Abdul-WAHID M Salih Abdulwahid.salih@univsul.edu.iq Dept. of surgery / School of Medicine University of Sulaimani. www.doctorabdulwahid.com

GI Hemorrhage Dr.AbdulWAHID M Salih

Incidence * 1-2% of all hospital admissions * Most common diagnosis of new ICU admits * 5-12% mortality * 40% for recurrent bleeders * 85% stop sponateously * Those with massive bleeding need urgent intervention * Only 5-10% need operative intervention after endoscopic interventions

Site Upper Lower * Esophageal * Stomach * Doudenum * Hepatic * Pancreatic Lower * Small bowel * Colon * Anus

Gastric varices

Gastric varices Esophageal Varices

Gastric varices Bleeding ulcers Esophageal Varices

Gastritis

Gastritis Dieulafoy’s lesion

Mallory-weiss

Watermelon stomach = Gastric antral vascular ectasia

Watermelon stomach = Gastric antral vascular ectasia

Watermelon stomach = Gastric antral vascular ectasia

Watermelon stomach = Gastric antral vascular ectasia

Upper GI hemorrhage * Etiology * Peptic ulcer disease - 50% * Varices – 10-20% * Gastritis – 10-25% * Mallory-weiss – 8-10% * Esophagitis – 3-5% * Malignancy – 3% * Dieulafoy’s lesion – 1-3% * Watermelon stomach – 1-2%

Gastrointestinal Bleeding Hematemesis- Vomiting of blood from the oropharynx to the ligament of Treitz. * Gross Blood And Blood Clots: rapid bleeding * Coffee-ground Emesis: chronic bleeding. Melena- Passage of black and tarry stool caused by digested blood. Hematochezia- Passage of maroon to red blood and blood clots. 19

Melena * 50-60 mL of blood in the GI tract produces melena * usually the result of severe upper GI bleeding. * without hematemesis :severe bleeding distal to the ligament of Treitz. * 50-60 mL of blood in the GI tract produces melena * after a 2 unit bleed: Melena can persist from 5-7 days and stools can remain occult positive up to 3 weeks. 20

Nose bleeds- Rarely the cause of major bleeding. 21

Esophagitis Hiatus hernia Significant bleeding in para- esophageal hernias. Reflux esophagitis is more likely to result in chronic occult 22

Varices Esophageal And Gastric: in the presence of liver disease are life threatening situations precipitated by the inability of the liver to synthesize clotting factors Alcoholism hepatitis B and C 24

Mucosal tear (Mallory-Weiss) * Esophagogastric mucosal tear Initially the patient has vomiting without blood. Continued emesis leads to pain from the tear and eventually the patient develops hematemesis 26

Gastritis * Diffuse gastritis. * Erosions are usually multiple and found primarily in the fundus and body of the stomach. * Chronic slow bleeds are most commonly associated with H. pylori * Brisk Bleeding: ingested substances as NSAIDs, alcohol, steroids, or other drugs. 28

Peptic ulcer * Most common cause of upper GI bleed 1/2- 2/3. * Causes:H. pylori 40-50%,NSAID’s 40-50% and other (Z-E syndrome) * Duodenal bleed is four times more common than gastric ulcer bleed. * Duodenal ulcers are usually posterior and involve branches of the gastroduodenal artery. * Benign gastric ulcers bleed more than malignant ulcers. * There will be significant bleeding in 10-15% * surgical intervention is needed in 20% 30

Duodenal ulcers * located on the anterior wall are prone to perforation and present as peritonitis and free air. * Those on the posterior wall, which is the more common location, lead to bleeding The gastroduodenal artery 31

Gastric antral vascular ectasia (GAVE) watermelon stomach Dilated small blood vessels in the antrum, or the last part of the Streaky long red areas.

Stress ulcers - Acute gastroduodenal lesions that arise after episodes of shock, sepsis, surgery, trauma and burns (curling’s ulcer) - or intracrainial pathology or surgery (cushing’s ulcer). - The result of bile reflux damage to the gastric protective barrier combined with decreased gastric blood flow secondary to splanchnic vasoconstriction. - Sepsis, coagulopathy, and activation of cytokines may also play a role. 35

Dieulafoy’s vascular malformations - Dilated Arterial Lesions

Other causes - Gastric neoplasms: malignant and benign usually mild and chronic. - Aorto-enteric fistulas : As a herald bleed followed by a massive bleed In patients with prior aortic reconstructions. - Hematobilia : following hepatic injuries or manipulations. 37

