute hospital admissions.
• 5% mortality.
• 90% cease spontaneously.
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Classification
• Level of bleeding - Upper / Low. (above and below the ligament of Trietz).
• Time - Acute / Chronic
• Severity of blood loss
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Clinical Presentation
• Hematemesis - bloody vomiting
• Coffee Ground vomiting
• Melena- dark/black stool.(degradation of hemoglobin).
• Hematochezia-Rectal bleeding
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Evaluation of the bleeding patient
-Patient assessment: anamnesis and hemodynamic status.
-resusitation.
-dignosis: bleeding source.
-treatment.
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Medical history
• Characteristics of bleeding ( melena, coffee ground, rectal bleeding).
• Symptoms reflect severity of bleeding. (syncope, dizziness, onset and frequency).
• Symptoms associate possible etiologies. Dyspepsia, abdominal pain, weight loss, early satiety, liver disease, alcohol abuse. Antececedent vomiting. Dysphagia and reflux.
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Cont-• Constipation, bowel movements.
• Medications: NSAIDS, coumadin.
• Coagulopathy.
• History of aortic surgery.
• Previous episodes.
• Comorbidities. (ability to respond to hemorrhage).
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Physical Examination• Determine degree of blood loss:
- pale, cold extremeties, sweating. -pulse, BP, orthostatism.
- consciousness.
• Epigastric tenderness. Abdominal mass.
• Signs of liver disease. (jaundices, ascites….)
• Oropharynx (rare).
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Cont-
• Rectal examination – quality of stool.
• Nasogastric tube. ( blood, coffee ground, bile, gastric fluids)
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Management and monitoring
• Large bore IV lines (Haggen/Pousseleur low)
• Fluids - Hartman’s solution (restoration of intravascular volume).
• Oxygen (espicially in IHD pts).• Blood typing and cross matching .• Blood tests- CBC, PT PTT, LFT.
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Cont-
• Unstable pt- start packed cells, consider intubation(prevent aspiration in obtunded pts) .
• Repair coagulation defects.• Consider central line cath (uaually not
needed).• Urine output.
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Level of bleeding-Upper/Low
• Upper GI bleeding - the source is above the Treitz ligament
• Lower GI bleeding – is below
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Upper GI Bleeding - Diagnosis
• Naso-gastric tube – blood or coffee ground
• Melena in rectal exam• After stabilisation and primary treatment
- upper GI endoscopy in first 12-24 hours• Specific treatment: medical, antibiotics,
endoscopy, angiography, surgery.
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Low GI Bleeding-diagnosis• Rectal bleeding – blood on rectal exam.• Normal NGT contents. • Melena with normal upper GI endoscopy• After stabilization – rectoscopy ,
colonoscopy • Proffuse bleeding – lateralisation of
bleeding site by angio or bleeding scan
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Upper Gastrointestinal Bleeding
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Upper GI Bleeding• Peptic disease – duodenal or gastric ulcer, 50%. • Erosive gastritis 15-30%.• Esophageal Varices 10-20%.• Gastrinoma – Zollinger-Ellison synd.• Mallory-Weiss tears 8-10%.• Malignancy- 3%.• Dieulafoy’s.• Esophagitis.• Osler weber rendu.• Hypertrophic gastritis – Menetrier disease or Water-Melon
Stomach• Aorto-duodenal fistula (rare)
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Peptic disease
• 5% - hemorrhage is presenting symptom.
• 20%- develop bleeding at least once.
• Hemorrhage is the most lethal form of complicated ulcer dis.
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Peptic disease- Pathogensis
• Acid peptic erosions into submucosal or extraluminal vessels.
• Helicobacter pylori. Most common etiology for duodenal ulcer.
• NSAIDS. Damage to GI mucosa. - inhibition of prostaglandin synthysis--> inhibition of
mucos and bicarbonate production. - delay ulcer healing. - epithlial acidification. - platelet dysfunction.• ZES. Gastrin secreting tumor.
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Peptic dis- prognostic factors
• Severity of bleeding, hemodynamic status.
• Persistent or recurrent.
• Transfusion requirements.
• Nasogastric aspirate, blood, coffee groud.
• Older pts.
• Comorbidities.
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Gastric ulcer- Classification
• Type 1- distal lesser curvature.
• Type 2- combined gastric and duodenal. High acid secretion.
• Type 3- prepyloric. High acid secretion.
• Type 4- proximal lesser curvature.
• Type 5- secondary to NSAIDS.
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Gastric ulcer
• 10% of gastric ulcers are malignant.
• Most bleedind ulcers arise in incisura, antrum and distal body of stomach.
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Duodenal ulcer
• 95% - secondary to Helicobacter pylori infection.
• 10% of pts with HP develop ulcer. 20% of pts with ulcer and HP bleed.
• Bleeding DU, usually located on the posterior duodenal wall.
