Gi bleed hegazy

‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬

Gastrointestinal
Bleeding
Dr.MOSTAFA HEGAZY

Question 1
• A 67-year-old man is evaluated because of
bright red blood in his stool 2 weeks ago,
which seemed to resolve spontaneously.
Rectal examination reveals increased
sphincter tone, a small fissure, and a normal
prostate gland. Stool is brown and negative
for occult blood.
• Which of the following is the most appropriate
next step in managing this patient?
( A ) No further investigation
( B ) Three tests of stool for occult blood
( C ) Colonoscopy
( D ) Barium enema
( E ) CT scan of the abdomen

Question 2
• 74-year-old woman is evaluated because of a second
episode of painless, large-volume hematochezia.
Three months ago, following her first episode,
colonoscopy demonstrated both right- and left-sided
diverticula, with a pigmented spot on a right-sided
diverticulum. She is now admitted to the hospital for
evaluation of a similar bout of painless hematochezia.
Physical examination reveals tachycardia with
orthostatic blood pressure changes, pale
conjunctivae and skin, and mild bilateral abdominal
tenderness. Laboratory tests show a hemoglobin of
10 g/dL.
• Which of the following is the most likely
diagnosis?
( A ) Colon cancer
( B ) Diverticulosis
( C ) Ischemic colitis
( D ) Ulcerative colitis

Question 3
• A 35-year-old man with chronic alcoholism is
evaluated because of bright-red hematemesis and
syncope. At 11 PM his pulse rate is 100/min and his
blood pressure is 100/60 mm Hg, and there is red-
tinged irrigant present in the nasogastric tube. The
patient has multiple, vascular spider angiomata and a
distended abdomen with shifting dullness. He has
received 2 L of normal saline solution, and an
octreotide drip. His vital signs have stabilized.
• What is the optimal management for this patient?
( A ) Immediate endoscopy
( B ) Endoscopy in the morning
( C ) Portocaval shunt surgery
( D ) Transjugular intrahepatic portosystemic shunt
(TIPS)

• Definitions and Classifications of GIB
• UGIB
– Etiology
• PUD, Portal htn, Mallory-Weiss, Boerhaave’s Tears, Vasc
Anomaly, Gastritis, Erosive Esophagitis, Gastric Cancer,
Other
– Assessment & Initial Management
– Diagnosis & Treatment
• LGIB
– Etiology
• Diverticulosis, AV Malformation/Angiodysplasia, Neoplasia,
IBD, Ischemic Colitis
– Evaluation & Initial Management
• Occult GIB:
– Etiology
– Evaluation &Treatment
Gastrointestinal Bleeding

Common and potentially life
threatening condition, which
results in hemodynamic
instability, anemia, or the need
for blood transfusion. It is
classified into:
• Upper GI bleeding
• Lower GI bleeding
GI Bleeding

Ligament of Treitz
•Ligament of Treitz: a
fibrous band by which the
duodenojejunal junction is
fixed to posterior wall of
abdominal cavity, usually at
the level of L1.
•Upper GIB – Bleeding
arising proximal to the
ligament of Treitz
•Lower GIB – Bleeding
arising distal the ligament of
Treitz

Definitions
Hematemesis
• Vomitus of red blood or "coffee-grounds" material.
• Represents an upper GI bleed.
Melena
• Black, tarry, foul-smelling stool resulting from
digested blood (at least 100 ml)
• Usually indicates upper GI bleed, but can
represent small bowel or right-sided colonic
hemorrhages if an obstruction is present or if
transit time is otherwise prolonged
• Estimated to take approximately 8 hours to turn
stool black

Hematochezia
•The passage of bright red or maroon blood from the
rectum.
•Represents lower GI bleeds (90%) or severe upper
GI bleeds (10%)
Occult GIB
Blood in the feaces too small to be seen
but detectable by chemical tests

Black Stool
• Non-GIB causes of black stool include:
• Bismuth subsalicylate
(Pepto-Bismol®)
• Iron
• Spinach
• Charcoal
• Dark beers (stout or Guinness)
• Swallowed blood from nose bleeding

Another Classification of GIB
Hematemesis Hematochezia Melena
PUD
Esophageal varices
Mallory-Weiss tear
Esophagitis
Vascular Anomalies
(Telangiectasia,
Angiodysplasia)
gastritis
Erosive Esophagitis
Gastric Neoplasms
(carcinoma, lymphoma,
leiomyoma, sarcoma)
Esophageal cancer
Diverticular disease
Angiodysplasia
Colorectal carcinoma
IBD
Hemorrhoid
Anal fissure
Colonic polyp
Brisk upper GI or small
bowel bleed
Meckel’s diverticulum
Crohn’s disease
All causes of
hematemesis
Neoplasm (rare)

