Approach to gastrointestinal bleeding
Samir Haffar M.D.
Associated Professor of Gastroenterology
Clinical Presentation of GI bleeding
• Hematemesis Vomiting of fresh or old blood
Proximal to Treitz ligament
Bright red b...
Assessing the severity of bleeding
First step
Bleeding severity Vital Signs Blood loss (%)
Minor Normal < 10 %
Moderate Po...
Resuscitation
Proportional to bleeding severity
• 2 large-bore IV catheters: Normal saline – Ringer lactate
• Oxygen by na...
History
• Elderly Diverticula - Angiodysplasia - Cancer
• Young Peptic ulcer – Varices – Esophagitis
• < 30 years Meckel d...
Physical examination
• PHT Spider naevi – caput medusa …
• Acanthosis nigricans Underlying cancer
• Pigemnted lip lesions ...
Spider Naevi
Central arteriole
Blanch if occluded with pinhead
SVC Chest above nipple
Face
Arms
Hands
DD Childhood
Pregnan...
Direction of blood flow in anterior abdominal wall
PV obstruction
S Sherlock & J Dooley. Diseases of the Liver & Biliary S...
Collateral circulation
Vein dilatation & tortuosity in abdominal wall
of a cirrhotic patient suffering from ascites & jaun...
Caput Medusa
Portal hypertension
Seen much less frequently
Occlusion of the IVC
Gynecomastia in cirrhosis
Seen in cirrhotic males
Spironolactone is frequent cause
Absent hair body
Associated diminished ...
Palmar erythema
Exagereted red flushing of palms
Fades on pressure
Specially Thenar eminence
Hypothenar eminence
Bases of ...
White nails
• Congenital
• Cirrhosis:
Present in most patients
Due to hypoalbuminemia
Bruising
Clotting disorder
Around venepuncture site
From intramuscular injection
Acanthosis nigricans
Pigmentation of Axilla
Groins
Angles of mouth
Hands
Malignant disease Gastric carcinoma
Pancreatic ca...
Hereditary telangiectasia
Rendu-Osler-Weber disease
Stomach
Tongue
Peutz-Jeghers Syndrome
Neurofirmatosis
“von Recklinghausen’s Disease”
“Café au lait” spots
Neurofibromas
Henoch-Scholein purpura
Age Prepubertal boys (6 m – 6 years)
Can occurs in adults
Tetrad Purpuric rash: feet – buttocks – ...
Henoch-Scholein Purpura
Extenseor surfaces of legs
Buttocks
Thyphoid fever
Rose spots
Frequency: 10 – 90 %
During second week
Erythematous macules (2 – 4 mm)
Upper abdomen & anterior...
Laboratory evaluation
• Hematocrit May not reflect blood loss accurately
• Elevated BUN Not correlated to creatinine level...
Hematocrit values before & after bleeding
Diagnostic test in GI bleeding
• Upper GI endoscopy
• Colonoscopy
• Small bowel endoscopy
• Capsule endoscopy & double bal...
Causes of UGI bleeding
Common
Peptic ulcer
Varices
Mallory-Weiss
Less Frequent
Dieulafoy’s lesion
Vascular ectasia
Waterme...
Causes & associations of PU
Sleisenger & Fordtran’s Gastrointestinal & Liver Disease -1998
Common forms of PU
(95%)
HP-ass...
Predisposing factors to bleeding PU
• Acid Most prominent factor
• Helicobacter pylori
• NSAIDs
• Biphosphnate alendronate...
Bleeding peptic ulcer
• Most frequent cause of UGI bleeding (50%)
• Especially high on gastric lesser curvature
or postero...
Forrest’s classification for PU bleeding
Stage Characteristics Rebleeding
I a Jet arterial bleeding 90 %
Ib Oozing 50 %
II...
Forrest’s classification for PU bleeding
III (clean base)II-b (adherent clot)
II-a (visible vessel)I-b (oozing)
II-c (blac...
GI side effects of NSAIDs
Organ Side Effects
Esophagus Esophagitis – Ulcer – Stricture
Stomach & duodenum Subepithelial he...
