1. Gastrointestinal Bleeding
Amr Mohsen, M.D., FRCS(Ed)
Professor of Surgery, Cairo University
GI bleeding may originate anywhere from the mouth to the anus and may be overt or occult
We shall go through this lecture a step by step
GI hge will be discussed in segments
Introduction
Occult bleeding
General principle of acute bleeding
Acute upper GI he
Acute lower GI he
Terminal part of lecture
And now let us start at the start point

2. Gastrointestinal Bleeding Spectrum of Disease
NOT one disease but various pathological processes
Common problem
Mortality rate still 10%
Massive acute hemorrhage to occult, trivial
Timely evaluation is critical to proper management
Before we start let us agree on some basic facts

3. Gastrointestinal Bleeding Definition of Terms
Upper Gastrointestinal Bleeding: proximal to Ligament of Treitz
Lower Gastrointestinal Bleeding: distal to the ligament of Treitz
Hematemesis: vomiting of blood
Melena: Passage of black tarry stools
Hematochezia: Passage of fresh blood per rectum
Hematemesis or emesis with red blood indicates an upper GI source of bleeding (almost always above the ligament of Treitz) that is often brisk, usually from an arterial source or varix.
"Coffee grounds" result from bleeding that has slowed or stopped, with conversion of red Hb to brown hematin by gastric acid.
Hematochezia usually indicates lower GI bleeding but may result from vigorous upper GI bleeding with rapid transit of blood through the bowels.
Melena typically indicates upper GI bleeding, but a small-bowel or right colon bleeding source may also be the cause. About 100 to 200 mL of blood in the upper GI tract is required to produce melena, which may continue for several days after severe hemorrhage and does not necessarily indicate continued bleeding. Black stool that is negative for occult blood may result from ingestion of iron, bismuth, or various foods and should not be mistaken for melena.
Chronic occult bleeding may occur anywhere in the GI tract and may be detected by chemical testing of a stool specimen.

4. Gastrointestinal Bleeding Definition of Terms
Manifest bleeding
Occult bleeding
Bleeding of obscure origin

5. I Chronic Gastrointestinal Bleeding Occult Bleeding – Manifestations
Weakness
Fatigue
Shortness of breath
Faintness
Accidentally discovered anemia
Routine screening
We move now to occult GI bleeding which will not take much of your time
The question is “So long as it is occult, i.e., hidden, then how can we discover it?”
The answer is by its manifestations which are those of iron deficiency anemia, weakness, fatigue, dyspnea, and fainting
Furthermore, occult bleeding may be discovered accidentally on routine examination of stools, and sometimes if there is a routine screening program

6. I Chronic Gastrointestinal Bleeding Occult Bleeding – Causes - Diagnosis
GIT malignancy
GERD & esophagitis
Peptic ulcer
NSAIDs
GIT polyps
Detection depends on peroxidase activity of hemoglobin
Guaiac test
Hemoccult test
The usual causes of occult GI bleeding are
Special tests are Guaiac or hemoccult test which depends on detection of peroxidase activity
The patient should avoid the use of a toothbrush, the intake of certain drugs as iron or aspirin, and certain foodstuffs as meat, fish, fresh vegetables and fruits for a few days before the test.
A positive test denotes the presence of a source of blood loss of about 20 ml/day, e.g., chronic peptic ulcer or malignancy of the gastrointestinal tract.