Upper Gastrointestinal
Bleeding
• Over 350,000 hospitalizations/yr in the US
• Cost $1 billion/yr
• Mortality rate: 10%; more common males
• Rarely die from exsanguinations but rather
from complication of an underlying dz
• UGIB is self-limited in 80% of pts

Variceal (portal hypertension)
• Esophagogastric varices (14%)
• Gastric varices
• Portal hypertensive gastropathy
Non variceal
• Peptic Ulcer Disease (55%)
• Mallory-Weiss Tears (5%)
• Vascular anomalies (6%)
• Hemorrhagic and erosive gastropathy or gastritis (3-11%)
• Erosive Esophagitis (2-8%)
• Gastric Neoplasms (1-4%)
• Others (7-25%)
– Aortoenteric fistula, hemobilia, pancreatic malignancy
UGIB - Etiology

• half of major UGIB w/ mortality of 6-
10%.
• Chronic ulcers, caused by exposure to
acid & pepsin
• Usually solitary
• Size ranges from ~ 0.6 - 4 cm
• Most common in duodenum and antrum
• Ratio of duodenal:gastric ~ 4 : 1
Peptic Ulcer Disease

• Clinical: epigastric pain 1-3 hours after meals
& is worse at night; nausea; vomiting;
belching, weight loss
• Complications:
• Hemorrhage - 25% of ulcer deaths
• Perforation – 66% of ulcer deaths
• Obstruction
• Malignant transformation
Peptic Ulcer Disease

Risk Factors for peptic ulcers
• H. pylori
• NSAIDS
• Stress
• Gastric Acid

H. Pylori
• Transmitted fecal-oral
• Disrupts mucous layer, liberating
enzymes and toxins causing mucosal
damage
• Assoc. w/ gastric cancer and non-
Hodgkin’s gastric lymphoma
• Eradication should be sought-PPI,
Clarithromycin and amoxicillin

NSAIDS
• Inhibition of prostaglandins
• Most of these ulcers are asymptomatic
and uncomplicated
• Implicated as an important factor for
non-healing ulcers

Stress related ulcers
• Stress is able to stimulate the limbic
system in the CNS which in turn
activates hypothalamic and medullary
systems
• Leads to gastric acid hypersecretion,
disturbances in GI motility, and
production of cathecholamines,
glucocorticoids, and histamine

Gastric Acid
• Rarely is hyperacidity the only
contributor to peptic ulcer formation
• Hyperacidity coupled with H. pylori,
NSAIDS, stress leads to increased
permeability to back diffusion of
hydrogen ions resulting in ulceration

• Bleeding from varices (2nd MCC of UGI
Bleeding):
• esophageal
• rarely gastric or duodenal
• Usually stops spontaneously -50%
• Mortality rate near 70-80% for those with
continued bleeding
• Untreated 50% will rebleed during
hospitalization
• Tx: propanolol or nadolol can decrease risk
of rebleeding or endoscopic variceal ligation
for high risk patients
Portal Hypertension

Mallory-Weiss Tears
• Hemorrhage induced by
vomiting, usually in
alcoholics
• Tearing occurs when the
cardia has been forced
into the thorax
• Morphology: irregular
longitudinal tear in the
esophago-gastric junction.
May involve only the
mucosa, or may rarely
penetrate the wall.
• 5-10% of UGI bleeding

Boerhaave’s Tears
• When a Mallory-Weiss tear penetrates
all layers of the wall, it is called
Boerhaave’s syndrome.
• Boerhaave’s tears may cause
mediastinitis or peritonitis.

• Found throughout the GI tract; chronic or acute
bleeding
• 7% of UGIB.
• Examples:
- Vascular ectasias (angiodysplasias)
- bright red stellate appearance.
- Hereditary hemorrhagic telangiectasia (Osler-Weber-
Rendu)
- gastric antral vascular ectasia ("watermelon stomach“)
- CREST syndrome
• Incidence increased in chronic renal failure
Vascular Anomalies

Watermelon Stomach
Gastric Antral Vascular Ectasia

This lesion results from multiple antral
vascular ectasias formed in a pattern of linear
streaks radiating from the pylorus.
• Histologically, it consists of multiple dilated
venules with focal thrombosis and fibromuscular
hyperplasia.
•Cause unknown
•primarily in older women
•iron-deficient anemia, which is usually
manageable with iron supplementation.
•In extreme cases, endoscopic thermal therapy
or surgical antrectomy may be necessary

