Acute Gastrointestinal hemorrhage

Acute Gastrointestinal
Hemorrhage
By Dr Mengistu.K

Acute Gastrointestinal Hemorrhage
• Hemorrhage can originate from any region of
the GI tract and is typically classified based on
the location relative to the ligament of Treitz.
• Upper GI hemorrhage (proximal to the ligament
of Treitz) accounts for more than 80% of acute
bleeding.
• Peptic ulcer disease (PUD) and variceal
hemorrhage are the most common etiologies.
7/30/2016 Dr.mengistu 2

• Most lower GI bleeding originates from the
colon, with diverticula and angiodysplasias
accounting for the majority of cases. In less than
5% of patients, the small intestine is responsible
• Obscure bleeding is defined as hemorrhage that
persists or recurs after negative endoscopy.
• Occult bleeding is not apparent to the patient
until presentation with symptoms related to the
anemia.

ACUTE UPPER GASTROINTESTINAL
HEMORRHAGE
• Upper GI bleeding refers to bleeding that arises
from the GI tract proximal to the ligament of
Treitz and accounts for nearly 80% of significant
GI hemorrhage.
• The causes of upper GI bleeding are best
categorized as either nonvariceal or bleeding
related to portal hypertension ( Table 46-1 ).
• The nonvariceal causes account for about 80% of
such bleeding, with PUD being the most
common.

Specific Causes of Upper
Gastrointestinal Hemorrhage
Nonvariceal Bleeding
1. Peptic Ulcer Disease:
 PUD still represents the most frequent cause of
upper GI hemorrhage, accounting for about 40% of
all cases.
 About 10% to 15% of patients with PUD develop
bleeding at some point in the course of their
disease.
 Bleeding is the most frequent indication for
operation and the principal cause of death.

• Bleeding develops as a consequence of acid-
peptic erosion of the mucosal surface.
• Although duodenal ulcers are more common
than gastric ulcers, gastric ulcers bleed more
commonly; as a result, in most series, the
relative proportions are nearly equal.

• The most significant hemorrhage occurs when
duodenal or gastric ulcers penetrate into
branches of the gastroduodenal artery or left
gastric artery, respectively.

Management
• The Forrest classification was developed in an
attempt to assess this risk based on endoscopic
findings, and to stratify the patients into low-,
intermediate-, and high-risk groups.

• Endoscopic therapy is recommended in cases of
active bleeding as well as a visible vessel
(Forrest I to IIa).
• In cases of an adherent clot (Forrest IIb), the
clot is removed and the underlying lesion
evaluated.
• Ulcers with a clean base or a black spot,
secondary to hematin deposition, are generally
not treated endoscopically.

• Medical Management In cases of an acute
peptic ulcer bleed, PPIs have been shown to
reduce the risk for rebleeding and the need for
surgical intervention
• Therefore, patients with a suspected or
confirmed bleeding ulcer are started on a PPI.

• Unlike perforated ulcers, which are commonly
associated with H. pylori infection, the
association between H. pylori infection and
bleeding is less strong.
• Only 60% to 70% of patients with a bleeding
ulcer test positive for H. pylori.

• Endoscopic Management After the bleeding
ulcer has been identified, effective local
therapy can be delivered endoscopically to
control the hemorrhage.
• The available endoscopic options include
epinephrine injection, heater probes and
coagulation, and the application of hemoclips.

Surgical Management
 Despite significant advances in endoscopic
therapy, about 10% of patients with bleeding
ulcers still require surgical intervention for
effective hemostasis.
 Ulcers greater than 2 cm, posterior duodenal
ulcers, and gastric ulcers have a significantly
higher risk for rebleeding.
 Patients with these ulcer characteristics require
closer monitoring and possibly earlier surgical
intervention.

• The first priority at operation is control of the
hemorrhage.
• The first step in the operation for duodenal
ulcer is exposure of the bleeding site. Because
most of these lesions are in the duodenal bulb,
longitudinal duodenotomy or duodenal pyloromyotomy is
performed.