Highest risk Azapropazone
Tolmetin
Ketoprofen
Piroxicam
GI safety of non-selective NSAIDs
RR of different NSAIDs could dif...
Prevention of GI toxicity
due to NSAIDs
Patients at increased risk for NSAIDs CV toxicity
High risk Patients with risk factors for CV disease often
receive prophy...
Patients at increased risk for NSAIDs GI toxicity
High risk 1. History of complicated ulcer especially recent
2. Multiple ...
Prevention of NSAID-related ulcer complications
Naproxen may have some cardioprotective properties
Patients with ulcer his...
Treatment of bleeding PU
• Pharmacological PPI 80 mg IV bolus
8mg / hr / 72 hours IV infusion
• Endoscopic Injection (epin...
Summary of therapy of bleeding PU
• Patients must be adequately resuscitated
• UGI endoscopy is the primary diagnostic mod...
Classification of esophageal varices
Grade 1
Small
Minimally elevated
veins above surface
AASLD practice guidelines: preve...
New classification of esophageal varices
• Small Varices: < 5 mm
• Large Varices: > 5 mm
Classification of gastric varices
Yamada T et all. Yamada’s textbook of gastroenterology.
Blackwell Publishing, West Susse...
Predictive factors for risk of bleeding
North Italian Endoscopic Club Index
• Variceal size Best predictor of bleeding
• S...
Child-Pugh score
Category 1 2 3
Bilirubin (mg/dl) < 2 2 - 3 > 3
Albumin (g/l) > 35 28 – 35 < 28
Ascites Absent Mild- Moder...
MELD Score
0.957 x Loge (creatinine mg/dL)
+
0.378 x Loge (bilirubin mg/dL)
+
1.120 x Loge (INR)
+
0.643∗
Multiply score b...
Score 3 month mortality
≥ 40 100%
30 – 39 83%
20 – 29 76%
10 – 19 27%
< 10 4%
Interpretation of MELD score
The maximum sco...
Treatment of acute variceal bleeding
Recommendations - 1
• Best approach is combined use of:
- Pharmacological agent start...
Treatment of acute variceal bleeding
Recommendations - 2
• Bleeding EV
Band ligation is the endoscopic treatment of choice...
• Shunt surgery
Mesocaval graft shunts or traditional portacaval shunts
may be an alternative to TIPS in Child A patients
...
Esophageal varices
Endoscopic view of
esophageal varices
Varix endoscopically
ligated with a band
TIPS
Transjugular Intrahepatic Portosystemic Shunt
Technique Metallic stent between branch of PV & HV
Under sedation with local...
General results of surgical shunts
Bleeding Prevented or at least decreased
Varices disappear in 6 – 12 months
Complicatio...
Side-to side porto-caval shunt
Distal spleno-renal shunt
Veins feeding varices ligated: coronary-rt gastric-rt gastroepiploic
Spleen is preserved
Distal spleno-renal shunt
Mortality similar to non-selective shunts
Hepatic encephalopathy similar to non-selective shunts...
Causes of bleeding in PHT
• Esophageal varices
• Gastric varices
• Ectopic varices
• Portal hypertensive gastropathy
Portal gastropathy
Mosaic-like mucosal pattern
Snake-skin appearance
Endoscopic images of PHT gastropathy
New Italian Endoscopic Club
• Mosaic-like mucosal pattern (snake-skin appearance)
• R...
PHT gastropathy – Four main findings
Mild (pink) Moderate (red)
Mosaic-like pattern
Snake-skin appearance
Black-brown Brow...
Mallory-Weiss syndrome
Retroflexed view
5- 10 % of UGI bleeding
Typically in gastric mucosa
Stop spontaneously in 80-90%
N...
LA classification system of esophagitis
Grade A
One (or more) mucosal break, no longer than 5 mm,
that does not extend bet...
One (or more) mucosal break, more than 5 mm long, that
does not extend between tops of two mucosal folds
LA classification...
One (or more) mucosal break continuous between tops of >
2 mucosal folds, but which involves < 75% of circumference
LA cla...
One (or more) mucosal break that involves at least
75% of the esophageal circumference
LA classification system of esophag...
Barrett’s esophagus
Endoscopic view of distal esophagus from a patient with GERD
Tongue of Barrett’s mucosa (b) & Schatzki...