Management Upper GIT Bleeding Complete history: alcohol use, cirrhosis, heart burn, reflux, and medications. Exam : - signs of cirrhosis including spider angiomata, palmer erythema, prominent abdominal veins, caput medusa, and ascites. - mucous membranes for melanin spots associated with Puetz-Jeghers syndrome. 38

Physical Exam signs of anemia, dehydration Abdominal exam: Vital signs: instability, respiratory distress, beware of beta blockade signs of anemia, dehydration Abdominal exam: Rectal exam: Look for perianal causes of bleeding. check for occult blood in the stool. 39

Laboratory studies: * Type and Cross * CBC: anemia? * hepatic dysfunction and renal compromise * Coags: coagulopathy * ABG: probe for acidosis 40

AGML = Acute Gastric Mucosal Lesions

Interventions to consider * ABC’s * Ensure adequate airway protection and adequate respirations:massive bleeding considered for intubation * Start 2 large bore IV’s. * Fluid bolus either NS or LR * 3-for-1 rule: Replace each milliliter of blood loss with 3 mL of crystalloid fluid. 42

Pharmacotherapy * Proton pump inhibitors (PPIs), orally or intravenously as an infusion * Octreotide is a somatostatin analog: shunt blood away from the splanchnic circulation. variceal and non-variceal upper GI hage. * vasopressin analog most commonly for variceal upper GI hemorrhage. * Anti-fibrinolytic drugs such as tranexamic acid * Factor VII for variceal hemorrhage * If Helicobacter pylori: antibiotics and a PPI

Tubes * Foley Catheter * NG with gastric lavage: * Iced saline lavage If the stomach contains bile but no blood, UGIB is less likely * Iced saline lavage * STAT Upper endoscopy

Early Endascopy * Both as a Diagnostic and Therapeutic: 1- Injection of adrenaline or sclerotherapy 2- Electrocautery: thermal 3- Endoscopic clipping 4- Banding of varices 5- Argon plasma coagulation. 6- Cryotherapy ablation is another possibility

Stigmata of high risk * Active bleeding * Oozing * Visible vessels * Red Spots

Red Spots Visible vessels oozing bleeding Active bleeding

Contraindications to endoscopy * Uncooperative * severe cardiac decompensation, acute myocardial infarction * perforated viscus (eg, esophagus, stomach, intestine).

Refractory cases * Repeat esophagogastroduodenoscopy * Angiography Embolization the feeder vessel * Balloon tamponade * Surgery, to oversew or remove

PU bleeding Treatment * Medical - Anti-ulcer medication - H. pylori treatment - Stop NSAIDs - Follow up EGD for gastric ulcer in 6 weeks

PU Treatment * Endoscopic interventions - Thermal coagulation - Injected agents • Success rate 95% initailly 80% will not rebleed

PU Treatment * Surgical intervention - Only 10% of patients - Indications: 1- Failure of endoscopy 2- Significant rebleeding after 1st endoscopy 3- Ongoing transfusion requirement 4- Need for >6 units over 24 hours 5- Earlier for elderly, multiple co-morbidities

PU Surgical intervention * Doudenal ulcer - Expose ulcer with duodenotomy or duodenopyloromyotomy - Direct suture ligation, - The gastroduodenal artery may be ligated if necessary - the pyloric channel is closed vertically resulting in a Heineke-Mikulicz pyloroplasty - Anti-secretory procedure • Truncal, parietal cell vagotomy • can use meds

PU Surgical intervention * Gastric ulcer 10% are maliganant 30% will rebleed with simple ligation Resection * Distal gastrectomy Bilroth I or II * Subtotal gastrectomy

Angiographic obliteration * of the bleeding vessel is considered in patients with poor prognoses

Gastritis Treatment - Vasopressin - Iced saline lavage - Sucralfate, h2 blockers, and proton pump inhibitors. Bleeds refractory to these treatments : - Electrocautery - Vagotomy and antrectomy - Even total gastrectomy. 58

Mallory-WeissTreatment • 90% resolves spontaneously no further therapy. • Bleeding persists: * Endoscopic inj of vasoconstrictive agents, * Iv vasopressin * Balloon tamponade: sengstaken-blakemoore tube * Gastrotomy with oversewing 59

Dieulafoy’s treatment Endoscopic Injection. Wedge resection after endoscopic marking

Treatments for GAVE Endoscope: * Argon plasma coagulation and electrocautery. * "Endoscopy with thermal ablation" is favored medical treatment * Cryotherapy ablation is another possibility

Varices management * shunting * transplant. * Sclerotherapy * Ligation * Vasopressin. If unsuccessful: * shunting * transplant. 62

Somatostatin or vasopressin w/wo NTG

TIPS

Sugiura procedure

Shunt procedures

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