1. Approach to gastrointestinal bleeding
Pongkamon Tongpong
Gastroenterologist, Maharaj Nakornsrithammarat hospital

2. Gastrointestinal (GI) bleeding
ภาวะที่มีเลือดออกจากอวัยวะต่างๆในทางเดินอาหาร ตั้งแต่ esophagus จนถึง anus

3. Classification of GI bleeding (New)
Upper GI bleeding =
Esophagus  Ampulla of Vater (EGD)
Mid GI bleeding =
Ampulla of Vater Terminal ileum
Lower GI bleeding =
Colonic bleeding (Colonoscopy)

4. Definitions Hematemesis Coffee ground emesis Hemoptysis Melena
Maroon stool
Hematochezia

5. Stage of hemorrhagic shock
Parameter I II
III IV
Blood loss (ml)
< 750
> 2000
Blood loss (%)
< 15
15-30
30-40
> 40
Heart rate (bpm)
< 100
100
> 120
> 140
BP (mmHg)
Normal
Orthostatic
Hypotension
Severe hypotension
CNS symptoms
Anxious
Confused
Obtunded
Hct แรก อาจไม่ represent actual hct
Schwartz’s principles of surgery.9th ed.

6. Upper GI hemorrhage

7. Etiology of upper GI hemorrhage
Variceal hemorrhage
Non-variceal hemorrhage
Peptic ulcer
Esophagitis
Upper GI tract tumor
Angioectasia
Mallory-Weiss tear
Erosions
Dieulafoy’s lesion
Other

8. Clues for variceal hemorrhage
History of chronic liver disease / presence of sign of chronic liver disease
Hematemesis
Red NG content
> 90% has hemodynamic change

9. History Differentiated from epitaxis and hemoptysis Characteristic
Severity : amount
Associated symptoms : abdominal pain, chest pain
Symptoms of volume depletion and cerebral hypoxia : diaphoresis, dizziness, fainting, dyspnea on exertion, anemic symptoms, oliguria

10. Physical examination Vital signs : low BP, tachycardia
General appearance : consciousness, anemia, cold and calmy skin, poor skin turgor
Sign of chronic liver disease
CVS : tachycardia, weak peripheral pulse
Abdomen : Sister Mary Joseph nodule, palpable mass, ascites, sign of cirrhosis

11. Investigation Complete blood count Coagulogram
Liver function test (cirrhosis)
Blood chemistry (BUN/Cr, electrolyte)
Esophagogastroduodenoscopy (EGD)
Angiography
Radionuclide scanning

12. Diagnosis of UGIB UGIB VS LGIB NG lavage  negative cannot R/O
Hematochezia  association with shock
Bowel sound  hyperactive
BUN/Cr ratio  inappropriate (> 20:1)
NG content for stool occult blood : not useful (trauma form NG)

13. Diagnosis of UGIB
Nonbloody NG aspirate may be seen in up to 16% of pts with UGIB usually from a duodenal source.
Propose mechanism  pyloric spasm
Bile content NG without bloody  can exclude UGIB

14. Assessment of severity
Rockall score : age, shock, co-existing illness
Blatchford score : pre-endoscopy
BP, BUN, Hb, HR, syncope, melena, liver disease, heart disease
Assess need for clinical intervention (e.g. transfusion, endoscopic Rx, surgery)
AIMS65 : albumin<3, INR>1.5, mental status, systolic BP<90, age>65
Score <2 : lower mortality, length of stay

15. Rockall scoring system (predicts mortality)

16. Rockall scoring system

17. Blatchford score (predicts needs for intervention)
Identify low risk patients
Score = 0; no intervention, early discharge

18. Management Resuscitation, Risk assessment, Pre-endoscopy management
Endoscopic management
Pharmacologic management (adjunct to endo Rx)
Non-endo & non-pharmacologic in hospital management

19. Resuscitation, Risk assessment, Pre-endoscopy management
Fluid resuscitation
Correct coagulopathy (keep INR < 2.5)
Transfuse if Hb < 7 g/dl
Proton pump inhibitor (PPI) ; downstage ulcer stigmata

20. Hematocrit Change in GIB
45%
45%
27%
Unreliable in the first hrs.
Ebert RV, et al . Arch Intern Med 1941

21. Endoscopic management
Early endoscopy
Second endoscopic treatment in recurrent bleeding

22. Pharmacologic management (adjunct to endo Rx)
High dose IV PPI for high-risk patients (decrease rebleeding, surgery rate)

23. Non-endo & non-pharmacologic in hospital management
Low risk patient : can be fed and/or discharge in 24 h
High risk patient : should be in hospital at least 72 h
Surgical consult if endo Rx fails
Angiography with embolization is alternative to surgery
H.pylori assessment

24. Treatment of variceal hemorrhage
General management :
Fluid resuscitation
FFP and platelet transfusion
Do not over transfuse (Hb 8 g/dl)
Maintain SBP of 100 mmHg
Antibiotic prophylaxis : norfloxacin 400 mg bid x7 days, IV ceftriaxone 1 g/d x7 days

25. Treatment of variceal hemorrhage
Specific therapy
Pharmacological therapy : Somatostatin
Endoscopic management :
ligation/sclerotherapy for EV, glue for GV
Balloon tamponade (Sengstaken Blakemore tube) :
bridging therapy
Shunt therapy : TIPS, surgical shunt

26. Hematemesis / Melena
Initial Assessment and Resuscitation
Risk Stratification
Low Risk
High Risk
6. PPI for Suspected
Non-variceal
Bleeding
7. Somatostatin for
Suspected Variceal
Bleeding
4. Supportive Treatment
and Monitoring
5. Elective Endoscopy
Endoscopy Available
Yes
8. No
Ulcer bleeding
Variceal bleeding
Others
Refer

27. Lower GI hemorrhage

28. Etiology of lower GI hemorrhage
Diverticulosis (43%)
Angiodysplasia (20%)
Neoplasia (9%)
Colitis (9%)
Miscellaneous (7%)

29. History

30. Physical examination Vital sign
General appearance : consciousness, anemia, cold and calmy skin, poor skin turgor
CVS : tachycardia, weak peripheral pulse
Abdomen: palpable mass, ascites
Per rectal examination / proctoscopy
Lymphatic system

31. Management Resuscitation and initial assessment
Diagnostic and therapeutic options :
Colonoscopy
Radionuclide scan
Angiography
CT angiography

32. Management of lower GI bleeding
2014 ASGE guideline

33. Management of lower GI bleeding
2014 ASGE guideline