• endoscopically visualized subepithelial
hemorrhages and erosions
• mucosal lesions, thus do not cause major
bleeding.
• Rarely causes UGIB (5%)
• more commonly results in chronic blood loss
• Common causes:
• ingestion of NSAIDs
– 50% of patients who chronically ingest NSAIDs.
• Alcohol
– 20% of actively drinking alcoholic patients
• stress (severe medical or surgical illness).
Gastritis

Gastritis produced by aspirin and other
nonsteroidal anti-inflammatory drugs

Erosive Esophagitis
• Severe erosive esophagitis due
to chronic GERD may rarely
cause UGIB.
• Other Predisposing Factors:
• Infections (esp. in
immunosuppressed
patients- candida, herpes,
bacteria)
• Ingestion of irritants:
alcohol, hot tea, smoking
• Uremia
• Cancer chemotherapy,
radiation therapy
• Prolonged gastric intubation

Two ulcers in the mid
oesophagus

Gastric Adenocarcinoma
(signet ring cell)

Dieulafoy’s lesion
• Uncommon cause of major
GIB.
• arteriole that protrudes
through a tiny mucosal defect
causing a single small ulcer
• usually within 6 cm of the
gastroesophageal junction on
the lesser curvature
• Can occur in distal
esophagus, small intestine,
colon, and rectum.

• History
• HPI
– Characteristics of bleeding, onset and duration of
bleeding, associated symptoms, etc.
• Medications
– Aspirin, NSAIDs
• PMH
– H/o dyspepsia or PUD suggests peptic ulcer; H/o
of vomiting, retching, or coughing preceding
hematemesis in an alcoholic pt suggests Mallory-
Weiss tear
• FH
Assessment

Assessment
• Physical Exam
– Signs of chronic liver disease
• Jaundice, ascites, edema, spider angiomata
implicate bleeding due to portal hypertension
– Vascular status
• Capillary refill, peripheral pulses
– Abdominal exam
– Rectal exam

• Fluid resuscitation and Blood Replacement:
– PRBC given to maintain a hematocrit of 25-
30%.
– Platelets if < 50,000/ul or if there is impaired
platelet function due to aspirin use.
– Uremic pts with active bleeding:
• Give 3 doses of desmopressin, 0.3 ug/kg IV Q12
hrs.
– Actively bleeding pts with coagulopathy and
INR>1.5:
• Fresh frozen plasma
Initial Management

• Initial Triage:
– Very Low Risk: Normal hemodynamics, no overt
bleeding within 48 hrs, neg NG lavage, normal lab
tests, and no serious comorbid med illnesses or
advanced liver disease
• Does not require hospital admission.
– Low to moderate risk
• Admit and undergo endoscopy usually within 24 hrs.
– High risk: Active bleeding (hematemesis or bright
red blood on NG aspirate), loss of > 5 units of
blood, persistent hemodynamic derangement
despite fluid resuscitation, serious comorbid med
illness, or advanced liver disease
• ICU admission.
Assessment & Initial
Management

• NG Tube
– ALL pts with suspected UGIB.
– Aspiration of red blood or “coffee grounds”
confirms an UGIB.
– 10% have nonbloody aspirates (doesn’t rule out
UGIB).
• Upper Endoscopy
– ALL pts
– when hemodynamically stable
– continued active bleeding require more
urgent endoscopic evaluation.
Diagnosis & Treatment

Subsequent Evaluation &
Treatment
- 90% of actively bleeding
varices can be treated w/
injection of a sclerosant or
application of a rubber band
to the bleeding varix.
- Similarly, 90% of actively
bleeding ulcers, angiomas,
or Mallory-Weiss tears
controlled w/ injection of
epinephrine or direct
cauterization of the vessel by
a heater probe or multipolar
electrocautery probe.

1. Acid inhibitory therapy:
• IV PPI
– Omeprazole or pantoprazole, 80 mg bolus,
followed by 8mg.h continuous infusion for 72hrs
– Reduces the risk of rebleeding in pts w/ peptic
ulcers w/ high risk features after endoscopic tx.
• High doses of oral PPI
– Give for suspected peptic ulcer bleeding while
pending the results of endoscopic exam.
Acute Pharmacologic
Therapies

2. Octreotide:
• IV 100ug bolus, followed by 50-100ug/h
• Reduces splanchnic blood flow and portal bp
• Effective initial control of bleeding related to
portal htn
• All UGIB and evidence of liver disease or portal
HTN until the source of bleeding can be
determined by endoscopy
Acute Pharmacologic
Therapies

Other Treatment
3. Intra-arterial embolization or
vasopressin:
• Angiographic tx w/ intra-arterial
infusion of vasopressin or
embolization is sometimes used in pt
w/ persistent bleeding who have
failed endoscopic therapy

Other Treatment
4. Transvenous intrahepatic portosystemic
shunts (TIPS):
• Performed percutaneously through the
jugular vein and involves the creation of a
permanent intrahepatic shunt between
the hepatic and portal veins, easing
portal hypertension.
• Indicated in pts in whom endoscopy has
failed to control acute variceal bleeding.
• TIPS decreases rebleeding more
effectively than endoscopic therapy.

