Upper GIT Haemorrhage Prof/ Walid Elshazly A prof of surgery

Acute Gastrointestinal Bleeding Prof/ Walid Elshazly

GI Bleeding Clinical Presentation Acute Upper GI Bleed Acute Lower GI Bleed

Clinical Presentation Hematemesis: bloody vomitus (bright red or coffee-grounds) Melena: black, tarry, foul-smelling stool Hematochezia: bright red or maroon blood per rectum Occult: positive guaiac test Symptoms of anemia: angina, dyspnea, or lightheadedness

Patient Assessment Hemodynamic status Localization of bleeding source CBC, PT, and T & C Risk factors Prior h/o PUD or bleeding Cirrhosis Coagulopathy ASA or NSAID’s

Resuscitation 2 large bore peripheral IV’s Normal saline or LR Packed RBCs Correct coagulopathy

Location of Bleeding Upper Lower Proximal to Ligament of Treitz Melena (100-200 cc of blood) Nasogatric aspirate Lower Distal to Ligament of Treitz Hematochezia

Acute UGIB Demographics 10,000 - 20,000 deaths annually Mortality stable at 10% 80% self-limited Continued or recurrent bleeding - mortality 30-40%

Acute UGIB Prognostic Indicators Cause of bleeding Severity of initial bleed Age of the patient Comorbid conditions Onset of bleeding during hospitalization

Acute UGIB Prognostic Indicators Tedesco et al. ASGE Bleeding Survey. Gastro Endo. 1981.

Acute UGIB Differential Diagnosis

Acute UGIB Differential Diagnosis Peptic ulcer disease Gastric ulcer Duodenal ulcer Portal hypertension Esophagogastric varices Gastropathy Esophagitis Mallory-Weiss tear Dieulafoy’s lesion Vascular anomalies Hemobilia Hemorrhagic gastropathy Aortoenteric fistula Neoplasms Gastric cancer Kaposi’s sarcoma

Acute UGIB Final Diagnoses of the Cause in 2225 Patients Tedesco et al. ASGE Bleeding Survey. Gastro Endo. 1981.

Acute UGIB Causes in CURE Hemostasis Studies (n=948) Savides et al. Endoscopy 1996;28:244-8.

Endoscopic Appearance of Ulcers

Endoscopic Therapy Thermal Mechanical Injection Bipolar probe Monopolar probe Argon plasma coagulator Heater probe Mechanical Hemoclips Band ligation Injection Epinephrine Alcohol Ethanolamine Polidocal

Endoscopic Therapy Laine and Peterson New Eng J Med 1994;331:717-27.

Adjuvant Medical Therapy Acid suppression (intragastric pH > 4) Histamine 2 Receptor Antagonists (H2RAs) Ranitidine (Zantac) Famotidine (Pepcid) Proton Pump Inhibitors (PPIs) Pantoprazole (Protonix) Lansoprazole (Prevacid) Esomeprazole (Nexium)

Mallory-Weiss Tear

Esophageal Varices

Variceal Band Ligation

Variceal Band Ligation

MEDICAL THERAPY Acute Variceal Bleeding Vasopressin/Glypressin Nonselective vasoconstrictor 50% efficacy in controlling bleeding 25% vasospastic side effects Octreotide Cyclic octapeptide analog of somatostatin Longer acting than somatostatin Equivalent to sclerotherapy and improves endoscopic results

TIPS Coronary Vein IVC Splenic Vein Portal Vein

Aortoduodenal Fistula Aorta Duodenum Fistula Graft

Lower GIT Haemorrhage Prof/ Walid Elshazly A prof of surgery

Lower gastrointestinal hemorrhage Lower gastrointestinal hemorrhage refers to a spectrum of intestinal bleeding that arises distal to the ligament of Treitz. Incidence rate: 20/100,000/ year Disease of the elderly 200 fold increase from the 3rd to 9th decades of life Mortality 2-4 % 80 – 85 % bleeding stop spontaneously

BLEEDING FRANK OCCULT SMALL BLEED MASSIVE BLEED (rare) ANAEMIA ٍٍٍSELF LIMITED ٍٍٍNON-SELF LIMITED

Degrees of hemorrhage Lower gastrointestinal bleeding presents with varying degrees of hemorrhage. Minor and self-limited, patient describe the passage of 100–250 mL of blood, possibly a few clots, and often mixed with mucous. 2) Major and self-limited Patients experience brisk, copious bleeding 3) Major and ongoing ? Patients present with massive and continuous hemorrhage associated with hypovolemia.

