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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
Definition
Upper 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 (gastric
varices) or other sites (ectopic varices) usually occurring as a
consequence of liver disease. Bleeding is characteristically severe
and may be life threatening.
• The size of the varices and their propensity to bleed is directly
related to the portal pressure, which, in the majority of cases, is
directly 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
 ในประเทศไทย
40-50 % Peptic ulcer disease
20-35 % Erosive gastritis/duodenitis
8-15 % variceal bleeding
8-15 % Mallory-Weiss syndrome
Initial Assessment and
 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

2
Resuscitation
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

3
Stratification

Host Factor

Bleeding Characters

• 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 drugrelated

• 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-variceal
bleeding
Variceal Hemorrhage
Painless Bleeding
Usually Hematemesis

Non-Variceal Hemorrhage
Pain or Painless Bleeding
Hematemesis, Coffee ground,
Melena
> 90% Hemodynamic change or Vary
Hct < 30%
Sign of chronic liver disease
none
Signs of Chronic Liver Disease
Spider angioma
Jaundice
Scleral icterus
Palmar erythema
Gynecomastia
Ascites
Asterixis
https://gi.jhsps.org/Upload/200711211057_12563_000.jpg
Medication Treatment for Non-variceal
Hemorrhage
Continuous 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 การให้ทั้งสองวิธี 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-variceal
Hemorrhage
 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 Hemorrhage
Sites
• 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
Etiology
Diverticulosis – 40-55%
Angiodysplasia – 3-20%
Neoplasia
Inflammatory conditions
Vascular
Hemorrhoids
Others
Hemorrhoid
Definition:
• 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 Treatment
WASH 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
Complication
Reactions to medications of anesthesia
Bleeding
Infection
Narrowing of the anus
*The outcome is usually very good in the majority of cases.
Prevention
Eat 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 Fissure
Fissure 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 Management
Almost 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 Management
Sphincter relaxants--“Chemical sphincterotomy”
Nitrate formulas
NTG, GTN, ISDN
Predominant nonadrenergic, noncholinergic neurotransmitter

Oral and topical calcium channel blockers
As effective as nitrates without the headache

Topical muscarinic agonists
Bethanechol

Phophodiesterase inhibitors
Botulinum toxin
Operative Treatment
Primary goal is to decrease abnormally high resting anal tone
Anal Dilatation
93-94% healing with few complications
Long term outcomes sparse
Incontinence can occur in around 12-27%

Lateral Internal Sphincterotomy
Keyhole deformity if done in posterior midline
Incontinence rates up to 36% but vary widely
Open or closed technique
Question and Answer
Thank you for your kind attention
Reference
1. 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
Reference
4. 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, ed
Peter Rosen et al. Mosby.St Louis.

