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ACUTE GASTROINTESTINAL
HEMORRHAGE
UPPER GI HEMORRHAGE
NON-VARICEAL
BLEEDING
VARICEAL
BLEEDING
.
.
.
.
.
LOWER GI HEMORRHAGE
COLONIC
BLEEDING
1.
2.
3.
4.
5.
6.
7.
8.
9.
DIVERTICULAR DISEASE1.
ISCHEMIA
ANORECTAL DISEASE 2.
NEOPLASIA
INFECTIOUS COLITIS
3.
POST-POLYPECTOMY
4.
IBD
5.
ANGIODYSPLASIA
RADIATION COLITIS
6.
7.
SMALL INTESTINAL
BLEEDING
ANGIODYSPLASIA
S
EROSIONS,ULCER
S
CROHNS DISEASE
RADIATION
MECKELS
DIVERTICULUM
NEOPLASIA
AORTOENTERIC
FISTULAS
CAUSES
Cause of Bleeding
Relative Frequency(%)
Peptic Ulcer
30-50
15-20
Gastritis/Duodenitis
10-15
Oesophagitis
5-10
Vascular Malformation
Tumours
Emergency Resuscitation
Takes priority over determining the diagnosis/cause
Class II
Class III
Class IV
750-1500
1500-2000
>2000
Loss (%)
0-15
15-30
30-40
>40
RR
14-20
20-30
30-40
>40
HR
<100
>100
>120
>140
BP
Unchanged
Unchanged
Reduced
Reduced
Urine
Output
(ml/hr)
>30
20-30
5-15
Anuric
Mental
State
Restless
Anxious
Anxious/con
fused
Confused/
lethargic
DIAGNOS
IS
DIAGNOSTIC ALGORITHM
Grade Ia
Grade IIb
Grade IIa
Grade IIc
Grade III
Radionuclide Scanning
Radionuclide scanning with 99mTclabeled RBC is the most
sensitive but least accurate method for localizing GI bleeding.
With this technique, the patients own red cells are labeled
and reinjected. The labeled blood is extravasated into the GI
tract lumen, creating a focus that can be detected
scintigraphically. Initially, images are obtained frequently and
then at 4-hour intervals, for up to 24 hours.
The RBC scan can detect bleeding as slow as 0.1 mL/min
and is reported to be more than 90% sensitive. Reported
accuracy of localization is in the range of only 40% to 60%
and it is particularly inaccurate for distinguishing right-sided
from left-sided colonic bleeding.
The RBC scan is not usually used as a definitive study before
surgery but instead as a guide to the usefulness of
Mesenteric Angiography
Selective angiography, using the superior or inferior
mesenteric arteries, can detect hemorrhage in the range of
0.5 to 1.0 mL/ min but is generally only used for the diagnosis
of ongoing hemorrhage.
It can be particularly useful in identifying the vascular
patterns of angiodysplasias. It may also be used for localizing
actively bleeding diverticula.
Catheter-directed vasopressin infusion can provide
temporary control of bleeding, permitting hemodynamic
stabilization, although as many as 50% of patients will
rebleed when the medication is discontinued. It can also be
used for embolization. Typically, such therapy is reserved for
patients whose underlying condition precludes surgical
therapy.
MANAGEMENT
Emergency resuscitation
Esophagoduodenoscopy urgent (within 24 hrs of admission)
Pharmacology
PPI (infusion) pH >6 stabilises clots and reduces risk of
re-bleeding following endoscopic
haemostasis
- PPI @ 8mg/hr is indictated.
Tranexamic acid (anti-fibrinolytic) maybe of benefit
(more studies needed)
If H pylori positive eradication therapy (only 60-70% of
patients with bleeding ulcer are H.pylori positive unlike
perforated ulcers)
Stop NSAIDs/aspirin/clopidogrel/warfarin/steroids/SSRIs if
safe to do so (risk:benefit analysis)
Endoscopic therapy
- Epinephrine injection (1 : 10,000) - to all four quadrants of the
lesion.
- Large-volume
injection (>13 mL)
gives better hemostasis
rebleeding rate;
practice is combination
therapy.
- Thermal energy - can be heater probes, monopolar or bipolar
electrocoagulation, or laser or argon plasma
coagulation (APC).
- The most commonly used
energy sources are electrocoagulation for
bleeding ulcers and APC for
superficial lesions.
- Hemoclips - studies have reported mixed results.
- may be particularly effective when dealing with a
spurting
vessel because they provide
immediate control of hemorrhage.
Endoscopic Injection
Ag Plasma Coagulation
Hemoclip
Angiographic techniques
- Are somewhat more generic and include selective
angiography with infusion of a vasoconstrictor, typically
vasopressin, or embolization.
-Embolic agents include temporary materials such as
gelatin sponge (Gelfoam; Pharmacia & Upjohn, Pfizer, New
York) and autologous clot or permanent devices such as
coils.
- There are few data comparing the efficacy of these
techniques.
Surgical therapy
- Approx. 10% of patients with bleeding ulcers still require surgery.
- Indications - Hemodynamic instability despite vigorous
resuscitation (>6 U transfusion)
- Failure of endoscopic techniques to arrest
hemorrhage
- Recurrent hemorrhage after initial stabilization (with
up
to two attempts at obtaining endoscopic
hemostasis) as
in >2cm ulcers, posterior
duodenal ulcers or gastric
ulcers
- Shock associated with recurrent hemorrhage
- Continued slow bleeding with a transfusion
requirement
>3 U /day
mucosal tear is
Score 0
Score 1
Score 2
Score 3
Age
<60
60-79
>80
Shock
Nil
HR >100
SBP <100
Comorbidity
Nil major
IHD/CCF/ma
jor
morbidity
Renal
failure/liver
failure
Diagnosis
Mallory
Weiss tear
All other
diagnoses
GI
malignancy
Endoscopic
Findings
None
Blood,
adherent
clot,
spurting
vessel
k
n
a
h
T
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