Interdepartmental Conference“Upper And Lower Gastrointestinal Hemorrhage”PRESENTED BY : SORAWIT BOONYATHEE, MD.

Outline

Definition and Anatomical related

Upper Gastrointestinal Hemorrhage

Lower Gastrointestinal Hemorrhage

Section 1 : Definition and Anatomical related

DefinitionUpper and lower gastrointestinal bleeding• Upper gastrointestinal bleeding (or hemorrhage) is that originating proximal to the

ligament of Treitz; in practice from the esophagus, stomach and duodenum.

• Lower gastrointestinal bleeding is that originating from the small bowel and colon.

Ligament of Trietz

http://www.normanallan.com/Misc/mingmen.htm

Definition (Cont.)Hematemesis • Hematemesis is vomiting of blood from the upper gastrointestinal tract or

occasionally after swallowing blood from a source in the nasopharynx. • Bright red hematemesis usually implies active hemorrhage from the esophagus,

stomach or duodenum. This can lead to circulatory collapse and constitutes a major medical emergency.

Coffee-ground vomitus (Hb + acid)• Coffee-ground vomitus refers to the vomiting of black material which is assumed to

be blood. Its presence implies that bleeding has ceased or has been relatively modest.

Definition (Cont.)Melena•Melena is the passage of black tarry stools usually due to acute upper

gastrointestinal bleeding but occasionally from bleeding within the small bowel or right side of the colon.

Hematochezia• Hematochezia is the passage of fresh or altered blood per rectum usually due to

colonic bleeding. Occasionally profuse upper gastrointestinal or small bowel bleeding can be responsible.

Definition (Cont.)Varices• Varices are abnormal distended veins usually in the esophagus

(esophageal varices) and less frequently in the stomach (gastricvarices) or other sites (ectopic varices) usually occurring as aconsequence of liver disease. Bleeding is characteristically severe and may be life threatening.

• The size of the varices and their propensity to bleed is directlyrelated to the portal pressure, which, in the majority of cases, isdirectly related to the severity of underlying liver disease.

http://quizlet.com/9551975/portal-hypertension-flash-cards/

Section 3 : Upper Gastrointestinal Hemorrhage

Prevalence of Upper Gastrointestinal Hemorrhage ในประเทศไทย40-50 % Peptic ulcer disease

20-35 % Erosive gastritis/duodenitis

8-15 % variceal bleeding

8-15 % Mallory-Weiss syndrome

Initial Assessment and Resuscitation2

Supportive Treatment

- Maintain Airway- Hx and PE for assessment of

severity and causes- NG irrigations- Fluid resuscitation- Blood for CBC, Cross-match

blood group for blood transfusion

Scoring for Categorized Patient (Cont.)How Important to Classify patient• For predicting of prognosis and progress of disease

• For planning of definite management

Scoring systems for Upper Gastrointestinal Bleeding• Rockall Scoring System

• Forrest classification

• Glasgow-Blatchford Bleeding Score

Risk Stratification3

Host Factor

• Age ≥ 60

• Co-morbid conditions e.g.

Renal failure, Cirrhosis, CVD,

COPD

• Hemodynamic instability e.g.

orthostatic hypotension, pulse

> 100/min, SBP < 100 mmHg

• Coagulopathy including drug-

related

Bleeding Characters

• Continuous red blood from NG

after irrigation

• Red blood per rectum

Patient Course

• Need blood transfusion

• Rebleeding

• Hemodynamic instability

How to differentiated to variceal or non-varicealbleeding

Variceal Hemorrhage Non-Variceal Hemorrhage

Painless Bleeding Pain or Painless Bleeding

Usually Hematemesis Hematemesis, Coffee ground, Melena

> 90% Hemodynamic change or Hct < 30%

Vary

Sign of chronic liver disease none

Signs of Chronic Liver DiseaseSpider angioma

Jaundice

Scleral icterus

Palmar erythema

Gynecomastia

Ascites

Asterixis

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Medication Treatment for Non-varicealHemorrhageContinuous or Bolus intravenous Proton pump inhibitor or oral double doses PPI• Continuous dose -> 80 mg iv bolus then iv drip 8 mg/hr for 72 hours

• Bolus dose -> 40 mg iv twice daily

• Both doses consider used in high risk

หมายเหตุ การให้ท้ังสองวธิี พบว่าสามารถเพิ่ม Gastric pH >4 และ 6 ได้เท่ากัน

Brunner G, Luna P, Hartman M, Wurst W. Optimising the intra gastric pH as supportive therapy in upper GI bleeding.Yale J Biol Med 1996;69:225-31

Medication Treatment for Non-varicealHemorrhage Role of PPI before endoscopy(1,2)

• Effect -> decrease stage of stigmata of recent hemorrhage

• Not effect -> rebleeding, surgery and mortality

Role of PPI after endoscopy(3,4)

For low dose can reduce risk of rebleeding

For high dose can reduce risk of rebleeding and surgery rate

Both low and high dose cannot reduce mortality rate

Medication Treatment for Variceal Hemorrhage Mechanism for reducing venous blood flow and arterial flow to stomach and small intestine