Lower gastrointestinal hemorrhage Massive lower intestinal hemorrhage is difficult to define. Patients often describe massive bleeding into their commode even when a small amount of blood discolors the water. True massive intestinal hemorrhage typically include Hematocrit less than 30%, Transfusion requirements (up to 3–5 units of blood/blood products), or Orthostasis requiring resuscitation.

Lower gastrointestinal hemorrhage The hemorrhage may present as melena or hematochezia. Melena typically suggests bleeding from a more proximal source in the colon or small intestine. Hematochezia suggests left colonic, rectal, or anal sources. It is wise to note that upper gastrointestinal hemorrhage may present with the rectal bleeding given blood’s cathartic effect and rapid intestinal transit.

Etiologies Common causes for lower gastrointestinal hemorrhage include Diverticulosis (30 - 50%) Angiodysplasia (20 - 30%) Neoplastic (10- 15%) cancer, polyp Inflammatory (15 - 20%) Inflammatory bowel disease. Ischemic colitis, and Anorectal diseases (5-10 %) Unusual causes include Hemorrhage also stems from intestinal tumors or malignancies. Nonsteroidal antiinflammatory drug (NSAID)-related nonspecific colitis, Meckel’s diverticulum, and

LGIB Diverticulosis(30 - 50%) Sac-like protrusions of the colonic mucosa, particularly at locations where blood vessels (vasa recta) enter the colon. LGIB (ARTERIAL) when the diverticula blood supply is damaged Trauma, Ischemia, or Poor clotting).

Diverticulosis

LGIB Diverticulosis(30 - 50%) 5 – 15 % of people with diverticula will have LGIB. Bleeding is PAINLESS. The bleeding In most cases, bleeding ceases spontaneously In 10 to 20 % of cases, the bleeding continues unabated in the absence of intervention

Diverticular Bleeding

LGIB Diverticulosis(30 - 50%) The risk of rebleeding After an episode of bleeding is approximately 25% Increases to 50% among patients who have had two or more prior episodes of diverticular bleeding. Diverticulitis- not a cause of GIT bleeding

LGIB Angiodysplasia (20 - 30%) Angiodysplasia (20 - 30%) (or AVM, or Vascular Ectasias) Composed of ectatic, dilated, thin-walled arteriovenous communications located within the submucosa and mucosa of the intestine. lined by endothelium alone.

LGIB Angiodysplasia (20 - 30%) No one is quite certain precisely why angiodysplasias occur. Current hypotheses suggest a loss of vascular integrity related to loss of transforming growth factor (TGF) β signaling cascade or a deficiency in mucosal type IV collagen.

Adults Angiodysplasia (20 - 30%) Risk Factors Older (65 y.o.) > Younger End stage renal disease Von Willebrand's disease Aortic stenosis? (Heyde’s syndrome), Hereditary hemorrhagic telangiectasias (Osler-Weber-Rendu) Low fiber diet Obesity

LGIB Angiodysplasia (20 - 30%) LGIB (VENOUS) is usually occult and PAINLESS. Located within Cecum 37%, Sigmoid 18%, Ascending 17%, Rectum 14%, Transverse and Descending 7%.

LGIB Angiodysplasia (20 - 30%) Angiography remains the gold standard for the diagnosis of angiodysplasia. After injection of contrast, a series of images are collected in three phases. Early venous filling which normally occurs in later phases. During the next phase, capillary phase, small, tortuous tufts are seen entangled and filled with contrast. Finally, the late phase study demonstrates a persistent of this arteriovenous tuft and a persistent of a slow, emptying vein.