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Gastrointestional bleeding

  • 1. Interdepartmental Conference “Upper And Lower Gastrointestinal Hemorrhage” PRESENTED BY : SORAWIT BOONYATHEE, MD.
  • 2. Outline Definition and Anatomical related Upper Gastrointestinal Hemorrhage Lower Gastrointestinal Hemorrhage
  • 3. Section 1 : Definition and Anatomical related
  • 4. Definition Upper 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.
  • 6. 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.
  • 7. 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.
  • 8. Definition (Cont.) Varices • Varices are abnormal distended veins usually in the esophagus (esophageal varices) and less frequently in the stomach (gastric varices) or other sites (ectopic varices) usually occurring as a consequence of liver disease. Bleeding is characteristically severe and may be life threatening. • The size of the varices and their propensity to bleed is directly related to the portal pressure, which, in the majority of cases, is directly related to the severity of underlying liver disease. http://quizlet.com/9551975/portal-hypertension-flash-cards/
  • 9. Section 3 : Upper Gastrointestinal Hemorrhage
  • 10. Prevalence of Upper Gastrointestinal Hemorrhage  ในประเทศไทย 40-50 % Peptic ulcer disease 20-35 % Erosive gastritis/duodenitis 8-15 % variceal bleeding 8-15 % Mallory-Weiss syndrome
  • 11.
  • 12. Initial Assessment and  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 2 Resuscitation
  • 13. 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
  • 14.
  • 15. Risk 3 Stratification Host Factor Bleeding Characters • 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 drugrelated • Continuous red blood from NG after irrigation • Red blood per rectum Patient Course • Need blood transfusion • Rebleeding • Hemodynamic instability
  • 16. How to differentiated to variceal or non-variceal bleeding Variceal Hemorrhage Painless Bleeding Usually Hematemesis Non-Variceal Hemorrhage Pain or Painless Bleeding Hematemesis, Coffee ground, Melena > 90% Hemodynamic change or Vary Hct < 30% Sign of chronic liver disease none
  • 17. Signs of Chronic Liver Disease Spider angioma Jaundice Scleral icterus Palmar erythema Gynecomastia Ascites Asterixis https://gi.jhsps.org/Upload/200711211057_12563_000.jpg
  • 18. Medication Treatment for Non-variceal Hemorrhage Continuous 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 การให้ทั้งสองวิธี 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
  • 19. Medication Treatment for Non-variceal Hemorrhage  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
  • 20. 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
  • 21.
  • 22. 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
  • 23.
  • 24.
  • 25. Section 4 : Lower Gastrointestinal Hemorrhage
  • 26. Lower Gastrointestinal Hemorrhage Sites • 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
  • 27. Etiology Diverticulosis – 40-55% Angiodysplasia – 3-20% Neoplasia Inflammatory conditions Vascular Hemorrhoids Others
  • 28.
  • 29. Hemorrhoid Definition: • 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
  • 30.
  • 31. Non-surgical Treatment WASH 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
  • 32. Painful or persistent hemorrhoids: Banding Sclerotherapy Infered Light Laser Therapy Freezing Electrical Current Surgery
  • 33. Indication for surgical management Persistent itching Anal bleeding Pain Blood clots Infection
  • 34. Complication Reactions to medications of anesthesia Bleeding Infection Narrowing of the anus *The outcome is usually very good in the majority of cases.
  • 35. Prevention Eat 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
  • 36. Anal Fissure Fissure 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
  • 37. 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
  • 38. Etiology Trauma due to passage of a hard stool History of constipation or diarrhea Associated with increased resting pressures • Sustained resting hypertonia
  • 39. 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
  • 40. Conservative Management Almost half will heal Sitz baths Fiber supplement +/- topical anesthetics or anti-inflammatory ointments WASH regimen • Warm water • Analgesic agent • Stool softeners • High fiber diet
  • 41. Medical Management Sphincter relaxants--“Chemical sphincterotomy” Nitrate formulas NTG, GTN, ISDN Predominant nonadrenergic, noncholinergic neurotransmitter Oral and topical calcium channel blockers As effective as nitrates without the headache Topical muscarinic agonists Bethanechol Phophodiesterase inhibitors Botulinum toxin
  • 42. Operative Treatment Primary goal is to decrease abnormally high resting anal tone Anal Dilatation 93-94% healing with few complications Long term outcomes sparse Incontinence can occur in around 12-27% Lateral Internal Sphincterotomy Keyhole deformity if done in posterior midline Incontinence rates up to 36% but vary widely Open or closed technique
  • 44. Thank you for your kind attention
  • 45. Reference 1. 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
  • 46. Reference 4. 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, ed Peter Rosen et al. Mosby.St Louis.

Editor's Notes

  1. This Guideline used for UGIH within 48 hrs from onsetOral double dose of PPI until EndoscopePatient should be referred if - High risk of bleeding include -&gt; recurrent bleed (no endoscopic or surgery treatment)
  2. ตอนใส่ Gastric balloon check ว่า bleed หรือไม่จากการ aspirate ดู ถ้าเลือด -&gt; bleed stomachถ้าใส -&gt; ห้ามเลือดได้ดีต้องมี NG tube ใส่ไปอีกเส้นจะอยู่ตรงesophagus ไว้ aspirate -&gt; check pressure จนหยุด bleed หรือ ประมาณ 25-40 mmHg