Esophageal candidiasis
Multiple small white plaques of Candida seen on background
of abnormally reddened esophageal mucosa
Herpes Simplex in the esophagus
Appearance not diagnostic of HSV infection
It could be due to drug-induced lesion (K suppl...
CMV esophagitis
Solitary deep well-circumscribed ulcer
at gastroesophageal junction
Cancer of gastroesophageal junction
Large malignant mass at GE junction
Watermelon stomach
Gastrointest Endosc 2005; 61 : 631 - 633.
Ampulloma
Endoscopic view
Hemobilia
Blood clot protruding
from the ampulla
Corresponding ERCP
Causes of lower GI bleeding
Common
Diverticula
Vascular ectasia
Less Frequent
Neoplasia
IBD
Colitis: ischemia – radiation
...
Diverticular disease of the colon
Wide-mouthed openings to diverticula are present
They were seen throughout the sigmoid c...
Mucosal telangiectasia of the colon
The patient presented with hematochezia
The lesion was subsequently cauterized endosco...
Telangiectasia
Telangiectasia in duodenum in
patient with microcytic anemia
Treatment with APC
(Argon Plasma Coagulation)
Endoscopic polypectomy
Snare passed through endoscope
& positioned around polyp (P)
Cautery applied & polyp resected
leavi...
Ulcerative colitis
Colonic mucosa in a patient with idiopathic ulcerative colitis,
showing a friable mucosa, extensive ulc...
Ulcerative colitis
Air contrast barium enema demonstrating luminal narrowing
& loss of haustra in sigmoid & descending col...
Crohn’s disease
Aphthous ulcers in the rectum in a patient
with Crohn’s disease
Lee YJ et al. Endoscopy 2006; 38 : 592 – 5...
Crohn’s disease
Longitudinal ulcers & cobblestone appearance
in a patient with Crohn’s disease
Lee YJ et al. Endoscopy 200...
Crohn’s disease of the ileum
Luminal narrowing
Mucosal ulceration
Separation of barium-filled loops (thickening of bowel w...
NSAIDs-induced colitis
Endoscopically nonspecific findings
Histologically nonspecific
DD: infections, IBD, ischemia, vascu...
Radiation proctitis
Radiation proctitis in a patient with hematochezia
Extensive neovascularization of the mucosa
Rectal Dieulafoy’s lesion
Gastrointest Endosc 2004 ; 60 : 796.
Endoscopic appearance During ligation After ligation
Classification of hemorrhoids
Degree Description
First degree Project a short way into anal canal
Only symptom is bleeding...
Internal hemorroids
Seen with the proctoscope
Prolapse of 3 mains hemorrhoidal piles
Preferences for treatment of hemorrhoids
Degree or Grade Treatment
1 Sclerosing injections
Infrared coagulation
2 Infrared...
Sclerosing injection
Infrared photocoagulation
Rubber band ligation
Rubber band ligation
Anal fissure
Meckel’s divertculum
Isotope scan with Tc99m
Approach to lower GI bleeding
• Less common than UGI bleeding
• Usually less hemodynamicaly significant
• Most common caus...
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  • Non-selective NSAIDs: Ibuprofen/Diclofenac/NaproxenC2SI: Celecoxib, EtoricoxibThe later introduced cyclooxygenase-2selective inhibitors (C2SI) exhibit a more favorable gastrointestinal safety profile, albeit with individual differences. However, serious concerns about their cardiovascular toxicity have led to the market withdrawal of rofecoxib and regulatory warnings (European Medicines Agency) for the others. Following new reports that the increased cardiovascular risk may also apply to non-selective NSAID, the US Food and Drug Administration issued ‘black box’ safety warnings for the entire NSAID drug class (July 2010).