• UGIB
– Etiology
Anomaly, Gastritis, Erosive Esophagitis, Gastric Cancer, Other
• LGIB
– Etiology
• Diverticulosis, AV Malformation/Angiodysplasia, Neoplasia, IBD,
Ischemic Colitis
• Occult GIB:
– Etiology
– Evaluation &Treatment

Lower Gastrointestinal
Bleeding
• ¼ as common as UGIB.
• Hospital mortality < 3%. Common in adult
women and children.
• 200-fold increase in incidence 3rd to 9th
decade
• Spontaneous cessation of bleeding > 85%.
• Less likely to present in shock; require less
transfusions

• Etiology varies with age
– Elderly – diverticulosis, angiodysplasia,
neoplasms, or ischemia
– Young adults – infectious colitis, anorectal
disease, inflammatory bowel disease,
diverticulosis, or angiodysplasia
– Children – Meckel’s diverticulum or
intussusception
• No source identified in ~20% of cases
Etiology

Diverticulosis
• Diverticula: Outpouchings in the
distal colon. They have a thin wall,
lined by mucosa & submucosa but
no muscularis propria.
• As it herniates, the vasa recta are
exposed to injury on the luminal
side leading to intimal thickening
and media thinning which
predisposes to rupture
• Found in half of people over the
age of 50, but <15% of these
patients develop LGIB.
• The most common cause of major
LGIB (50% of cases).
• Pathogenesis: low fiber diet  
stool bulk  peristaltic
contractions   intraluminal
pressure  diverticula. Diverticular
trauma from things such as
impacted fecaliths=> Bleeding.

Diverticulosis
• Diverticula are more
prevalent in the left colon,
but bleeding occurs more in
the right.
• S&S’s: acute, painless,
large-volume maroon or
bright red hematochezia in pt
over age 50.
• Subsides spontaneously in
80% of people but may recur
in up to 25%.
• > 95% of cases requires < 4
units of blood transfusion;
15-25% require surgery
• Mortality is 5-20%.
• May be complicated by
perforation, peritonitis,
abscesses, stenosis.

Angiodysplasia/AV Malformations
• Dilated torturous
submucosal vessels
whose walls lack SM
• Causes painless bleeding
ranging from melena or
acute hematochezia to
chronic occult blood loss.
• 5-10% of LGIB
• Occur commonly in the
distal ileum, cecum and
ascending colon.
• Bleeding usually episodic
and self limited

Chronic colonic mucosal contraction
obstructs venous mucosal drainage. Over
time, the mucosal capillaries dilate and
become incompetent. The cause of gastric
and small intestine is unknown. Some are
congenital (hereditary hemorrhagic
telangiectasia) or related to autoimmune
disorders (scleroderma).

• Men>women
• Increases with age
• Increased incidence in
patients with chronic renal
failure, aortic stenosis, and
von Willebrand’s disease
• Re-bleeding occurs in up to
85% who are untreated
• Mortality rate is 10-15%
• Generally treated
endoscopically

• Pt w/ Crohn’s Disease or Ulcerative Colitis
often have diarrhea with hematochezia, fever,
dehydration.
• Can have extra-intestinal manifestations such
as arthritis, iritis, episcleritis, sclerosing
cholangitis, and erythema nodosum.
• Associated with urgency, tenesmus,
abdominal pain/cramping.
• Rarely causes massive bleeding, but if it does
=> surgical intervention.
Inflammatory Bowel Diseases

Crohn’s disease involving terminal ileum resulting in stricture formation (left)
Crohn’s disease with transmural inflammation and fibrosis (right)

UC w/ crypt abscesses on the right pic.

Ischemic Colitis
• More commcon in
elderly
• mostly those with
known
atherosclerosis
• Other causes-
hypotension, HF,
arrythmia
• watershed areas
such as the
splenic flexure
and rectosigmoid
junction.