7. II Acute Gastrointestinal Bleeding Initial Evaluation
Estimate severity of bleeding
Institute resuscitation
Localize site of bleeding (UGI vs LGI)
Diagnose and treat specific lesion
Initial evaluation includes resuscitation
For elective cases we have the privilege to diagnose the disease and its implications, and then to start treatment
For emergency case we don’t have this luxury. We are short of time. Resuscitation to save life should start very early even before reaching a diagnosis

8. II Acute Gastrointestinal Bleeding Estimation of Severity
BEST METHOD: vital signs
Massive hemorrhage: shock (supine hypotension) 20-25% loss of vascular volume
Submassive hemorrhage: orthostatic hypotension 15-20% loss of vascular volume
Trivial hemorrhage: No change in vital signs < 15% loss of vascular volume
Other Indicators
Rate/Volume of clinical bleeding
Hematemesis, melena, hematochezia
Hematocrit: least sensitive
The manifestations of GI bleeding depend on the source, rate of bleeding, and underlying or coexistent disease; eg, a patient with underlying ischemic heart disease may present with angina or MI after brisk GI bleeding.

9. II Acute Gastrointestinal Bleeding Localization
Distinguishing LGI and UGI
Clincal Signs
Hematemesis: UGI bleeding
Melena: Usually UGI
Hematochezia: Usually LGI
Nasogastric aspirate (ALL PATIENTS)
Lavage +: UGI bleeding
15% miss rate

10. IIa Acute UGI Bleeding Management
Hematemesis, or melena is an emergency.
Admission to an ICU for all patients with severe GI bleeding.
The team approach includes a gastroenterologist, a surgeon with expertise in GI surgery, and skilled nurses.
A major cause of morbidity and mortality is aspiration of blood. To prevent this complication in patients with altered mental status, endotracheal intubation should be considered.
Always keep in mind that
These are emergency situations
ICU admission is recommended for severe cases
A team work provides better results
In unconscious persons ………….. intubate

11. IIa Acute Gastrointestinal Bleeding Resuscitation
All patients need 2 large-bore IVs
Crystalloid solutions until blood available
Send blood for Hct, coagulation studies (PT, PTT, platelet), crossmatch
Transfuse blood for:
Obvious massive blood loss
Hematocrit < 25% with active bleeding
Symtpoms due to low Hct
Correct coagulopathies
Fresh frozen plasma
Platelet transfusion
The general principles of resuscitation of acute bleeding are

12. IIa Acute UGI Bleeding Etiology (Egypt)
Esophageal varices 55%
Acute gastric erosions 15%
Chronic DU
Chronic GU
Esphagitis & erosions
Mallory Weiss tears
Duodenitis
Gastric cancer
Coagulopathies
Kasr El-Aini stastistics over 10 years from 1991
Over cases

13. IIa Acute UGI Bleeding Diagnosis
History
of previous bleeding
of peptic ulcer symptoms
of previous surgery
of medications: NSAID
Physical Exam
Stigmata of cirrhosis: spider angiomata, jaundice, gynecomastia, palmar erythema, testicular atropy, splenomegaly, ascites, noular liver.
Surgical scars
Tenderness
Abdominal examination is commonly negative

14. IIa Acute UGI Bleeding Diagnostic Procedures
Endoscopy
90-95% accurate
Diagnosis and treatment
Barium radiography
80% accurate
Barium makes further studies difficult
Arteriography (failure of localization / active bleeding)
Nuclear Scanning (Technetium-99m) ??
Endoscopy is routinely used first, particularly in patients with significant hemorrhage
Emergency endoscopy, during the acute attack is the procedure of choice

15. IIa Acute UGI Bleeding Contrast radiography
Contrast radiography is seldom used for diagnosis of acute upper GI he.
Nevertheless, these X-rays are commonly shown in oral examinations
These are esophageal varices. The arrows point at what looks like an irregular filling defect, but with no proximal dilatation, i.e., without obstruction
The X-ray to the left shows grape-like defects, again without dilatation proximally
The trap is that these varices may not be bleeding. The blood possibly coming from superficial gastric erosions for example, which do not show on radiograms

16. IIa Acute UGI Bleeding Contrast radiography
Chronic duodenal ulcer on barium meal
Again the same problem. Bleeding may not be coming from the ulcer
Contrast radiography is, therefore, not dependable
Emergency endoscopy is
To see is to believe