Can reduce risk of rebleeding and surgery rate

Somatostatin

250 microgram iv bolus then iv drip 250 microgram/hr

Octreotide

50 microgram iv bolus then iv drip 50 microgram/hr

Sengstaken-Blakemore tube (S-B tube) Suspected in Variceal bleeding group and used somatostatin analog 1-2 hours that not improved bleeding

Esophageal Balloon Pressure -> 25 - 40 mmHg (20-30 ml of air)

Gastric Balloon volume ->50 ml then 250 – 300 ml of air

Section 4 : Lower Gastrointestinal Hemorrhage

Lower Gastrointestinal HemorrhageSites• Colon – 95-97%

• Small bowel – 3-5%

Only 15% of massive GI bleeding

Finding the site• Intermittent bleeding common

• Up to 42% have multiple sites

EtiologyDiverticulosis – 40-55%

Angiodysplasia – 3-20%

Neoplasia

Inflammatory conditions

Vascular

Hemorrhoids

Others

HemorrhoidDefinition:• Dilated or enlarged veins in the lower portion of the rectum or anus.

Symptoms• Rectal Bleeding, Bright red blood in stool, Pain during bowel movements, Anal

Itching, Rectal Prolapse, Thrombus

Cause• Pressure -> Constipation, Diarrhea, Sitting or standing for long periods of time,

Obesity, Pregnancy

Non-surgical TreatmentWASH regimen•Warm water

•Analgesic agent

•Stool softeners

•High fiber diet

If prolapses, gently push back into anal canal Use a sitz bath with warm water Use moist towelettes or wet toilet paper instead

of dry toilet paper. Increased fluid intake Avoidance of straining

Painful or persistent hemorrhoids:Banding

Sclerotherapy

Infered Light

Laser Therapy

Freezing

Electrical Current

Surgery

Indication for surgical management

Persistent itching

Anal bleeding

Pain

Blood clots

Infection

ComplicationReactions to medications of anesthesia

Bleeding

Infection

Narrowing of the anus

*The outcome is usually very good in the majority of cases.

PreventionEat high fiber diet

Drink Plenty of Liquids

Fiber Supplements

Exercise

Avoid long periods of standing or sitting

Don’t Strain

Go as soon as you feel the urge

Anal FissureFissure is a tear in the anal canal extending from just below the dentate line to the anal verge.

Most commonly in young and middle age adults.

The cardinal symptom is pain during and for minutes to hours following defecation.

Bright red blood is common

Anal fissure (cont.)90% in the posterior midline

25% anterior midline in women, 8% in men

3% have anterior and posterior fissures

Lateral positions should raise concern for other disease processes—Crohn’s, TB, syphilis, HIV/AIDS, or anal ca

Early (acute) fissures appear as a simple tear in the anoderm

Chronic fissures (symptoms more than 8-12 wks) have edema and fibrosis

Etiology Trauma due to passage of a hard stool

History of constipation or diarrhea

Associated with increased resting pressures• Sustained resting hypertonia

Symptoms Hallmark is pain during, and particularly after, a BM

May be short-lived or last hours or all day

Described as passing razor blades or glass shards

Bleeding usually limited to bright red blood on the tissue

Conservative ManagementAlmost half will heal Sitz baths

Fiber supplement

+/- topical anesthetics or anti-inflammatory ointments

WASH regimen• Warm water

• Analgesic agent

• Stool softeners

• High fiber diet

Medical ManagementSphincter relaxants--“Chemical sphincterotomy”Nitrate formulasNTG, GTN, ISDN

Predominant nonadrenergic, noncholinergic neurotransmitter

Oral and topical calcium channel blockersAs effective as nitrates without the headache

Topical muscarinic agonistsBethanechol

Phophodiesterase inhibitors

Botulinum toxin

Operative TreatmentPrimary goal is to decrease abnormally high resting anal tone

Anal Dilatation93-94% healing with few complicationsLong term outcomes sparseIncontinence can occur in around 12-27%

Lateral Internal SphincterotomyKeyhole deformity if done in posterior midlineIncontinence rates up to 36% but vary widelyOpen or closed technique

Question and Answer

Thank you for your kind attention

Reference1. Dorward S, Sreedharan A, Leonatiadis GI, et al. Proton pump inhibitor

treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2006;18(4):CD005415

2. Lau JY, Leung WK, Wu JCYN, et al. Omeprazole before endoscopy in patients with gastrointestinal bleeding. N Engl J Med 2007;356:1631-40

3. Leontiadis GI, Sharma VK, Howden CW, et al. Proton pump inhibitor treatment for acute peptic ulcer bleeding. Cochrane Database Syst Rev. 2006 Jan 25;(1):CD002094

Reference4. Sung JJ, Chan FK, Lau JY, et al. The effect of endoscopic therapy in patients

receiving omeprazole for bleeding ulcers with nonbleeding visible vessels or adherent clots: a randomized comparison. Ann Intern Med 2003;139:237-43.

5. Mallinkrodt Medical product information leaflet for Sengstaken-Blakemore tube product no: 156-20.

6. Hudak C, Gallo B, and Morton P (1998).Critical Care Nursing A Holistic Approach.(7th ed) Lippincott, New York.

7. Henneman PL (1998).”Gastrointestinal bleeding “ in Emergency Medicine, edPeter Rosen et al. Mosby.St Louis.