GI Hemorrhage April 6, 2017 David Hughes

Incidence 1-2% of all hospital admissions 5-12% mortality 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 Small bowel Colon Anus

Etiology 85% are due to: Peptic ulcer disease Variceal hemorrhage Colonic diverticulosis Angiodysplasia

Chain of events Recognize severity Establish access for resusitation Resusitate Identify source Intervention

Question #1 JB a 30 y/o with hematemesis presents with orthostatic hypotension, clammy hands, but without tachycardia. How much blood has he lost? >40% 20-40% 10-20% <10%

Question #1 JB a 30 y/o with hematemesis presents with orthostatic hypotension, clammy hands, but without tachycardia. How much blood has he lost? b) 20-40%

Upper GI hemorrhage How do you know its upper? 85% of all GI hemorrhage is upper Hematemesis diagnostic Don’t forget about nasal bleeding as possible source Melena Degradation of hemoglobin to hematin by acid Bowel bacteria and digestive enzymes also contribute Hematochezia 10% of patients with very rapid UGI source

Gastric varices

Gastric varices Esophageal Varices

Gastric varices Bleeding ulcers Esophageal Varices

Gastritis

Gastritis Dieulafoy’s lesion

Mallory-weiss

Watermelon stomach 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%

Upper GI hemorrhage Crampy abdominal pain common Large caliber NGT Coffee grounds or gross blood No blood Can be used for lavage prior to endoscopy Upper endoscopy indications Melena or hematochezia with hypotension Hematemesis NGT with guiac positive fluid Should be completed in 24hrs for stable patients

AGML = Acute Gastric Mucosal Lesions

Peptic ulcer hemorrhage Peptic ulcer disease 20% of patients bleed at least once Most lethal complication Vessel is usually <1mm diameter Causes H. pylori 40-50% NSAID’s 40-50% Other (Z-E syndrome)

Peptic ulcer hemorrhage Predictors of mortality Renal disease 29%  Acute renal failure 63% Liver disease 25%  Jaundice 42% Pulmonary disease 23%  Respiratory failure 57% Cardiac disease 13%  Congestive heart failure 28%

Peptic ulcer hemorrhage Medical management Anti-ulcer medication H. pylori treatment Stop NSAIDs Follow up EGD for gastric ulcer in 6 weeks

Peptic ulcer hemorrhage Endoscopic interventions Thermal coagulation Injected agents Success rate 95% initailly 80% will not rebleed Repeat treatment after 1st rebleed salvages 50% Increased risk of mortality

Peptic ulcer hemorrhage Surgical intervention Only 10% of patients Indications Failure of endoscopy Significant rebleeding after 1st endoscopy Ongoing transfusion requirement Need for >6 units over 24 hours Earlier for elderly, multiple co-morbidities

Peptic ulcer hemorrhage Anti-secretory surgery?? Indicated for NSAID pts who need to continued meds H. pylori ulcer disease controversial Only 0.2% of pts every require surgery for bleeding ulcer Surgery pts had lower than average H. pylori positivity Oversewing and antibiotics still leave 50% at high risk for rebleeding Bottom line: still recommended but without definitive evidence

Peptic ulcer hemorrhage Doudenal ulcer Expose ulcer with duodenotomy or duodenopyloromyotomy Direct suture ligation, four quadrent ligation, ligation of gastroduodenal artery Anti-secretory procedure Truncal, parietal cell vagotomy If unstable can use meds

Peptic ulcer hemorrhage Gastric ulcer 10% are maliganant 30% will rebleed with simple ligation Need Resection Distal gastrectomy with Bilroth I or II Subtotal gastrectomy for 10% high on lesser curve

Variceal hemorrhage Cirrhotics usually 25% mortality for each bleeding episode 75% will rebleed 50% mortality with surgery Based on Child’s class

Somatostatin or vasopressin w/wo NTG

TIPS Shunt procedures Sugiura procedure

Other sources of UGI hemorrhage Mucosal lesions Gastritis, ischemia, stress ulceration Key is prevention with acid supression Surgery often requires resection and Roux-en-Y due to multiple bleeding sites >50% mortality with surgery Mallory-Weiss 10% will have significant bleeding 90% stop spontaneously Surgery rare, but gastrotomy with oversewing effective Dieulafoy’s Wedge rxn after endoscopic marking Aortoenteric fistula 1% of AAA repair patients Herald bleed preceeds exsangunation by hours to days Endoscopy and if negative CT scan and if negative angiography Surgery – graft removal and extraanatomic bypass

LGI hemorrhage Sites Only 15% of massive GI bleeding Finding the site 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

Bleeding diverticulosis

Colonic angiodysplasia Bleeding diverticulosis

LGI hemorrhage Etiology Diverticulosis – 40-55% Angiodysplasia – 3-20% Right sided lesions > left 90% stop spontaneously 10% rebleed in 1st year and 25% at 4 years Angiodysplasia – 3-20% Most common cause of SB bleeding in >50 y/o >50% are in right colon Neoplasia Typically bleed slowly Inflammatory conditions 15% of UC patients, 1% of chron’s patients Radiation, infectious, AIDS rarely Vascular Hemorrhoids >50% have hemorrhoids, but only 2% of bleeding attributed to them Others Others = meckel’s, juvinial polyps, solitary rectal ulcer, Dieulafoy’s lesion of the colon, portal colopathy, NSAIDs, intussusception, or bleeding following colonoscopic biopsy or polypectomy.

LGI hemorrhage Evaluation Same for UGI bleed After stable If unstable with hematochezia need EGD 1st After stable Rectal Anoscopy for hemorrhoids

LGI hemorrhage diagnostics Colonoscopy Within 12 hours in stable patients without large amounts of bleeding Selective viseral angiography Need >0.5 ml/min bleeding 40-75% sensitive if bleeding at time of exam Tagged RBC scan Can detect bleeding at 0.1 ml/min 85% sensitive if bleeding at time of exam Not accurate in defining left vs right colon

Meckel’s Diverticulum Cecal angiodysplasia with extravasation Small bowel ulceration due to NSAIDS

LGI hemorrhage treatment Endoscopy Great for angiodysplasia and polypectomy sites Angiographic Selective embolization for poor surgical candidates Can lead to ischemic sites requiring later resection Surgery Ongoing hemorrhage, >6 units or ongoing transfusion requirement Site selection Blind segmental will rebleed in 75% Based on TRBC scan will rebleed in 35%

GI hemorrhage from unknown source Only 2-5% are not upper or lower Average patient 26 month duration of intermittent bleeding 1-20 diagnostic tests Average of 20 units transfused

Localization of GIHOUS CT scan Tumors, inflammation, diverticuli Enteroclysis Ulcerations, inflammation Only 10-20% yeild (SBFT is 0-6%) Meckel’s scan Initial test for patients <30 years old Endoscopy Push or pull endoscopy Video capsule endoscopy Intraoperative endoscopy – 70% successful

Etiology of GIHOUS Arteriovenous malformation 40 Small bowel leiomyoma 11 Small bowel adenocarcinoma 7 Small bowel lymphoma 6 Crohn’s disease 6 “Watermelon” stomach 4 Meckel’s diverticulum 4 Small bowel leiomyosarcoma 3 Metastatic colon carcinoma to small bowel 3 Small bowel varices 3 Small bowel melanoma 3 Others 10 Szold A, Katz L, Lewis B: Surgical approach to occult gastrointestinal bleeding. Am J Surg 163:90–93, 1992.

Treatment Surgery Without localization only for acute exsanguinating hemorrhage Intraoperative endoscopy Segmental resection