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Peptic dis- Treatment
• NPO.• Fluids.• Stop NSAIDS.• Antisecretory agent. H2-rec blockers or proton
pump inhibitors.• PPI may reduce rebleeding.• Endoscopy- diagnostic and therapeutic. within
12-24 hours.• Anti H pylori treatment. Not immediatly. • Massive bleeding- consider emergent endoscopoy.
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The Role of Adjunctive Pharmacological Therapy
• Clot stabilization: at a pH of above 6.0 pepsin is inactivated and cannot lyse clots
• Effective clotting may not occur at pH<6.
• Antacids, iced saline gastric lavage and H2-blockers and other interventions are ineffective in reducing rebleeding.
• PPI decreases the incidence of rebleeding.
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Peptic dis- Endoscopy
• Rebleeding 10-20%. Consider re-endoscopy• Prognostic endoscopic findings for rebleed:
1) appearence -small clean ulcer base. 0%
- flat, pigmented 10%
- adherent clot. 20%
- visible vessel. 40%
- active bleeding.
2) size > 2cm.
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Peptic Ulcer
• Endoscopic manipulation- Coagulation- Injection of sclerosant or
vasoconstricting agent.- Clip.
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Peptic Ulcer Endoscopy
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Endocliping of Bleeding Ulcer
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Angiography- embolization
• To consider in:
- high risk pts.
- rec bleeding.
Duodenum: gastroduodenal art.
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Angioembolization of bleeding duodenal ulcer
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Surgical therapy
• Indications: -active bleeding not responsive to endoscopic
treatment. - significant rec bleeding after endoscopic
treatment. -ongoing transfusion requirment. 6 pc/d.• The goal of surgery: to control hemorrhage.• Acid reducing procedure is secondary, but
important.
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Surgery for bleeding ulcer
• DU: Suturing of bleeding ulcer +/- vagotomy with or without drainage. Rebleeding<10%.
• GU: Partial gastrectomy or wedge resection.
• Antrectomy+truncal vagotomy
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Vagotomy
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Drainage Procedure
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Gastrectomy
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Bleeding ulcer in pts with HP
• Eradication of HP decrease the incidence of rebleeding.
• Only 0.2 % of ulcer pts with HP infection need surgery for bleeding peptic ulcer.
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Erosive Gastritis• common source of
bleeding in critically ill pts, elderly and NSAIDS treated pts.
• Lesions distributed throught the gastric mucosa.
• Pathogenesis- acid peptic injury and mucosal ischemia d/t hypoperfusion
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Erosive gastritis• in critically ill pts- prophylaxis H2 rec antagonist
is recommended.• Treatment- conservative+ treat the underlying dis.• PPI• In profuse bleeding : - angiography- embolization. - surgery- rarely indicated, if single bleeding site gastrotomy,
suturing of and vagotomy. if multiple sitesnear/total gastrectomy
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Esophageal varices• Dilated submucosal
veins that communicate portocollateral circulation and the systemic venous system secondary to Liver cirrhosis or portal hypertension.
• 25-30% develop hemorrhage.
• 70% rebleeding.
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Esophageal varices
• Pathogenesis: elevated portal venous pressure. Hepatic pressure gradient>12 mmHg varices.
• Risk for hemorrhage: size. red color signs on endoscopy. poor liver function. active alcohol use.
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Primary treatment
• B-blockers.
• Nitrate. Less common.
• Endoscopy. Band ligation , sclerotherapy.
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Treatment of acute hemorrhage
• Vasoactive drugs:Vasopressin IV, empiric
Somatostatin IV.
effective 80-90%.• Emergent Endoscopy-ligation or
sclerotherapy.
- Rule out other etiologies.
- decrease rebleeding and mortality.
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Esophageal Varices Endoscopy
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Endoscopic Ligation of Varices
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Varices – acute hemorrhage
• Blackmore tube insertion- massive bleeding
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Varices-Treatment of rec bleeding
• B-blocker. Decrease rebleed- 30%.• Repeated endoscopy.• TIPS: - nonselective shunt. decrease hepatic flow may
induce encephlopathy. - rebleeding-20%. - thrombosis- 30-40%. - useful in acute hemorrhage. -definitive or temporary treatment.• Surgical shunt.• Liver Tx.
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Surgical porto-systemic shunt
• High mortality rate as emergency procedures.
• Nonselective- more effective in reduce hemorrhage. - greater risk for encephalopathy. - effective for ascites.• Selective- selective decompressing of left side portal
system and esophageal varices. -allow hepatic perfusionlower rate of
encephlopathy. • Procedure of choice- distal splenorenal shunt.• Devascularization procedure- if shunt procedure not
possible.
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Mallory-Weiss Tears• Tear in the gastric
mucosa near GEJ.• Characterized by
antecedent history of vomiting,retching or coughing.
