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Significance
Newer diagnostic modalities
New therapeutic interventions
Mortality still high
Better understanding needed
Potential to bring down mortality
Over last 20 years-
Rampant use of NSAIDs and SSRIs
Advent of newer PPIs
•Overall, the incidence of hospitalization for acute
gastrointestinal bleeding has fallen by a modest 4%
between years 1998 and 2006.*
*Ref:Sabiston,20th edition, page 1139
1. Upper GI bleed
2. Lower GI bleed
3. Obscure GI bleed
Resuscitation – First priority
Attempts made at diagnosis – when
patient stable
Run parallel – when possible
Better revive the
patient before you
have to diagnose him
in AUTOPSY
Resuscitation
1. Securing airway
2. Maintaining Breathing
3. Maintenance of circulation:
Crystalloids
Colloids
Blood & blood products
4. Disability
5. Proper exposure
Ascites
Spider angioma
Caput medusae
Palmer erythema
Nasogastric tube insertion
Catheterisation
Empirical treatment: Blind
attempt at
arresting
the bleed1. Proton pump inhibitors –
Omeprazole, Pantoprazole,
Rabeprazole etc.
2. Stopping NSAIDs or SSRIs
3. Antifibrinolytics- Tranexamic acid
Differentiate between upper and lower GI bleeding
Further investigation- find out the exact cause
and location
Treatment according to cause
1. Chief complaints
2. History
3. Physical
examination
Directly due to the
bleed-
1. Haematemesis
2. Haematochezia
3. Malena
As a Consequence of the blood loss
Signs of shock
Respiratory distress due to aspiration
As symptoms of underlying disease
Pain
Vomiting
In case of scanty blood loss
Only symptoms of anemia
•Detailed account of pain and vomiting
•Age
•Bowel habit & other personal histories
•History of medication and prior surgery
•History of past illnesses
1. General survey
2. Examination of the oral cavity, nasopharynx
and oropharynx
3. Abdominal examination
4. Looking for signs (stigmata) of chronic liver
disease- such as jaundice, ascites, palmer
erythema, caput medusa etc.
History and physical
examination strongly suggests
Oesophagogastrodudenoscopy (preferably within first 24 hours)
Diagnostic
Treatment
Non-diagnostic
Slow haemorrhage
RBC scan
Massive haemorrhage
Angiography
Operation
Time is of paramount importance
Merits-
-Highly accurate
-helps in risk stratification
-Identify the underlying disease
-Therapeutic interventions
-Taking biopsy specimen
Duodenal ulcer
Gasric ulcer
Oesophagial
varices
Hemoclip applied to
bleeding varix
Band ligation of
ulcer
Therapeutic interventions
Fix the leak after
you’ve found it
Rockall classification
Forrest classification
When in
doubt,
perform EGD
to exclude
Upper GI
bleed
When history and physical
examination strongly suggests
Lower GI bleeding
Extent of
bleeding
Slow
haemorrhage
colonoscopy
Massive
haemorrhage
angiography
Diagnostic
Non-diagnostic
•RBC scan
•Capsule
endoscopy
•CT angiography
Lower gastrointestinal haemorrhage-
•Multiple sources (40% cases)
•Longer list of D/D
•More difficult to diagnose
•Intermittent
•commonly ceases spontaneously
•Less extensive
•lower mortality rates
Lower Gastrointestinal bleeding:
causes
- minimal to moderate bleeding
-within 24 hours, can be quite accurate
-Can identify :active bleeding site, clot adherent
to mucosa,diverticula, Polyps, cancers, and
inflammatory causes;
-therapeutic intervention
-collection of biopsy sample
-Ineffective in massive haemorrhage
-Risk of complications are high
-Needs expertise for performance
Crohn’s disease
Colorectal
carcinoma
Colonic
diverticula
RBC
scanning
Alternative investigations
Radionuclide (RBC) scanning:
Can be used in massive haemorrhage
Able to identify bleeding at a rate of 0.1mL/min
90% sensitive
Predicts outcome of angiography
Inaccurate
CT angiography
Sensitivity and specificity similar to radionuclide
scanning
More accurate in localizing the bleeding
CT angiograhy
Mesenteric artery angiography
Can only be used in ongoing haemorrhage
Can diagnose bleeding at a rate of 0.5-1.0mL/min
Best for diagnosing angiodysplasia and actively bleeding diverticula
Can be used therapeutically- vasopressors and embolization
High risk of complications
Selective
mesenteric
Mesenteric artery
angiography
Obscure GI bleeding
Obscure GI hemorrhage is defined as bleeding that persists or recurs after an initial
negative evaluation with EGD and colonoscopy.*
1. Obscure-overt bleeding: EGD and colonoscopy fail to localize the site but visible bleeding
present.