  • A:Mild mosaic-like gastric mucosal patternB: Moderate mosaic-like gastric mucosal pattern C: Red point lesionsD: Cherry-red spotsE: Black–brown spots, including an intramucosal hemorrhage F:brown spot
  • Approach to gastrointestinal bleeding

    1. 1. Approach to gastrointestinal bleeding Samir Haffar M.D. Associated Professor of Gastroenterology
    2. 2. Clinical Presentation of GI bleeding • Hematemesis Vomiting of fresh or old blood Proximal to Treitz ligament Bright red blood = significant bleeding Coffee ground emesis = no active bleeding • Melena Passage of black & foul-smelling stools Usually upper source – may be right colon • Hematochezia Passage of bright red blood from rectum If brisk & significant → UGI source • Occult bleeeding Bleeding not apparent to patient May lead to dyspnea, AP & even MI
    3. 3. Assessing the severity of bleeding First step Bleeding severity Vital Signs Blood loss (%) Minor Normal < 10 % Moderate Postural (Orthostatic hypotension) 10 – 20 % Massive Shock (Resting hypotension) 20 – 25 %
    4. 4. Resuscitation Proportional to bleeding severity • 2 large-bore IV catheters: Normal saline – Ringer lactate • Oxygen by nasal cannula or facemask • Monitoring of vital signs & urine output • Blood Transfusion: Ht raised to Elderly: 30 % Young: 20 – 25 % PHT: 27 – 28 % • Fresh frozen plasma & platelet transfusion If transfusion of > 10 units of packed red blood cells
    5. 5. History • Elderly Diverticula - Angiodysplasia - Cancer • Young Peptic ulcer – Varices – Esophagitis • < 30 years Meckel diverticula • Previous bleeding Bleeding from similar causes • Aortic surgery Aortoenteric fistula • Known liver disease Esophageal or gastric varices • NSAIDs • Retching Mallory-Weiss tear • Non GI sources Especially from nasopharynx
    6. 6. Physical examination • PHT Spider naevi – caput medusa … • Acanthosis nigricans Underlying cancer • Pigemnted lip lesions Peutz-Jeghers syndrome • Cutaneous lesions Neurofibromatosis • Purpura Henoch-Schonlein purpura • Splenomegaly PHT - portal vein thrombosis • Telangiectasia Osler-Weber-Rendu disease
    7. 7. Spider Naevi Central arteriole Blanch if occluded with pinhead SVC Chest above nipple Face Arms Hands DD Childhood Pregnancy Chronic liver disease
    8. 8. Direction of blood flow in anterior abdominal wall PV obstruction S Sherlock & J Dooley. Diseases of the Liver & Biliary System – 2002. IVC obstruction
    9. 9. Collateral circulation Vein dilatation & tortuosity in abdominal wall of a cirrhotic patient suffering from ascites & jaundice
    10. 10. Caput Medusa Portal hypertension Seen much less frequently
    11. 11. Occlusion of the IVC
    12. 12. Gynecomastia in cirrhosis Seen in cirrhotic males Spironolactone is frequent cause Absent hair body Associated diminished libido Associated testicular atrophy
    13. 13. Palmar erythema Exagereted red flushing of palms Fades on pressure Specially Thenar eminence Hypothenar eminence Bases of fingers DD Pregnancy Thyrotoxicosis Bronchial carcinoma Genetically determined
    14. 14. White nails • Congenital • Cirrhosis: Present in most patients Due to hypoalbuminemia
    15. 15. Bruising Clotting disorder Around venepuncture site From intramuscular injection
    16. 16. Acanthosis nigricans Pigmentation of Axilla Groins Angles of mouth Hands Malignant disease Gastric carcinoma Pancreatic carcinoma Bronchial carcinoma
    17. 17. Hereditary telangiectasia Rendu-Osler-Weber disease Stomach Tongue
    18. 18. Peutz-Jeghers Syndrome
    19. 19. Neurofirmatosis “von Recklinghausen’s Disease” “Café au lait” spots Neurofibromas
    20. 20. Henoch-Scholein purpura Age Prepubertal boys (6 m – 6 years) Can occurs in adults Tetrad Purpuric rash: feet – buttocks – legs Colicky abdominal pain - bloody diarrhea Arthralgia Glomerulonephritis Prognosis Self-limited Complications Rapidly progressive renal failure GI hemorrhage
    21. 21. Henoch-Scholein Purpura Extenseor surfaces of legs Buttocks