• Common- associated alcoholism, nsaids, hiatal hernia, age>60.
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Mallory-Wiess treatment
• 90% stop spontaneously.
• Endoscopy for diagnosis and treatment.
• Rebleeding:pts with active bleeding in initial endoscopy, or pts with coagulation disorders.
• Surgery rarely needed.(gastrotomy and oversewing of the mucosal tear).
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Esophageal sources
• Esophagitis
• GERD.
• Barrett’s
• Malignancy.
• Medications.
• Radiation.
• IBD.
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Rare Source - Dieulafoy• Aberrant submucosal
vessel m/p in the lesser curv.
• Treatment- endoscopy / surgery.
• Endoscopic diagnosis is difficult, no ulcerated lesion.
• Rebleeding is common.
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Hypertrophic Gastritis• Water-melon stomach
or Menetrier syndrome
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Zollinger-Ellison Syndrome
• Bleeding from ulcers – duodenal and postbulbar origin
• CT and EUS are diagnostic tools
• Operation with complete resection or at least debulking is treatment of choice
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Lower GI Tract Bleeding
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LGIB
• Bleeding below ligament of Trietz.
• 97% colon
• 3% small bowel.
• Incidence increases with age.
• Slow bleeding may present as melena.
• Shock is less common than in UGIB.
• Usually intermittent.
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LGIB- Etiology
• Diverticulosis of the colon• AV malformation or angiodysplasia• Colon Cancer• IBD-Ulcerative colitis/Crohn’s• Hemorrhoides and anorectal diseases.• Ischemic colitis.• Radiation injury.(proctitis)• Meckle’s diverticulum, or other small bowel
diverticula.
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Etiology by age group, in order of frequency
Adults over 55 y.o. Adults to 55 y.o.Adolescents and young adults
- Diverticulosis
- AVMs
- Polyps
- Malignancy
-Anorectal dis
- Inflammatory
bowel disease
- Diverticulosis
- Polyps
- Malignancy
- AVMs
- Meckel’s
diverticulum
- Inflammatory
bowel disease
- Polyps
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Diagnostic procedures
• Rigid proctoscopy- in the ER, for all pts.
• Colonoscopy.
• Nuclear scintigraphy.
• Angiography.
• Operative intervention.
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proctoscopy
• Rule out anorectal disease.
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Colonoscopy
• Useful in evaluating patients with: - occult chronic GI bleeding -Acute self limited hemorrhage that has stopped bleeding.(test of choice).
• Use in patients with massive ongoing bleeding remains controversial.
• PROS :Diagnostic and therapeutic tool.(laser, coagulation, Injection).
• CONS:-Technical difficulty in not prepared pts. -Complications, Perforation.
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Nuclear scintigraphy
• Bleeding scan- detect intraluminal extravasation of blood, utilize technetium sulfur colloid or technetium 99m-labeled red blood cells.
• PROS:-Noninvasive. -Detects bleeding as slow as 0.1 mL/min. - repeated scans are possible up to 24h,
it can detect intermittent bleeding.• CONS:-not therapeutic. - delay in diagnosis. -lateralization lt or rt , but not localization
of bleeding.
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Red blood cells bleeding scan
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Angiography
• Selective catheterization of mesenteric vessels and injection of contrast – Looking for extravasation and pooling of media within
intestinal lumen – In absence of preangiographic localization catheterize
SMA IMA Celiac. – Once site of hemorrhage found intra-arterial infusion
of vasopressin arterial, venous, and bowel contraction promotes thrombosis at bleeding site
--If patient an operative risk, transcatheter embolization with gel foam, wire coils, or autologous blot clots.(may be complicated with bowel infarction).
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Angiography• PROS:- localization of bleeding. - visualize nonbleeding vascular malformations, neoplasms and
other lesions. - Detects bleeding as slow as 0.5 mL/min.
- therapeutic - recently superselective embolization is optional . - 85% effectiveness – identify and control hemorrhage.
• CONS: - achieves temporary control before definitive surgical resection.
- Invasive. - Complications: cardiac, visceral, and peripheral ishchemia
(relative contraindication) - Chance of rebleeding.
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Angiography
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Diverticulosis• Diverticular bleeding is
the most common source of LGIB, 40-50%.
• Diverticulosis Present in > 50% of population > 60 y.o.
• Risk of bleeding 5% of pts.
• Hemorrhage is not associated with diverticulitis.
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Diverticulosis
• Hemorrhage d/t weakening and erosion/rupture of vasa recta/branches of the marginal arteries,at the dome or the neck of the diverticulum, with decompression into bowel lumen.
• Luminal traumatic factors lead to hemorrhage .• Hemorrhage tends to be massive d/t arterial source• The most common source of massive LGIB, from
the lt colon.