LGIB Angiodysplasia (20 - 30%) When angiography identifies a bleeding angiodysplasia, treatment with Embolization therapy or Directed infusion of vasopressin will decrease or stop the bleeding.

LGIB Angiodysplasia (20 - 30%) The colonoscopic criteria in describing these lesions. The mucosal surface contains a cherry red lesion that is typically flat. The lesions are greater than 2 mm in size and have a “fern-like” appearance. A central feeding vessel is not always visible.

LGIB Neoplastic (10- 15%) Cancer Polyps

LGIB Inflammatory (15 - 20%) Radiation Intestinal damage due to fibrosis and ischemia. IBD Ulcerative Crohn’s Disease Radiation colitis Ulcerative colitis Sever Crohn’s Disease

LGIB Inflammatory (15 - 20%) Infectious (E. Coli, C. Difficile, C. Jejuni …) Ischemic (Hypoperfusion and Vasoconstriction) Hypotension, Heart Failure, Arrhythmia Vasculitis Infective colitis Ischemic colitis

LGIB Inflammatory (15 - 20%) Pseudomembransous Colitis Complication of antibiotic therapy that causes severe inflammation, irritation and swelling of the colon mucosa. Almost any antibiotic can cause this condition. Clostridium difficile, which occurs normally in the intestine, overgrows when antibiotics are taken. This bacterium releases a powerful toxin which causes the symptoms.

LGIB Inflammatory (15 - 20%) Pseudomembransous Colitis Ampicillin is the most common cause of this condition in children. Stopping the antibiotic with rehydration therapy and metronidazole is usually used to treat the disorder.

LGIB Ano-rectal causes (5 – 10%) Hemorrhoids (< 50 y.o. most common) Anal fissures (most common in child) Anal fistulas Proctitis Gonorrheal or mycoplasmal infections Rectal trauma Foreign objects Rectal CA Rectal polyp

LGIB Others (5 – 10%) Small intestinal tumors, known also as gastrointestinal stromal tumors (GIST). These lesions enlarge and surpass their blood supply. In that event, the ischemia in the tumor will ulcerate and may cause a localized hemorrhage. Post-polypectomy bleeding Aortoenteric fistula Coagulation deficiency

LGIB Others (5 – 10%) Finally, NSAID-associated intestinal hemorrhage occurs most frequently in the terminal ileum and cecum. Diaphragm-like strictures are pathognomonic for NSAID injuries and may result from a healing ridge related to repeated injuries from the agents.

LGIB Others (5 – 10%) Intussusception Most common abdominal emergency to affect children under 2 years of age. Boys = 2 X Girls, in frequency Meckel’s Diverticulum (embryonic diverticulum) Rule of 2's: 2% of the population 2% of cases are symptomatic 2 feet from the ileocecal valve 2 inches in length Often present within 2 years of age

Children and Young Adults LGIB Anal Fissure Most often the result of hard stool and prolonged constipation. After forced hard bowel movement. Infectious Colitis IBD Crohn’s Disease Ulcerative Colitis Polyps Intussusception Meckel’s Diverticulum (embryonic diverticulum) Pseudomembransous Colitis

Management Resuscitation for major bleeds Find site Treat the cause

Information about bleeding Volume and frequency of bleeding Painful defecation? Relationship of bleeding to defecation? [before, during (mixed into faeces or coating surface?) or after] Associated abdominal pain? Colour of blood?

Initial Assessment, Resuscitation, and Stabilization Placement of vascular access with large bore intravenous fluids. Further hemodynamic monitoring requires Cardiac rhythm monitoring and placement of a urinary catheter. A nasogastric tube placed will screen for the presence of upper gastric sources for bleeding.