Ischemic Colitis
• 5% of pts after surgery for ileoaortic or
abdominal aortic aneurysm.
• Young pts may develop colonic ischemia due
to vasculitis, coagulation disorders, estrogen
therapy, and long distance running.
• Presents as hematochezia and/or bloody
diarrhea typically associated with mild
cramps.
• Bleeding is generally mild and self-limited.

Infectious colitis
• 3 MCC of bacterial diarrhea are
Salmonella, Camplyobacter and
Shigella
• Ingestion of these bacteria allow them
to proliferate, invade, and destroy
mucosal epithelial cells
• Bleeding due to infectious causes are
sometimes distinguished from other
LGIB because of the clinical setting

Neoplasms
• Benign polyps and carcinoma are a/w chronic occult blood
loss or intermittent anorectal hematochezia.
• Rare in SI, more common in colon.
• Colonic neoplasms cause 10% of acute LGIB.
• Benign Polyps
• Adenomatous: Tubular, Tubulovillous, Villous variants
• 90% of APs in the colon, progress in >10 yrs to adenocarcinoma
• Hamartomatous (Peutz-Jeghers)
• Malignant:
• Adenocarcinoma
• 98% of all cancer of the colon; peak age is 60-79 yr for sporadic cases
• predisposing factors include adenomatous polyps, UC, genetic
factors (defective APC tumor suppressor gene), low fiber, high
animal fat diet

Tubular Adenoma and Adenocarcinoma

• Radiation-induced colitis.
• Usually occurs years later, but can occur any
time following radiation therapy
• Aortoenteric fistula in patients with prior history
of aortic surgery.
• Vasculitis syndromes – Polyarteritis Nodosa,
Wegener’s granulomatosis, Rheumatoid
arthritis.
• Osler-Weber-Rendu Syndrome.
• NSAID induced ulcers.
• Infection – Shigella, Campylobacter, EHEC,
Typhoid, CMV, C. difficile, Amebiasis, etc.
Usually accompanied by diarrhea.
Other Causes

Etiology in Children
• Meckel’s Diverticulum:
– MC congenital anomaly of SI
– MC source of LGIB in children.
– A remnant of the embryonic
vitelline duct, and located 2 feet
from ileocecal valve.
– Symptoms usually occurs in 2% of
children, within the first 2 years of
life (Rule of 2’s).
– Commonly presents w/painless
rectal bleeding.
– Bleeding is almost always due to
ulceration of ectopic gastric
mucosa.

Etiology in Children
• Intussusception
– Invagination of a proximal
segment of bowel into a
more distal segment.
– Most common cause of
bowel obstruction in
young children.
– Associated with sudden
onset of paroxysmal
abdominal pain and
passage of currant jelly
stool.
– Diagnostic barium enema
can also be therapeutic,
but surgery is usually
necessary.

• History:
• HPI (Characteristics of bleeding, onset and duration of
bleeding, associated symptoms, etc.), Medications, PMH
and PSH, FH.
• Characteristics of bleeding:
• Brown stools mixed or streaked w/ blood=> rectosigmoid
or anus.
• Large volumes of bright red blood=> colonic source.
• Melena=> UGIB (although 10% of UGIB report
hematochezia).
• Painless large volume bleeding=>diverticular bleeding or
vascular ectasias
• Bloody diarrhea a/w cramping abd. Pain, urgency, or
tenesmus=> IBD, infectious colitis, or ishemic colitis.
LGIB Evaluation

• Physical Exam:
• VS (check for orthostatic hypotension)
• Vascular status (capillary refill, peripheral pulses)
• Scars from previous surgeries
• Evidence of cirrhosis
• Abdominal exam (masses?)
• Rectal exam
• Labs:
• CBC, PT, PTT, INR, BUN, serum creatinine, LFT,
and cross-matching.
Evaluation

• Fluid resuscitation
• Blood replacement
• Medications:
• H2-blockers
• Vasopressin
• Somatostatin
• Octreotide
Management

• Exclusion of An Upper Tract Source
• A NG tube aspirating red blood or dark brown
“coffee grounds” of guaiac-positive material=>
UGIB, however if absent could be due to no
current bleeding from that site
• Anoscopy and sigmoidoscopy:
• Look for evidence of anorectal disease, IBD, or
infectious colitis.
• In pt over age 45 w/ small volume hematochezia,
the entire colon must be evaluated w/ either
colonoscopy or sigmoidoscopy and barium
enema, to exclude tumor.
Diagnosis

Diagnosis
• Colonoscopy
• Most frequently use to determine the site of
bleeding in LGIB.
• Identified bleeding site in 70-85% of cases.
• Usually performed within 6-24hrs of admission
after stabilization.
• Low cost.
• Lower sensitivity and specificity than nuclear
imaging or angiography.
• Difficult if pt having severe active bleeding.