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Diverticulosis
• Most cases stop spontaneously.– Risk of rebleeding 25% at 4 years.– 50% risk if patient has suffered two prior
episodes of diverticular bleeding
• 10-20% bleeding continues in absence of intervention.
• Colonoscopy- diagnostic and therapeutic.• Consider surgery for recurrent episodes.
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Endoscopy of Diverticulosis
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Angiodysplasia=AVM• Small ectatic vessels in the
submucosa, arteriovenous malformation.
• common in old cardiac pts, CRF, AS.
• 5-20% of LGIB.• The most common cause
of hemorrhage from SB.• The most common cause
of massive LGIB from rt colon.
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Endoscopy of angiodyspasia
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AVM- diagnosis
• Occur primarily in cecum and ascending colon of elderly patients> 50%.
• Recurrent intermittent bleeding.• Colonoscopy-most sensitive tool. - diagnostic and therapeutic.• Angiographic criteria for identification of AVM
– 1) early and prolonged filling of draining vein– 2) clusters of small arteries– 3) visualization of vascular tufts
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Colon Cancer
• Most common after AVM and diverticulosis.
• 5-10%.• Colonoscopy and
biopsy is essential• massive bleeding
uncommon.
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Endoscopy of Colon Cancer
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COLON CANCER
• Proximal colonic tumors have high propensity for occult bleeding
• Rectosigmoid tumors easily confused with hemorrhoidal bleeding– Treatment of hemorrhoids should be preceded
by flexible sigmoidoscopy in patients > 40-50 y.o.
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Inflammatory Bowel Disease
• bleeding more common in ulcerative colitis
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IBD- UC
• Minor and hemodynamically insignificant bleeding conservative treatment directed at inflammatory disease
• Hemodynamically significant bleeding surgery– total abdominal colectomy– End ileostomy + Hartmann’s pouch
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Anorectal disease
• Small amounts of bright red blood on surface of stool and toilet tissue, hemodynamically insignificant– Precipitated by strained passage of hard stool
• Hemorrhoids– Engorgement of venous plexi of rectum/anus with
protrusion of mucosa
• Anal Fissure– Tear in anal epithelium
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Colitis
•Infectious
•Ischemic
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Obscure GI bleeding
• Intermittent GI bleeding for which no source has been determined, despite rigorous endoscopic (gastroscopy+colonoscopy) and radiologic investigation.
• Almost all are from small bowel.
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Bleeding from obscure source• Angiodysplasia of small bowel, most common.
40%. Acquired lesions, may recur .• Polyps and neoplasms.• Meckel’s Diverticulum. Most common in young.• Submucosal lesion – lymphoma, stromal cell
tumor etc.• Others.
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Obscure GIB- Diagnostic modalities
-Enteroclysis or CT enterography: Able to detect SB tumors (80%), but poor modality for
superficial mucosal lesions as AVM.– Enteroscopy : can visualize through to the jejunum.– Arteriography: special attention to evidence of
angiodysplasia. 60% sen– Meckel’s scan. Initial evaluation in young pts. – GI capsule- camera.– Laparotomy and intraopertive enteroscopy. (70%sen)– Provocative testing: arteriography + heparin or
thrombolytics to precipitate acute bleeding
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Obscure GI bleeding (cont.)
• Operative exploration– Exploratory laparotomy with examination from GE
junction to intraperitoneal rectum followed by:• Transillumination of bowel wall with fiberoptic light source
• Intraoperative endoscopy
• Vigorous hydrationaccentuates thin walled veins that constitute most AVMs
– Treatment = resection of segment of SB or LB containing the offending lesion
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Meckel’s Diverticulum
• Rare, true diverticulum.• Gastric, pancreatic
mucosa.• The origin of bleeding is
ulceration of small bowel mucosa distally to the diverticulum.
• Treatment: excision of diverticulum and segment of ileum to assure inclusion of adjacent ulceration.
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Submucosal lesions
• Lymphoma of small bowel – rare disease
• Stromal cell tumor - GIST may be a reason of mucosal erosions and bleeding.
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Operative intervention in massive unidentified bleeding source
• Exploratory laparotomy :– Thorough examination of entire GI tract
• Initial step: determine visually location of blood within GI tract
• Next: careful inspection and gentle palpation of entire GI tract
• Intraoperative upper endoscopy in absence of obvious bleeding source.
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Operative intervention (cont.)
• If bleeding site localized preoperatively:– Segmental bowel resection that includes
offending lesion– Usually safe to perform primary anastomosis– End stoma + mucous fistula if patient
hemodynamically unstable, malnourished
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Operative intervention (cont.)
• If bleeding site not localized preoperatively:– intraoperative colonoscopy followed by segmental
colectomy.– if bleeding site still not identified: “blind” total
colectomy is indicated.• repeat proctoscopy to definitely rule out rectal source of
bleeding.
• 5% mortality rate.
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Thank You!