17. IIa Acute UGI Bleeding Endoscopy
Always keep in mind that esophageal varices are the usual source of upper GI bleeding in Egypt.
This is not enough for diagnosis, the endoscopist should proceed to examine the stomach and duodenum
Varices
Normal

18. IIa Acute UGI Bleeding Endoscopy
Acute gastric erosions
Signs of recent bleeding
Ah, here we are. This is the source of bleeding. Multiple superficial gastric erosions with overlying small blood clots. The presence of a blood clot is a sign of recent he.
A frequent complication of the use of aspirin and other NSAIDs

19. IIa Acute UGI Bleeding Endoscopy
DU – signs of recent bleeding

20. IIa Acute UGI Bleeding EndoscopyGU
Endoscopic criteria that warn us of possible recurrence of an attack of bleeding are
Continuous trickling of blood
A clot over the ulcer
A visible vessel in the ulcer base
Blood clot
Visible vessel

21. IIa Acute UGI Bleeding Endoscopy
Mallory Weiss tears occur in the lower esophagus
The pathogenesis is inco-ordinated vomiting. The stomach empties its contents into the lower esophagus. Unfortunately the esophageal musculature does not work in harmony. It does not relax. The pressure builds up in its lower part which becomes over-distended. The mucosa cracks. In severe cases the whole esophageal wall ruptures
Mallory Weiss tears usually occur in Drunks, and in head injuried persons
Mallory Weiss tear

22. IIa Acute UGI Bleeding Treatment of Specific Lesions
Esophageal varices
URGENT
Endoscopic sclerotherapy or banding
Vasopressin infusion
Surgery

23. IIa Acute UGI Bleeding Treatment of Specific Lesions
Esophageal varices
Sengstaken tube Temporary measure

24. IIa Acute UGI Bleeding Treatment of Specific Lesions
Esophageal varices
Endoscopic sclerotherapy or banding
To the left is endoscopic view of a varix being injected
To the right another view of banded veins
Both techniques achieve almost the same results

25. IIa Acute UGI Bleeding Treatment of Specific Lesions
Esophageal varices
Endoscopic sclerotherapy or banding
Highly successful
Failure Repeat injection
Followed by chronic sclerotherapy
Failure rate ~15%
From esophageal varices
Missing fundal varices
Difficulty injecting fundal varices

26. IIa Acute UGI Bleeding Treatment of Specific Lesions
Esophageal varices
2. Vasopressin (1 unit/min) IV infusion
Beware of coronary heart disease
Stops 75% of bleeding cases

27. IIa Acute UGI Bleeding Treatment of Specific Lesions
Esophageal varices
3. Urgent surgery
Emergency shunt surgery is losing favor
For the minority of bleeding esophageal varices cases that do not respond to previous measures, surgery is the last resort
We know that these patients have hepatic dysfunction, and on top they develop hypovolemia. In fact they are critically ill and, therefore, cannot withstand major surgery. For this reason shunts have dropped out of favor for emergency cases

28. IIa Acute UGI Bleeding Treatment of Specific Lesions
Esophageal varices
3. Urgent surgery
Most popular procedure
The most popular in such critical circumstances is stapling of gastro-esophageal junction and ligation of left gastric vein.

29. IIa Acute UGI Bleeding Treatment of Specific Lesions
Peptic Ulcers
Antacids or H2 blockers and proton pump antagonists promote healing but DON’T stop acute bleeding
URGENT
Endoscopic coagulation
Angiographic embolization
Surgery
Remember that medications promote healing but do not stop bleeding. They are given anyway
Endoscopic coagulation is the most practical of ways and is usually effective. Methods include fibrin glue, electrocautery, thermal coagulation, Argon laser, and injection of adrenaline in ulcer base.
If not successful angiography and embolization if available may be used
Otherwise surgery comes to rescue