• Because the pylorus has often been opened in
a longitudinal fashion to control the bleeding,
closure as a pyloroplasty combined with
truncal vagotomy is the most frequently used
operation for bleeding duodenal ulcer.
• Parietal cell vagotomy may represent a better
therapy for a bleeding duodenal ulcer in the
stable patient.

• For bleeding gastric ulcers, similar to bleeding
duodenal ulcers, control of bleeding is the
immediate priority.
• This may require gastrotomy and suture ligation,
which, if no other procedure is performed, is
associated with about a 30% risk for rebleeding.
• In addition, because of the approximate 10%
incidence of malignancy, gastric ulcer resection
is generally indicated.

2. Mallory-Weiss Tears
• Mallory-Weiss tears are mucosal and
submucosal tears that occur near the
gastroesophageal junction.
• Classically, these lesions develop in alcoholic
patients after a period of intense retching and
vomiting after binge drinking, but they can
occur in any patient who has a history of
repeated emesis.

• The mechanism, proposed by Mallory and
Weiss in 1929, is forceful contraction of the
abdominal wall against an unrelaxed cardia,
resulting in mucosal laceration of the proximal
cardia as a result of the increase in intragastric
pressure.
• Mallory-Weiss tears account for 5% to 10% of
cases of upper GI bleeding.

• Supportive therapy is often all that is necessary
because 90% of bleeding episodes are self-
limited, and the mucosa often heals within 72
hours.
• In rare cases of severe ongoing bleeding, local
endoscopic therapy with injection or
electrocoagulation may be effective.

3. Stress Gastritis
• Stress-related gastritis is characterized by the
appearance of multiple superficial erosions of
the entire stomach, most commonly in the
body.
• It is thought to result from the combination of
acid and pepsin injury in the context of
ischemia from hypoperfusion states.

• These lesions are different from the solitary
ulcerations, related to acid hypersecretion, that
occur in patients with severe head injury
(Cushing's ulcers).
• When stress ulceration is associated with
major burns, these lesions are referred to as
Curling's ulcers.

• In patients who develop significant bleeding,
acid-suppressive therapy is often successful in
controlling the hemorrhage.
• In rare cases when this fails, consideration is
given to administration of octreotide or
vasopressin selectively through the left gastric
artery, endoscopic therapy, or even
angiographic embolization.

4. Esophagitis
• Esophageal inflammation secondary to repeated
exposure of the esophageal mucosa to the acidic
gastric secretions in gastroesophageal reflux
disease (GERD).
• Treatment typically includes acid-suppressive
therapy. Endoscopic control of the hemorrhage,
usually with electrocoagulation or heater probe, is
often successful.
• In patients with an infectious etiology, targeted
therapy is appropriate. Operation is seldom
necessary.

5. Dieulafoy's Lesion
• Dieulafoy's lesions are vascular malformations found
primarily along the lesser curve of the stomach within
6 cm of the gastroesophageal junction.
• They represent rupture of unusually large vessels (1-3
mm) that are found in the gastric submucosa.
• Erosion of the gastric mucosa overlying these vessels
leads to hemorrhage. The mucosal defect is usually
small (2-5 mm) and may be difficult to identify.

• Initial attempts at endoscopic control are often
successful.
• Application of thermal or sclerosant therapy is
effective in 80% to 100% of cases.
• In cases that fail endoscopic therapy,
angiographic coil embolization can be
successful. If these approaches fail, surgical
intervention may be necessary.

6. Hemobilia
• It is typically associated with trauma, recent
instrumentation of the biliary tree, or hepatic
neoplasms.
• This unusual cause of GI bleeding is suspected
in anyone who presents with hemorrhage,
right upper quadrant pain, and jaundice.
Unfortunately, this triad is seen in less than
half of patients, and a high index of suspicion
is required.

• Endoscopy can be helpful by demonstrating
blood at the ampulla.
• Angiography is the diagnostic procedure of
choice.
• If diagnosis is confirmed, angiographic
embolization is the preferred treatment.

7. Hemosuccus Pancreaticus
• Is bleeding from the pancreatic duct.
• This is typically caused by erosion of a
pancreatic pseudocyst into the splenic artery.
• It presents with abdominal pain and
hematochezia.
• Angiography is diagnostic and permits
embolization, which is often therapeutic.