2. Obscure-occult bleeding: characterized by iron deficiency anemia or guaiac-positive stools
without visible bleeding.
*Sabiston, 20th edition, page 1155
Significance of obscure GI bleeding:
•Accounts for 1% of gastrointestinal haemorrhage
•Frustrating for both patient and doctors
•25% cases remain undiagnosed (mostly lower GI origin)
•High rate of rebleeding (33-50% within 3-5 years)
•Repeated blood transfusion needed
Repeated endoscopy:
Repeat esophagoduodenoscopy and colonoscopy
Identifies the lesion in 35% cases (most cases distal to ligament of Treitz)
Conventional imaging:
RBC scanning, angiography
Provocative tests
Small bowel enteroclysis (largely abandoned now)
Computed tomographic enterography
Meckel’s diverticulum scanning (especially in young patients)
Meckel’s scan
Small bowel enteroclysis
Small bowel enteroscopy
& sonde pull endoscopy, double balloon endoscopy
Push endoscopy uses paediatric colonoscope;
Can reach up to 50-70 cm beyond ligament of Treitz;
Success rate 40%
Double balloon endoscopy is successful in 85% cases of occult bleeding
(performed within 1 month);
if done within 72 hours, more successful than capsule endoscopy
Therapeutic intervention, biopsy possible
Video Capsule Endoscopy
•Well tolerated
•Has a high success rate of 90%
•Best for haemodynamically stable patients
having ongoing GI bleed
•Time consuming
•Warrants
continuous presence of a doctor
•Contraindicated
in intestinal obstruction and motility disorders
Intraoperative endoscopy
•In patients with
transfusion-dependent occult-obscure bleeding
•Paediatric colonoscope used
•Introduced through mouth/anus/entereotomy
•Whole bowel can be run
•Obscure bleeding sources identified
•Therapeutic intervention
Colonic polyp
Small intestinal
ulcer
Resuscitation first, and resuscitate fast
EGD within 24 hours: in upper GI bleed
Colonoscopy: in moderate lower GI bleed
Treat underlying disease: prevent rebleed
Newer modalities attempted only after EGD and colonoscopy fail
repeatedly.
APPROACH TO GASTROINTESINAL BLEEDING

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APPROACH TO GASTROINTESINAL BLEEDING

  • 1.
  • 2. Significance Newer diagnostic modalities New therapeutic interventions Mortality still high Better understanding needed Potential to bring down mortality
  • 3. Over last 20 years- Rampant use of NSAIDs and SSRIs Advent of newer PPIs •Overall, the incidence of hospitalization for acute gastrointestinal bleeding has fallen by a modest 4% between years 1998 and 2006.* *Ref:Sabiston,20th edition, page 1139
  • 4. 1. Upper GI bleed 2. Lower GI bleed 3. Obscure GI bleed
  • 5. Resuscitation – First priority Attempts made at diagnosis – when patient stable Run parallel – when possible Better revive the patient before you have to diagnose him in AUTOPSY
  • 7. 3. Maintenance of circulation: Crystalloids Colloids Blood & blood products
  • 8. 4. Disability 5. Proper exposure Ascites Spider angioma Caput medusae Palmer erythema
  • 10. Empirical treatment: Blind attempt at arresting the bleed1. Proton pump inhibitors – Omeprazole, Pantoprazole, Rabeprazole etc. 2. Stopping NSAIDs or SSRIs 3. Antifibrinolytics- Tranexamic acid
  • 11. Differentiate between upper and lower GI bleeding Further investigation- find out the exact cause and location Treatment according to cause
  • 12. 1. Chief complaints 2. History 3. Physical examination
  • 13. Directly due to the bleed- 1. Haematemesis 2. Haematochezia 3. Malena
  • 14. As a Consequence of the blood loss Signs of shock Respiratory distress due to aspiration As symptoms of underlying disease Pain Vomiting In case of scanty blood loss Only symptoms of anemia
  • 15. •Detailed account of pain and vomiting •Age •Bowel habit & other personal histories •History of medication and prior surgery •History of past illnesses
  • 16. 1. General survey 2. Examination of the oral cavity, nasopharynx and oropharynx 3. Abdominal examination 4. Looking for signs (stigmata) of chronic liver disease- such as jaundice, ascites, palmer erythema, caput medusa etc.