• Small Intestine Push Enteroscopy:
– To evaluate bleeding from small bowel (ie.
Vascular ectasias).
– Consists of passage of a long, small diameter
endoscope that may reach from the proximal to
the distal jejunum.
• Capsule Imaging:
– a wireless video capsule device ingested and
reaches the SI in a few hrs and video images are
transmitted to a portable recorder.
– Allows to identify vascular ectasias and other
bleeding lesions but does not permit precise
localization or therapy.
Diagnosis

• Nuclear Bleeding Scan (Technetium-99m labeled
RBC):
– Can localize slow bleeding (0.1ml/min) to the SI, right colon, or
left colon.
– Accuracy of a positive study is only 78% b/c the bleeding may
be slow or intermittent.
– Low risk (less invasive)
– Usually used as a preliminary study to target confirmatory
studies (angiography or colonoscopy).
• Angiography (Selective Mesenteric Angiography):
– Used more for LGIB than UGIB
– Localizes source of bleeding at a rate of 0.5 ml/min or greater.
– Accurate 50-75% of time in patients who are actively bleeding.
– Complication rate is 3%: stroke, renal failure, and thrombosis.
Diagnosis

• Enteroclysis:
- filling of the SI with contrast medium
through a catheter
- Localizes mass lesions.
- Cannot identify AVM.
• Barium Enema:
- Not used much anymore.
- Can be both diagnostic and therapeutic in
cases of intussusceptions.
Diagnosis

• Discontinue Aspirin, NSAIDs, and
Anticoagulants.
• Platelet transfusion (3-6 units) should be
administered for persistent bleeding.
• Therapeutic Colonoscopy:
• High risk lesions (eg, diverticulum w/ active
bleeding or a visible vessel, or vascular ectasia)
may be treated w/ saline or epinephrine
injection, cautery (bipolar or heater probe) or
application of metallic clips.
• Main intervention for post-polypectomy bleeding.
• Used prior to surgery to clarify bleeding site.
Treatment

• Intra-Arterial Vasopressin:
• Arrest bleeding in 80% of patients (diverticulum or
vascular ectasia). However, re-bleeding is up to 50%.
• Primarily used to achieve temporary hemostasis
before surgical resection.
• Complications include MI, pulmonary edema, and
mesenteric thrombi.
• Intra-arterial embolization:
• Control bleeding in up to 90%.
• Embolic agents: Microcoils (safest), gelatin-sponge
pledgets, polyvinyl alcohol particles.
• Used for patients who are poor operative candidates.
• Complications: abd pain, fever, and ischemia
infarction in up to 15%.
Treatment

• Surgery
– 15-35% of GIB.
– Indications:
• All hemodynamically unstable patients with active
bleeding who do not respond to intravascular volume
replacement and correction.
• Active bleeding that requires > 4-6 u blood within
24h or > 10 total units.
– Preoperative localization of the bleeding site by
endoscopy, nuclear imaging or angiography => allows
limited resection of the bleeding segment of SI and
colon.
– If accuate localization is not possible or if emergency
surgery is required for massive bleeding => total abd.
colectomy with ileorectal anastomosis => increases
morbidity and mortality more than limited resections.
– Re-bleeding rate is less than 10%.
Treatment

• UGIB
– Etiology
Anomaly, Gastritis, Erosive Esophagitis, Gastric Cancer,
Other
• LGIB
– Etiology
• Diverticulosis, AV Malformation/Angiodysplasia, Neoplasia,
IBD, Ischemic Colitis
• Occult GIB:
– Etiology

Occult Gastrointestinal
Bleeding
• 1-2.5% of pts in screening test for colorectal
neoplasia=> positive.
• In the US, 2% of men and 5% of women have
iron deficiency anemia.
– In premenopausal women, menstruation and
pregnancy are common causes of IDA.
– In men and postmennopausal women,
• colon (15-30%)
• UGI (35-55%)
• malignancy (10%)

• Manifested by either a positive test for
fecal occult blood or iron deficiency
anemia.
• Etiology: Neoplasms, vascular ectasias,
portal hypertensive gastropathy, acid
peptic lesions, infection (nematodes-
hookworm, TB), medication, and IBD.
Occult GIB

Occult GIB
• Evaluation:
• Generally begin w/ colonscopy, particularly
in pt older than 40 y. If neg, perform upper
endoscopy. If endoscopic tests are
unrevealing, enteroscopy and/or small
bowel series or enteroclysis may be
considered to look for mass lesions.
• Treatment:
• Treat the underlying causes.