Initial Assessment, Resuscitation, and Stabilization The treatment goals for resuscitation are to Restore volume and, Replete red blood cell deficiencies and their impact on oxygen delivery. In addition, all coagulopathies require reversal. Patients require laboratory profiles that include a Complete blood count, Serum electrolytes, Coagulation profile, and a type and cross match for packed red blood cells.

Initial Assessment, Resuscitation, and Stabilization The initial specific diagnostic evaluation begins with Digital anorectal examination and anoscopy. A rigid proctosigmoidoscopy will allow the examiner to evacuate the rectum of blood and clots. A complete mucosal assessment serves to exclude internal hemorrhoids, anorectal solitary ulcers, neoplasms, and colitis.

Initial Assessment, Resuscitation, and Stabilization Once the resuscitation demonstrates a stable patient, the next phase of the diagnostic evaluation ensues. What is the first test to evaluate the cause of bleeding? Currently, three tests are considered for the initial evaluation. These tests include Colonoscopy, Nuclear scintigraphy, and Angiography.

Initial Assessment, Resuscitation, and Stabilization Colonoscopy and angiography offer therapeutic intervention whereas nuclear scanning is purely diagnostic. Decisions as to which test to use depend on The clinical judgment, Local expertise, Severity of the event, and The current activity of the hemorrhage.

Initial Assessment, Resuscitation, and Stabilization It may be helpful to subdivide patients into three general clinical categories based on the history, physical, and the initial laboratory data. Is the hemorrhagic event 1) Minor and self-limited, 2) Major and self-limited, or 3) Major and ongoing ?

Initial Assessment, Resuscitation, and Stabilization Major ongoing hemorrhage requires prompt intervention with Angiography or Surgery. Minor, self-limited may undergo a colonic lavage and colonoscopy within 24 hours.

Initial Assessment, Resuscitation, and Stabilization Major, self-limited may be more difficult to define create the current controversy. These patients need a diagnostic test to determine if they require prompt therapy or observation. Should these patients undergo nuclear imaging or colonoscopy?

Colonoscopy Colonoscopy should be the first study in patients with major bleeding that appears self-limited. Patients with extremely brisk hemorrhage require a prompt angiogram. Colonoscopy in such patients proves difficult to prep with lavage and the acute exsanguinations may limit intraluminal visualization

Colonoscopy The major benefit of colonoscopy depends on the ability to provide a definitive localization of ongoing active bleeding and the potential for therapy. Once the endoscopist highlights a bleeding source, the region of the intestine requires a tattoo to mark the site with India ink. In such patients, if the hemorrhage continues and fails medical management, the tattoo greatly assists the surgeon in localizing the hemorrhage.

Colonoscopy

Colonoscopy Therapeutic options for the colon includes Thermal agents such as heater probes, bipolar coagulation, argon beam, and laser therapy Injection therapy primarily uses topical and intramucosal epinephrine. Mechanical therapy includes endoscopically applied clips.

Colonoscopy Precise localization Can be therapeutic 70 – 90% accurate Cecum reached in over 95% of cases. Advantages Colon must be prepped Risks of sedation Dis-advantages

Argon beam arrest of AVM

Radionuclide imaging Two general techniques are used for nuclear imaging, Technetium sulfur colloid scans and 99mTc pertechnetate-tagged red blood cells (RBCs). Sulfur colloid scans have a short half-life and detect very low rates of hemorrhage (0.1 mL/min). It is effective to detect brisk hemorrhage but cannot detect sporadic bleeding. The more frequently preferred agent for lower gastrointestinal hemorrhage radionuclide scanning is the pertechnetate-tagged RBC scans. The tagged RBC scans may cover a period of hours and allow for re-imaging within 24 hours.

Radionuclide imaging Radionuclide imaging detects the slowest bleeding rates. It is able to detect rates of 0.1 – 0.5 mL/min. Thus, it is a technique that is more sensitive than angiography. Unfortunately, the nuclear scanning cannot reliably localize the site of hemorrhage. Nuclear scintigraphy has variable results, suggesting that scan timing, technical skills, and experience may increase accuracy. Current reports suggest accuracies ranging from 24% to 91%.