Bleeding Related to Portal Hypertension
• Hemorrhage related to portal hypertension is
most commonly the result of bleeding from
varices.
• These dilated submucosal veins develop in
response to the portal hypertension, providing a
collateral pathway for decompression of the
portal system into the systemic venous
circulation.

• Although they are most common in the distal
esophagus, they also may develop in the
stomach and the hemorrhoidal plexus of the
rectum.
• Gastroesophageal varices develop in about
30% of patients with cirrhosis and portal
hypertension, and 30% in this group develop
variceal bleeding.

• Compared with nonvariceal bleeding, variceal
hemorrhage is associated with an increased
risk for rebleeding, need for transfusions,
increased hospital stay, and mortality.

Management
Medical Management
• Vasopressin produces splanchnic vasoconstriction
and has been shown to significantly reduce bleeding
when compared with placebo.
• Unfortunately, this agent results in significant
cardiac vasoconstriction, with resulting myocardial
ischemia.
• Somatostatin, a natural peptide (with a very short
half-life) that induces splanchnic vasoconstriction
without cardiac side effects, has been used
worldwide.

Endoscopic Management
• If bleeding esophageal varices are identified, both
sclerotherapy and variceal banding have been
shown to control hemorrhage effectively.
• These endoscopic approaches, sometimes with as
many as three treatments over 24 hours, control the
hemorrhage in up to 90% of patients with
esophageal varices.
• Unfortunately, gastric varices are not effectively
managed by endoscopic techniques.

Other Management
• In cases in which pharmacologic or endoscopic
therapies fail to control the hemorrhage,
balloon tamponade can be successful in
temporizing the hemorrhage.
• The Sengstaken-Blakemore tube consists of a
gastric tube with esophageal and gastric
balloons.

• The TIPS procedure can be lifesaving in
patients who are hemodynamically unstable
from refractory variceal bleeding and is
associated with significantly less morbidity
and mortality than surgical decompression.
• Studies have shown that TIPS can control
bleeding in 95% of cases.

• Isolated gastric varices are managed in much
the same way as esophageal varices, although
endoscopic therapy tends to be less successful.
• Pharmacotherapy is primarily indicated, but
when this fails, portal decompression by
means of TIPS or a surgical shunt is
recommended.

Prevention of Rebleeding:
• After the initial bleeding has been controlled,
prevention of recurrent hemorrhage needs to be a
priority.
• When no further therapy is undertaken, about
70% of patients have another hemorrhagic event
within 2 months.
• The risk for rebleeding is highest in the initial few
hours to days following a first episode.

• Medical therapy to prevent recurrence includes
a nonselective β-blocker, such as nadolol, and
an antiulcer agent, such as a PPI or carafate.
• These are combined with endoscopic band
ligation repeated every 10 to 14 days until all
varices have been eradicated.

ACUTE LOWER GASTROINTESTINAL
HEMORRHAGE
• In more than 95% of patients with lower GI
bleeding, the source of hemorrhage is the
colon.
• The small intestine is only occasionally
responsible for lower GI bleeding.
• In general, the incidence of lower GI bleeding
increases with age, and the etiology is often
age related

• Specifically, vascular lesions and diverticular
disease affect all age groups but have an
increasing incidence in middle-aged and
elderly patients.
• In children, intussusception is most commonly
responsible, whereas Meckel's diverticulum
must be considered in young adults.

• The clinical presentation of lower GI bleeding
ranges from severe hemorrhage with
diverticular disease or vascular lesions to a
minor inconvenience secondary to an anal
fissure or hemorrhoids.

• Colonoscopy is the mainstay of diagnosis
because it allows both visualization of the
pathology and therapeutic intervention in
colonic, rectal, and distal ileal sources of
bleeding.
•

Specific Causes of Lower
Gastrointestinal Bleeding
Colonic Bleeding
1. Diverticular Disease
 In the United States, diverticula are the most
common cause of significant lower GI bleeding.
Some series suggest that diverticula are
responsible for up to 55% of cases.
 Only 3% to 15% of individuals with diverticulosis
experience episodes of bleeding.