    22. 22. Thyphoid fever Rose spots Frequency: 10 – 90 % During second week Erythematous macules (2 – 4 mm) Upper abdomen & anterior thorax Occur in small numbers Blanch on pressure Lasts 2 – 3 days
    23. 23. Laboratory evaluation • Hematocrit May not reflect blood loss accurately • Elevated BUN Not correlated to creatinine level Breakdown of blood proteins to urea Mild reduction of GFR • Iron deficiency anemia • Low MCV • Low ferritin level
    24. 24. Hematocrit values before & after bleeding
    25. 25. Diagnostic test in GI bleeding • Upper GI endoscopy • Colonoscopy • Small bowel endoscopy • Capsule endoscopy & double balloon enteroscopy • Barium radiograph • Radionuclide imaging • Angiography • Miscellaneous tests: abdominal US or CT
    26. 26. Causes of UGI bleeding Common Peptic ulcer Varices Mallory-Weiss Less Frequent Dieulafoy’s lesion Vascular ectasia Watermelon stomach Gastric varices Neoplasia Esophagitis Rare Esophageal ulcer Erosive duodenitis Hemobilia Crohn’s disease Aorto-enteric fistula
    27. 27. Causes & associations of PU Sleisenger & Fordtran’s Gastrointestinal & Liver Disease -1998 Common forms of PU (95%) HP-associated NSAID-associated Stress ulcer Uncommon forms of P U (5%) Acid hypersecretion :ZES – mastocytosis Other infections: HSV type 1 – CMV Duod obstruction: bands-annular pancreas Radiation-induced lesions Chemotherapy-induced lesions Idiopathic
    28. 28. Predisposing factors to bleeding PU • Acid Most prominent factor • Helicobacter pylori • NSAIDs • Biphosphnate alendronate • Chronic pulmonary disease • Cirrhosis • Anticoagulants • Ethanol
    29. 29. Bleeding peptic ulcer • Most frequent cause of UGI bleeding (50%) • Especially high on gastric lesser curvature or postero-inferior wall of duodenal bulb • Most ulcer bleeding is self-limited (80%)
    30. 30. Forrest’s classification for PU bleeding Stage Characteristics Rebleeding I a Jet arterial bleeding 90 % Ib Oozing 50 % IIa Visible Vessel 25 - 30 % IIb Adherent clot 10 - 20% IIc Black spot in ulcer crater 7 - 10% III Clean base ulcer 3 - 5 %
    31. 31. Forrest’s classification for PU bleeding III (clean base)II-b (adherent clot) II-a (visible vessel)I-b (oozing) II-c (black spot) I-a (arterial jet )
    32. 32. GI side effects of NSAIDs Organ Side Effects Esophagus Esophagitis – Ulcer – Stricture Stomach & duodenum Subepithelial hemorrhage – Erosion – Ulcer Small Intestine Ulcers – Strictures – NSAID enteropathy Colon No pre-existing colonic disease: Ulcerations – Stricture – Diaphragm – Colitis Pre-existing colonic disease: ↑ Complications of diverticular disease Activate IBD Ano-rectum Inflammation – Ulcer – Stricture
    33. 33. Highest risk Azapropazone Tolmetin Ketoprofen Piroxicam GI safety of non-selective NSAIDs RR of different NSAIDs could differ 10-fold Lowest risk Ibuprofen * Diclofenac * Risk at higher doses (> 1.5 –2.4 g/d) comparable to others NSAIDs Br Med J 1996 ; 312 : 1563 – 1566. Longer half-time Moderate risk Indomethacin Naproxen Sulindac Aspirin
    34. 34. Prevention of GI toxicity due to NSAIDs
    35. 35. Patients at increased risk for NSAIDs CV toxicity High risk Patients with risk factors for CV disease often receive prophylactic aspirin Arbitrarily defined as requirement for low-dose aspirin for prevention of serious CV events Low risk No risk factors
    36. 36. Patients at increased risk for NSAIDs GI toxicity High risk 1. History of complicated ulcer especially recent 2. Multiple (> 2 risk factors) HP is independent & additive risk factor & addressed separately ACG guidelines for prevention of NSAID-related ulcer complications . Am J Gastroenterol 2009 ; 104: 728 – 738. Moderate risk (1 – 2 risk factors) 1. Age > 65 years 2. High dose NSAID therapy 3. Previous history of uncomplicated ulcer 4. Concurrent use of aspirin 5. Concurrent use of corticosteroids 6. Concurrent use of anticoagulants Low risk No risk factors