Selected images from a 99mTc-labeled RBC gastrointestinal bleeding study in a patient with known diureticulosis.Images acquired at 1 minute (A) and 14 minutes (B). Abnormal increased isotopic activity developed in the proximal transverse colon, which progressed antegrade to the descending colon.

Technetium labelled RBC scan showing extravasation of radiolabelled blood in a loop of ileum (arrow(

Radionuclide Noninvasive High sensitivity 90+ sensitivity, 80+ specificity Advantages Requires active bleeding of > 0.1 ml/min Does not localize site Dis-advantages

Angiography Angiography is diagnostic and therapeutic in the treatment of intestinal hemorrhage. The clinical judgment for choosing angiography involves three different types of hemorrhage. First, acute, major hemorrhage with ongoing bleeding requires emergency angiography. Second, patients with an early blush during nuclear scintigraphy may benefit from therapeutic angiography. Finally, angiograms may define a potential source for hemorrhage in occult and recurrent gastrointestinal hemorrhage.

Angiography To appreciate an angiographic blush of contrast, the study requires a hemorrhage rate of at least 1 mL/min. Angiography provides Highly accurate localization of the site of bleeding . Angiographic blush may suggest a specific etiology, but it lacks the accuracy of colonoscopy. Angiography could used for treatment by either Intra-arterial vasopressin infusion Arterial embolization

Diverticular hge in the caecum Extravasation hge in the caecum AVM

Angiography vasopressin infusion Hemorrhagic site may receive highly selective, intra-arterial vasopressin infusion. Vasopressin controls bleeding in as many as 91% of patients. Bleeding may recur in as many as 50% of patients once the vasopressin is tapered.

Angiography Arterial embolization Angiographic technology also allows for arterial embolization to control hemorrhage. Superselective mesenteric angiography with current microcatheters allows for embolization of the vasa recta of the intestine, vessels as small as 1 mm. In the past, arterial embolization of larger vessels risked intestinal ischemia or infarction. The risk of intestinal infarctions of larger selective vessels may exceed 20%. Arteriography also has complication rates related to angiography, separate from the therapy delivered at the site of bleeding. These include arterial thrombosis, distant arterial emboli, and renal toxicity from the angiographic dye.

Angiography Arterial embolization Embolization therapy provides immediate arrest of the bleeding. Embolization uses a combination of agents to control bleeding including Gelfoam pledgets, Coils, and Polyvinyl alcohol particles.

Angiography Precise localization (100% specific) No bowel prep Therapeutic via Vasopressin infusion or Embolizati Advantages Variable sensitivity Requires active bleeding of 1 – 1.5 ml/min Complications with procedure Dis-advantages

Occult Hemorrhage The traditional tests of Colonoscopy, and Nuclear scintigraphy, and Angiography provide no solution Occult bleeding noted in no more than 5% of all patients admitted with lower gastrointestinal massive hemorrhage. Patients in this situation may benefit from Small bowel contrast radiography or Capsule endoscopy. Additionally, elective angiography with cecal magnification may reveal small angiodysplasias.

Capsule Endoscopy

Capsule Endoscopy Bleeding Suspected Crohn’s Tumors Celiac Disease

Occult Hemorrhage If the occult hemorrhage recurs and investigations fail to reveal the source a variety of provocative diagnostic angiographic studies have been described. Most studies prefer to incite bleeding using either heparin or thrombolytics. Once the site of bleeding is identified, it may be difficult to control without an operation. In these instances, the surgeon should prepare and hold an operating room. Once the location is identified, a superselective catheter is left in the distal artery. During the conduct of surgery, the surgeon can palpate the catheter within the vessel and direct the surgical resection.

Operative Therapy Surgical therapy for massive lower intestinal bleeding is Rare, Often definitive, and Associated with significant mortality. Most sources of bleeding spontaneously resolve or are controlled with the current therapeutic interventions.