• Bleeding generally occurs at the neck of the
diverticulum and is believed to be secondary
to bleeding from the vasa recti as they
penetrate through the submucosa.
• Of those that bleed, more than 75% stop
spontaneously, although about 10% rebleed
within 1 year and almost 50% within 10 years.

• Although diverticular disease is much more
common on the left side, right-sided disease is
responsible for more than half of the episodes of
bleeding.
• The best method of diagnosis and treatment is
colonoscopy.
• If the bleeding diverticulum can be identified,
epinephrine injection may control the bleeding.

• Electrocautery can also be used, and most
recently, endoscopic clips have been
successfully applied to control the hemorrhage.
• If none of these maneuvers is successful or if
hemorrhage recurs, angiography with
embolization can be considered.

2. Angiodysplasia
 Angiodysplasias of the intestine, also referred to
as arteriovenous malformations (AVMs).
 In some reports, hemorrhage secondary to
angiodysplasia accounts for up to 40% of lower
GI bleeding; however, most recent reports place
the incidence much lower than that.

• They are thought to be acquired degenerative
lesions secondary to progressive dilation of
normal blood vessels within the submucosa of
the intestine.
• Angiodysplasias are distributed equally
between the sexes and are almost uniformly
found in patients older than 50 years of age.

• These lesions are notably associated with aortic
stenosis and renal failure, especially in elderly
patients.
• The hemorrhage tends to arise from the right
side of the colon, with the cecum being the most
common location.
• Most patients present with chronic bleeding; in
up to 15% of patients, hemorrhage may be
massive. Bleeding stops spontaneously in most
cases, but about half of patients experience
rebleeding within 5 years.

• In acutely bleeding patients, angiodysplasias
have been successfully treated with intra-arterial
vasopressin, selective gel foam embolization,
endoscopic electrocoagulation, or injection with
sclerosing agents.
• If these measures fail or bleeding recurs and the
lesion has been localized, segmental resection,
most commonly right colectomy, is effective.

3. Neoplasia
• Colorectal carcinoma is an uncommon cause of
significant lower GI hemorrhage.
• The bleeding is usually painless, intermittent,
and slow in nature. Frequently, it is associated
with iron deficiency anemia.
• juvenile polyps are the second most common
cause of bleeding in patients younger than 20
years of age

4. Anorectal Disease
• The major causes of anorectal bleeding are
internal hemorrhoids, anal fissures, and colorectal
neoplasia.
• Although hemorrhoids are by far the most
common of these entities, they account for only
5% to 10% of all acute lower GI bleeding.
• Most hemorrhoidal bleeding arises from internal
hemorrhoids, which are painless and often
accompanied by prolapsing tissue.

5. Colitis
• Ulcerative colitis is much more likely than
Crohn's disease to present with GI bleeding.
Ulcerative colitis is a mucosal disease that starts
distally in the rectum and progresses proximally
to occasionally involve the entire colon.
• Patients can present with up to 20 bloody bowel
movements per day.

• The diagnosis is confirmed by a careful history and
flexible lower endoscopy with biopsy.
• Medical therapy with steroids, 5-aminosalicylic
acid (ASA) compounds, immunomodulatory
agents, and supportive care are the mainstays of
treatment.
• Surgical therapy is rarely indicated in the acute
setting unless the patient develops a toxic
megacolon or hemorrhage that is refractory to
medical management.

• Crohn's disease typically is associated with
guaiac-positive diarrhea and mucus-filled
bowel movements but not with bright-red
blood.
• Crohn's disease can affect the entire GI tract.
It is characterized by skip lesions, transmural
thickening of the bowel wall, and granuloma
formation.

6. Mesenteric Ischemia
• Acute colonic ischemia is the most common
form of mesenteric ischemia.
• It tends to occur in the watershed areas of the
splenic flexure and the rectosigmoid colon, but
can be right-sided in up to 40% of patients.
• Patients present with abdominal pain and bloody
diarrhea.

• Treatment focuses on supportive care
consisting of bowel rest, intravenous
antibiotics, cardiovascular support, and
correction of the low-flow state.
• In 85% of cases, the ischemia is self-limited
and resolves without incident, although some
patients develop a colonic stricture.

Acute Gastrointestinal hemorrhage

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