    37. 37. Prevention of NSAID-related ulcer complications Naproxen may have some cardioprotective properties Patients with ulcer history: search for HP & if present eradicated ACG guidelines for prevention of NSAID-related ulcer complications. Am J Gastroenterol 2009 ; 104: 728 – 738. NSAID alone (least ulcerogenic at lowest dose) NSAID + PPI/misoprostol Alternative therapy or Coxibs + PPI/misoprostol Naproxen + PPI/misoprostol Naproxen + PPI/misoprostol Avoid NSAIDs & coxibs Use alternative therapy High GI riskModerate GI riskLow GI risk Low CV risk High CV risk
    38. 38. Treatment of bleeding PU • Pharmacological PPI 80 mg IV bolus 8mg / hr / 72 hours IV infusion • Endoscopic Injection (epinephrine 1/10.000) Monopolar coagulation Bipolar coagulation Heater probe Hemoclips Argon plasma coagulation • Surgical When endoscopic treatment fails
    39. 39. Summary of therapy of bleeding PU • Patients must be adequately resuscitated • UGI endoscopy is the primary diagnostic modality • Intubation if severe bleeding or altered mental status • Endoscopic therapy indicated in high risk lesions Combine 2 methods of endoscopic treatment • IV PPI should be used in high risk patients
    40. 40. Classification of esophageal varices Grade 1 Small Minimally elevated veins above surface AASLD practice guidelines: prevention & management of gastroesophageal varices. Hepatology 2007 ; 46 : 922 – 938. Grade 2 Medium Tortuous veins occupying < 1/3 of esophageal lumen Grade 3 Large Occupying > 1/3 of esophageal lumen
    41. 41. New classification of esophageal varices • Small Varices: < 5 mm • Large Varices: > 5 mm
    42. 42. Classification of gastric varices Yamada T et all. Yamada’s textbook of gastroenterology. Blackwell Publishing, West Sussex, UK, 5th edition, 2009. Gastro-Oesophageal Varices Type I Along lesser curve Type II To gastric fundus Isolated Gastric Varices Type I Fundal Type II Ectopic
    43. 43. Predictive factors for risk of bleeding North Italian Endoscopic Club Index • Variceal size Best predictor of bleeding • Severity of liver disease Expressed by Child-Pugh • Red signs On the varices NIEC. N Engl J Med 1988 ; 319 : 983 – 989.
    44. 44. Child-Pugh score Category 1 2 3 Bilirubin (mg/dl) < 2 2 - 3 > 3 Albumin (g/l) > 35 28 – 35 < 28 Ascites Absent Mild- Moderate Severe Encephalopathy 0 I – II III – IV INR < 1.7 (70%) 1.7 – 2.3 (40 – 70%) > 2.3 (< 40%) Class A: 5 – 6 Class B: 7 – 9 Class C: 10 – 15
    45. 45. MELD Score 0.957 x Loge (creatinine mg/dL) + 0.378 x Loge (bilirubin mg/dL) + 1.120 x Loge (INR) + 0.643∗ Multiply score by 10 & round to nearest whole number Laboratory values < 1.0 are set to 1.0 Maximum creatinine within MELD score: 4.0 mg/dl Dialysis twice/week prior to creatinine test: creatinine 4.0 mg/dl * 0.643 for etiology to make score comparable to previous published data
    46. 46. Score 3 month mortality ≥ 40 100% 30 – 39 83% 20 – 29 76% 10 – 19 27% < 10 4% Interpretation of MELD score The maximum score given for MELD is 40 All values > 40 are given a score of 40 www.unos.org/resources/MeldPeldCalculator
    47. 47. Treatment of acute variceal bleeding Recommendations - 1 • Best approach is combined use of: - Pharmacological agent started from admission & - Endoscopic procedure • Terlipressin & somatostatin preferable if available Octreotide, vasopressin + nitroglycerin may be used • Drug therapy maintained for at least 48 h 5 day therapy recommended to prevent early rebleeding
    48. 48. Treatment of acute variceal bleeding Recommendations - 2 • Bleeding EV Band ligation is the endoscopic treatment of choice Sclerotherapy may be used • Bleeding GV Obturation with cyanoacrylate • TIPS Rescue procedure if medical & endoscopic tt fails Bleeding from GV may require earlier decision for TIPS
    49. 49. • Shunt surgery Mesocaval graft shunts or traditional portacaval shunts may be an alternative to TIPS in Child A patients • Blood transfusion Done cautiously using packed red cells (Ht: 25 – 28 %) Plasma expanders to maintain hemodynamic stability • Prophylaxis of infection Given to all patients (norfloxacin 400 mg /12 hours) Treatment of acute variceal bleeding Recommendations - 3