Obscure gastrointestinal bleeding
Definition
• Obscure GI bleeding is bleed of
unknown origin that persist or recurs
after an initial endoscopic evaluation
•OGIB comprises 5% of all patients of
GI bleeding
•Majority leisions in small intestine
•Occult OGIB as IDA
•Overt OGIB as haematochezia,
melena

Common small intestinal leisions
• Angiodysplasia
• Leiomyoma
• Carcinoid
• Lymphoma
• Adenocarcinoma
• Tumours
• NSAIDS enteropathy
• Meckle’s deverticulum & associated ulcers
• Hemosuccus pancreaticus
• Strongyloides stercoralis infection
• Pelvic radiopathy
• Dieulofy’s leision

Diagnostic approach
• Upper & lower GI repeated endoscopy
• Push enteroscopy
• Capsule endoscopy
• Radiographic contrast study- small bowel
• Nuclear scans
• Angiography
• Intraoperative entroscopy

Upper endoscopy
• Indicated for initial evaluation
• Repeat EGD may yield source-when initial
negative
• One study suggest 64% lesions identified on
PE were within the reach of standard
endoscope (gastointest endosc 47;372’6-
1998)
• Rpeat EGD yield more-large hiatal hernias &
h/o NSAIDS

Push enteroscopy
• Working length is about 210cm with full
range of therapeutic & biopsy channel.
• Diagnostic yield is 40% 65%(QMJ
1996;89,685-9)(endoscopy 1996;31452-
5)
• Advantage of PE are diagnosis &
therapeutic interventions

Sonde enteroscopy
• Working length is 250-400 cm, lack of
tip deflection & biopsy channel
• Advanced duodenum by wire or other
endoscope from there to distal bowel by
passive process
• Diagnostic yield is 77% (gastrointest
endo sc1991;37:5-8)

Capsule endoscopy
• It is a wireless video capsule endoscopy
• Cpsule measuring 26.4mm long 11mm
in diameter
• Consists off, lens, light source,
complementary metal oxide,
semiconductor chip, battery &
transmitter.
• Capsule ingested after 8 hr fasting
which propel by peristalsis.

cont• Two images transmitted
in 1 sec- recorded in the
device & downloaded on
the computer.
• CE has higher yield than
PE in OGIB & IDA( Am J
gastroentrol 2002,
97;2776-9)
• CE is complementary to
PE
• Limitation, inability to
provide therapy or to
locate precisely the site of
lesion
• Entrapment

Swallowable Camera Pill
• Approved August 1, 2001
• A swallowable capsule
containing a tiny camera
that snaps picture twice a
second as it glides through
the small intestine.
• A technological advance in
methods of examining GI
tract by visualizing inside of
small intestine to detect
polys, cancer, or causes of
bleeding and anemia.
Given Diagnostic Imaging System
http://www.givenimaging.com/

Radiology
• Small bowel follow-through has been
used to screen the small intestine for a
potential bleeding source
• SBFT yield is OGIB in ranges 0%to
5.6%(radiology 1981;140:47-50)
• Retrospective study shows the yield is
21% (gastroenterology 1989;97:58-60)

Nuclear scans
• Nuclear scans helpful in overt GI bleeding,0.1
to 0.4 ml/min
• Tc 99m-labbled red blood cellscan used
commonly
• This scan can aid in localization of bleeding
verified by endoscopically & angiographically
• Early blush more accurate
• Although relatively sensitive NS can only
identify general area of bleeding limited in
directing the treatment

Angiography
• Helpful in evaluation of OGIB, rate greater
than 0.5ml/min
• Manifested as active extravasation into the
lumen of bowel.
• Less sensitive than nuclear scan
• More effective in localizing the bleeding site.
• Preoperative angiographic catheter
placement in conjunction with intraoperative
methylene blue dye injection
• Potential to identify non bleeding dysplasia &
tumour

Angiography-bleeding from ileocolic a.

CT Angiography
• New and evolving technology
• Requires modern CT scanner
• Fast - < 15mins
• Non-invasive
• Identifies large and small bowel haemorrhage
• Sensitivity and specificity 72-80%

Meckle’s scannig
• Meckle’s scannig is useful test for OGIB
• 99m-Tc-pertechnetate radioisotope
used has sensitivity of 75%to 80%
• Positive scan only suggest the presence
of gastric mucosa not a definitive
bleeding source.