  • 17. History and physical examination strongly suggests Oesophagogastrodudenoscopy (preferably within first 24 hours) Diagnostic Treatment Non-diagnostic Slow haemorrhage RBC scan Massive haemorrhage Angiography Operation Time is of paramount importance
  • 18.
  • 19. Merits- -Highly accurate -helps in risk stratification -Identify the underlying disease -Therapeutic interventions -Taking biopsy specimen
  • 21. Hemoclip applied to bleeding varix Band ligation of ulcer Therapeutic interventions Fix the leak after you’ve found it
  • 24. When in doubt, perform EGD to exclude Upper GI bleed When history and physical examination strongly suggests Lower GI bleeding Extent of bleeding Slow haemorrhage colonoscopy Massive haemorrhage angiography Diagnostic Non-diagnostic •RBC scan •Capsule endoscopy •CT angiography
  • 25. Lower gastrointestinal haemorrhage- •Multiple sources (40% cases) •Longer list of D/D •More difficult to diagnose •Intermittent •commonly ceases spontaneously •Less extensive •lower mortality rates
  • 27. - minimal to moderate bleeding -within 24 hours, can be quite accurate -Can identify :active bleeding site, clot adherent to mucosa,diverticula, Polyps, cancers, and inflammatory causes; -therapeutic intervention -collection of biopsy sample -Ineffective in massive haemorrhage -Risk of complications are high -Needs expertise for performance
  • 29. RBC scanning Alternative investigations Radionuclide (RBC) scanning: Can be used in massive haemorrhage Able to identify bleeding at a rate of 0.1mL/min 90% sensitive Predicts outcome of angiography Inaccurate
  • 30. CT angiography Sensitivity and specificity similar to radionuclide scanning More accurate in localizing the bleeding CT angiograhy
  • 31. Mesenteric artery angiography Can only be used in ongoing haemorrhage Can diagnose bleeding at a rate of 0.5-1.0mL/min Best for diagnosing angiodysplasia and actively bleeding diverticula Can be used therapeutically- vasopressors and embolization High risk of complications Selective mesenteric Mesenteric artery angiography
  • 32. Obscure GI bleeding Obscure GI hemorrhage is defined as bleeding that persists or recurs after an initial negative evaluation with EGD and colonoscopy.* 1. Obscure-overt bleeding: EGD and colonoscopy fail to localize the site but visible bleeding present. 2. Obscure-occult bleeding: characterized by iron deficiency anemia or guaiac-positive stools without visible bleeding. *Sabiston, 20th edition, page 1155
  • 33. Significance of obscure GI bleeding: •Accounts for 1% of gastrointestinal haemorrhage •Frustrating for both patient and doctors •25% cases remain undiagnosed (mostly lower GI origin) •High rate of rebleeding (33-50% within 3-5 years) •Repeated blood transfusion needed
  • 34.
  • 35. Repeated endoscopy: Repeat esophagoduodenoscopy and colonoscopy Identifies the lesion in 35% cases (most cases distal to ligament of Treitz) Conventional imaging: RBC scanning, angiography Provocative tests Small bowel enteroclysis (largely abandoned now) Computed tomographic enterography Meckel’s diverticulum scanning (especially in young patients) Meckel’s scan Small bowel enteroclysis
  • 36. Small bowel enteroscopy & sonde pull endoscopy, double balloon endoscopy Push endoscopy uses paediatric colonoscope; Can reach up to 50-70 cm beyond ligament of Treitz; Success rate 40% Double balloon endoscopy is successful in 85% cases of occult bleeding (performed within 1 month); if done within 72 hours, more successful than capsule endoscopy Therapeutic intervention, biopsy possible
  • 37. Video Capsule Endoscopy •Well tolerated •Has a high success rate of 90% •Best for haemodynamically stable patients having ongoing GI bleed •Time consuming •Warrants continuous presence of a doctor •Contraindicated in intestinal obstruction and motility disorders
  • 38. Intraoperative endoscopy •In patients with transfusion-dependent occult-obscure bleeding •Paediatric colonoscope used •Introduced through mouth/anus/entereotomy •Whole bowel can be run •Obscure bleeding sources identified •Therapeutic intervention Colonic polyp Small intestinal ulcer
  • 39. Resuscitation first, and resuscitate fast EGD within 24 hours: in upper GI bleed Colonoscopy: in moderate lower GI bleed Treat underlying disease: prevent rebleed Newer modalities attempted only after EGD and colonoscopy fail repeatedly.