Operative Therapy Few patients currently require surgical treatment. If the patient is hemodynamically unresponsive to the initial resuscitation, then radiographic, radionuclide, and endoscopic evaluations are usurped by the need for urgent surgery. Other patients may have the site of hemorrhage localized, yet the available therapeutic interventions fail to control the bleeding.

Operative Therapy Patient mortality increases with their transfusion requirements Mortality of (7%) for patients requiring < 10 units of blood. Mortality increased to (27%) for patients > 10 units. Therefore, once a patient reaches 6–7 units during the resuscitation and the hemorrhage remains ongoing, surgical intervention becomes eminent.

Operative Therapy The surgeon tailors the approach to the patient and depends on the diagnostic information gathered before the operation. All patients require Open laparotomy Thorough examination of the entire intestine. The first objective in surgery focuses on the location of the intraluminal blood with the hope of segmentally isolating the possible sources of bleeding.

Operative Therapy Once the surgeon completes the initial visual inspection, a complete exploration ensues. The exploration begins in the stomach, duodenum, and considers possible missed upper gastrointestinal sources. Next, the small intestine must undergo examination from the ligament of Treitz to the ileocecal valve. Palpation of the intestine may demonstrate such etiologies as a Meckel’s diverticulum, ileitis, colitis, or a GIST.

Operative Therapy Upon completion of the exploration phase, if no source appears obvious, the surgeon may consider intestinal enteroscopy. The enteroscope or colonoscope will expose the luminal surface and transilluminate the intestinal wall for occult lesions. Transillumination may identify vascular anomalies, small ulcers or tumors. Endoscopic access to the intestine may require Upper enteroscope, Transgastric approach, Transcolonic approach, or Insertion through the anus.

Operative Therapy Once a hemorrhage site is identified, the surgeon can perform an appropriate segmental resection. Intra-operative endoscopy is a technically difficult endeavor. A team approach with two surgeons or The availability of an experienced endoscopist is important to identify the elusive lesions causing the hemorrhage.

Operative Therapy If the source of bleeding cannot be found, and it appears to arise from the colon, the surgeon should perform a subtotal or total colectomy. Stable patients will tolerate a primary ileosigmoid or ileorectal anastomosis in this circumstance. Unstable patients require an end ileostomy with closure of the rectal stump or a mucous fistula. Once stable, the patient may return for ileostomy closure. The rectum and sigmoid colon require reexamination endoscopically to assure no bleeding persists.

Operative Therapy The key concerns with operative management are, first, a delay in the decision to operate until the hemorrhage reaches a critical point beyond 10 units of blood. This seems to contribute to the high mortality rate. Second, mortality rates for patients requiring urgent surgery consistently reach a range between 10% and 35%. Third, notable recurrence rates of 10% are attributable to the limits of isolating the precise cause of the bleeding.

Operative Therapy The key concerns with operative management are, The rates of recurrence increase if a surgeon Elects to perform a limited right or left colectomy without precise localization of the hemorrhage excessive persistent bleed rates of 20%, and still have high mortalitiy A total colectomy offers the same mortality with a lower chance of recurrent or persistent hemorrhage.

Massive lower GIT bleeding Hypotension and shock Yes No Resuscitation Digital rectal examination and ano-proctoscopy Nasogastric tube or upper GIT endoscopy Positive Negative Bleeding source could be localized Treat pathology Colonoscopy Yes No Bleeding source detected Bleeding source not detected Endoscopic therapy Endoscopic treatment or other Hematochezia Massive bleeding

Bleeding source not detected Colonoscopy Bleeding source not detected Hematochezia with negative UGIE Massive bleeding Active bleeding of 1 – 1.5 ml/min Active bleeding of > 0.1 ml/min Small bowel contrast radiography Capsule endoscopy. elective angiography with cecal magnification. RBC radionucleotide scan Angiography diagnostic and therapeutic success failed Surgery

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