    50. 50. Esophageal varices Endoscopic view of esophageal varices Varix endoscopically ligated with a band
    51. 51. TIPS
    52. 52. Transjugular Intrahepatic Portosystemic Shunt Technique Metallic stent between branch of PV & HV Under sedation with local anesthesia US guidance essential during the procedure Time of procedure: 1 – 2 hours Difficult (skilled interventional radiologist) Indications Control of bleeding from EV or GV Medical & endoscopic tt given before TIPS Results Bleeding control 90 % Mortality < 1 %
    53. 53. General results of surgical shunts Bleeding Prevented or at least decreased Varices disappear in 6 – 12 months Complications Post-operative jaundice Increase cardiac output & failure Hepatic encephalopathy May be transient Chronic changes in 30 – 40 % Increase with the size of shunt More common in older patients Mortality 5 % in good-risk patients 50 % in poor-risk patients
    54. 54. Side-to side porto-caval shunt
    55. 55. Distal spleno-renal shunt Veins feeding varices ligated: coronary-rt gastric-rt gastroepiploic Spleen is preserved
    56. 56. Distal spleno-renal shunt Mortality similar to non-selective shunts Hepatic encephalopathy similar to non-selective shunts Better results in non-alcoholic patients & in gastric varices Does not interfere with subsequent liver transplant Technically difficult (fewer surgeons willing to perform it)
    57. 57. Causes of bleeding in PHT • Esophageal varices • Gastric varices • Ectopic varices • Portal hypertensive gastropathy
    58. 58. Portal gastropathy Mosaic-like mucosal pattern Snake-skin appearance
    59. 59. Endoscopic images of PHT gastropathy New Italian Endoscopic Club • Mosaic-like mucosal pattern (snake-skin appearance) • Red point lesions Small (<1 mm), red, flat, point-like marks • Cherry-red spots Large (>2 mm), round, red-colored, protruding lesions • Black–brown spots Irregular black & brown flat spots not fading upon washing Might represent intramucosal hemorrhage Primignani M et al. Gastroenterology 2000 ; 119 : 181 – 187.
    60. 60. PHT gastropathy – Four main findings Mild (pink) Moderate (red) Mosaic-like pattern Snake-skin appearance Black-brown Brown spot Black–brown spots Red point lesions Small (<1 mm) Cherry-red spots Large (>2 mm) Gastroenterology 2000;119:181-187.
    61. 61. Mallory-Weiss syndrome Retroflexed view 5- 10 % of UGI bleeding Typically in gastric mucosa Stop spontaneously in 80-90% Not bleeding: discharge promptly Active bleeding: injection – banding
    62. 62. LA classification system of esophagitis Grade A One (or more) mucosal break, no longer than 5 mm, that does not extend between tops of 2 mucosal folds
    63. 63. One (or more) mucosal break, more than 5 mm long, that does not extend between tops of two mucosal folds LA classification system of esophagitis Grade B
    64. 64. One (or more) mucosal break continuous between tops of > 2 mucosal folds, but which involves < 75% of circumference LA classification system of esophagitis Grade C
    65. 65. One (or more) mucosal break that involves at least 75% of the esophageal circumference LA classification system of esophagitis Grade D
    66. 66. Barrett’s esophagus Endoscopic view of distal esophagus from a patient with GERD Tongue of Barrett’s mucosa (b) & Schatzki’s ring(s) (arrow)
    67. 67. Esophageal candidiasis Multiple small white plaques of Candida seen on background of abnormally reddened esophageal mucosa
    68. 68. Herpes Simplex in the esophagus Appearance not diagnostic of HSV infection It could be due to drug-induced lesion (K supplement) Presence of vesicles in mucosa virtually diagnostic of HSV Small volcano-like ulcers due to HSV
    69. 69. CMV esophagitis Solitary deep well-circumscribed ulcer at gastroesophageal junction
    70. 70. Cancer of gastroesophageal junction Large malignant mass at GE junction
    71. 71. Watermelon stomach Gastrointest Endosc 2005; 61 : 631 - 633.