Provocative testing
• To avoid the false negative studies use
of
Vasodilators
Anticoagulants
Fibrinolytic agents
• Query about the cost-effectiveness &
safety of this approach

Intra-operative
enteroscopy
• Typically use as a last resort in patient
with OGIB requiring multiple
transfusions & or repeated
hosptalization
• Endoscopic evaluation at the time of
operation
• One study shows overall diagnostic
yield is 58%

Therapeutic approach
• Treatment of OGIB depends on the
etiology
• Tumor – surgical resection
• Angiodysplasia – electrocartery, argon
plasma coagulation
• Angiodysplasia diffussely throughout
the GI tract – medical therapy-including
iron supplementation, blood transfusion
or hormonal therapy is preferred

Answer 1
• Follow-up rectal bleeding in an older pt.
• Correct Answer = C
• Age and first-time bleeding are risk factors
for significant colonic disease associated
with episodes of bright red blood in the
stool. This patient who has a visible rectal
fissure should still undergo colonoscopy
based on the history of a first-time bleed 2
weeks before the visit.

Question 2
• 74-year-old woman is evaluated because of a second
episode of painless, large-volume hematochezia. Three
months ago, following her first episode, colonoscopy
demonstrated both right- and left-sided diverticula, with
a pigmented spot on a right-sided diverticulum. She is
now admitted to the hospital for evaluation of a similar
bout of painless hematochezia. Physical examination
reveals tachycardia with orthostatic blood pressure
changes, pale conjunctivae and skin, and mild bilateral
abdominal tenderness. Laboratory tests show a
hemoglobin of 10 g/dL.
• Which of the following is the most likely diagnosis?
( A ) Colon cancer
( B ) Diverticulosis
( C ) Ischemic colitis
( D ) Ulcerative colitis

Answer 2
• Recognize that diverticular bleeding is the most
common cause of lower gastrointestinal bleeding
in older adults.
• Correct Answer = B
• Diverticular bleeding is the most common source
of lower intestinal bleeding. Rectal bleeding may
be evident in 10% to 30% of patients with
diverticular disease. Right-sided diverticula bleed
more commonly. Clinical features include painless,
rapid hematochezia and an urge to defecate, with
or without signs of hypovolemia.

, with severe blood loss in 3% to 5%. Recurrent bleeding is
noted in 20% to 25% of patients. Most bleeding episodes
cease spontaneously. Proctosigmoidoscopy should be the
initial diagnostic test to exclude other nondiverticular
causes. Occasionally, as in this patient, blood can be seen
coming from the diverticulum or a red spot may be seen in a
diverticulum, indicating the location of the bleeding. After
appropriate colonic lavage, colonoscopy can identify a
bleeding source in up to 75% of patients. Ischemic colitis
would present with pain and bleeding, not painless bleeding.
Colon cancer and ulcerative colitis would be unlikely
considering this patient’s normal colonoscopy three months
go. Diverticulitis is associated with fever and left side pain
but not bleeding. Angiodysplasia can also produce a
painless bleeding in older adults, but the results of the
previous colonoscopy showing a pigmented spot on a
diverticulum is more suggestive of diverticulosis.

Answer 3
• Manage upper gastrointestinal bleeding in a
patient with liver disease.
• Correct Answer = A
• This patient is most likely bleeding from
esophageal varices. He has decompensated liver
disease as manifested by ascites. Other potential
sources of gastrointestinal bleeding include peptic
ulcer disease, portal gastropathy, and Mallory-
Weiss tear. Because of the high risk of continued
active or recurrent bleeding and the high
associated mortality rate, urgent endoscopy is
appropriate.

In actively bleeding varices, band ligation has a high
success rate of stopping bleeding. If no other
bleeding source is observed and large esophageal
varices are present, band ligation offers a
therapeutic approach with significantly fewer
complications than sclerotherapy, and endoscopic
therapy is as effective as surgical shunting for the
management of variceal hemorrhage.
In this high-risk setting, it would not be appropriate to
wait until morning to perform endoscopy. A
transjugular intrahepatic portosystemic shunt (TIPS)
may be considered if endoscopic therapy is
unsuccessful. Portocaval shunt surgery is not
indicated because lower risk options are available.

SOURCES:
1. Lawrence, Current Medical Diagnosis Treatment.
2. Robbins, Pathologic Basis of Disease.
3. Rhodes and Tsai, Clinical Problems in Gastroenterology
4. Rome Jutabha, “Major causes of upper gastrointestinal
bleeding.”
www.uptodate.com.
5. Sammy Saab, “Etiology of lower gastrointestinal bleeding”
www.uptodate.com.

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