    72. 72. Ampulloma Endoscopic view
    73. 73. Hemobilia Blood clot protruding from the ampulla Corresponding ERCP
    74. 74. Causes of lower GI bleeding Common Diverticula Vascular ectasia Less Frequent Neoplasia IBD Colitis: ischemia – radiation Hemorrhoids Small bowel source UGI source Rare Dieulafoy’s lesion Colonic ulceration Rectal varices
    75. 75. Diverticular disease of the colon Wide-mouthed openings to diverticula are present They were seen throughout the sigmoid colon in this patient
    76. 76. Mucosal telangiectasia of the colon The patient presented with hematochezia The lesion was subsequently cauterized endoscopically
    77. 77. Telangiectasia Telangiectasia in duodenum in patient with microcytic anemia Treatment with APC (Argon Plasma Coagulation)
    78. 78. Endoscopic polypectomy Snare passed through endoscope & positioned around polyp (P) Cautery applied & polyp resected leaving clean mucosal defect
    79. 79. Ulcerative colitis Colonic mucosa in a patient with idiopathic ulcerative colitis, showing a friable mucosa, extensive ulceration, and exudates.
    80. 80. Ulcerative colitis Air contrast barium enema demonstrating luminal narrowing & loss of haustra in sigmoid & descending colon in UC
    81. 81. Crohn’s disease Aphthous ulcers in the rectum in a patient with Crohn’s disease Lee YJ et al. Endoscopy 2006; 38 : 592 – 597.
    82. 82. Crohn’s disease Longitudinal ulcers & cobblestone appearance in a patient with Crohn’s disease Lee YJ et al. Endoscopy 2006; 38 : 592 – 597.
    83. 83. Crohn’s disease of the ileum Luminal narrowing Mucosal ulceration Separation of barium-filled loops (thickening of bowel wall) Small bowel follow-through in ileal Crohn’s disease
    84. 84. NSAIDs-induced colitis Endoscopically nonspecific findings Histologically nonspecific DD: infections, IBD, ischemia, vasculitis
    85. 85. Radiation proctitis Radiation proctitis in a patient with hematochezia Extensive neovascularization of the mucosa
    86. 86. Rectal Dieulafoy’s lesion Gastrointest Endosc 2004 ; 60 : 796. Endoscopic appearance During ligation After ligation
    87. 87. Classification of hemorrhoids Degree Description First degree Project a short way into anal canal Only symptom is bleeding Second degree Prolapse during defecation Reduce spontaneously Third degree Must be reduced manually Fourth degree Irreducible
    88. 88. Internal hemorroids Seen with the proctoscope
    89. 89. Prolapse of 3 mains hemorrhoidal piles
    90. 90. Preferences for treatment of hemorrhoids Degree or Grade Treatment 1 Sclerosing injections Infrared coagulation 2 Infrared coagulation Rubber band ligation 3 Rubber band ligation 4 Hemorrhoidectomy
    91. 91. Sclerosing injection
    92. 92. Infrared photocoagulation
    93. 93. Rubber band ligation
    94. 94. Rubber band ligation
    95. 95. Anal fissure
    96. 96. Meckel’s divertculum Isotope scan with Tc99m
    97. 97. Approach to lower GI bleeding • Less common than UGI bleeding • Usually less hemodynamicaly significant • Most common cause of severe bleeding: diverticula • Most common cause of minor bleeding: hemorrhoids • Controversial best diagnostic approach if severe: Urgent colonoscopy – RBC scintigraphy – angiography
    98. 98. Thank You
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