30. IIa Acute UGI Bleeding Treatment of Specific Lesions
Peptic Ulcers
Surgery
As pointed before, surgery is the last resort, as the majority of cases respond to non-surgical means
Ideally an upper midline abdominal incision
The pulorus is divided along the gut axis. The usual source of major bleeding is an eroded gastroduodenal artery that runs on the posterior wall of first part of duodenum
Hemostasis is achieved by under-running sutures
The pylorus is closed transversely to affect a pyloroplasty
Truncal vagotomy is added

31. IIb Acute LGI Bleeding General Considerations
Spontaneous remission rate is 80%
Bleeding has usually ceased by the time the patient presents to hospital
No source of bleeding can be identified in 12%
Bleeding is recurrent in 25%
Thanks God bleeding stops spontaneously in 80% of cases
The problems arise in cases which continue bleeding, and in those who have recurrence of bleeding. These are really challenging cases
As you see

32. IIb Acute LGI Bleeding Common causes
Hemorrhoidal bleeding
Fresh bright red
Jet or drops separate from stools
With straining at end of defecation
Massive bleeding in adults
1. Diverticula 2. UC 3. Ischemic colitis
4. Angiodysplasia 5. Massive bleeding from upper GIT
Massive bleeding in children
Meckel’s diverticulum
Remember that haemorrhoids and carcinoma of the rectum can coexist

33. IIb Acute LGI Bleeding General Considerations
Initial evaluation is the same
Judge severity
Resuscitate
Localize site (usually difficult)
Patient usually notes hematochezia (bright red rectal bleeding)
Most of LGI bleeding is from anus or rectum especially trivial bleeding
The source of bleeding should be sought while the patient is being resuscitated
The duration and quantity of bleeding are assessed; however, the duration of bleeding is often underestimated and the quantity is often overestimated.
Hematochezia. Bright red or maroon blood per rectum suggests a lower GI source; however, 11-20% of patients with an upper GI bleed will have hematochezia as a result of rapid blood loss.
Melena. Sticky, black tarry, foul-smelling stools suggest a source proximal to the ligament of Treitz.

34. IIb Acute LGI Bleeding Management
Hematochezia should be considered an emergency.
Admission to an ICU is recommended for all patients with severe GI bleeding.
The team approach includes a gastroenterologist, a surgeon with expertise in GI surgery, and skilled nurses.
Notice that the outline of management is the same as for Upper GI bleeding

35. IIb Acute LGI Bleeding Diagnosis
History
Previous bleeding episodes
Rectal pain/hemorrhoids
IBD
Change in stool caliber
Weight loss
Physical Exam
Rectal examination: hemorrhoids, tears, fissures, fistulas
Anoscopy: hemorroids, fissures
Sigmoidoscopy
Associated Findings
Abdominal pain may result from ischemic bowel, inflammatory bowel disease, or a ruptured aortic aneurysm.
Painless, massive bleeding suggests vascular bleeding from diverticula, angiodysplasia or hemorrhoids.
Bloody diarrhea suggests inflammatory bowel disease or an infectious origin.
Bleeding with rectal pain is seen with anal fissures, hemorrhoids, and rectal ulcers.
Chronic constipation suggests hemorrhoidal bleeding. New onset constipation or thin stools suggests a left-sided colonic malignancy.
Blood on the toilet paper or dripping into the toilet water after a bowel movement suggests a perianal source.
Blood coating the outside of stool suggests a lesion in the anal canal.
Blood streaking or mixed in with the stool may result from a polyp or malignancy in the descending colon.
Maroon colored stools often indicate small bowel and proximal colon bleeding.

36. IIb Acute LGI Bleeding Evaluation
Nasogastric tube if massive bleeding
Sigmoidoscopy
Colonoscopy
Angiography ­ require blood loss > 0.5 ml/min
Isotope scanning
Barium enema ­ not for initial diagnosis
Sigmoidoscopy. The rigid sigmoidoscope can reach up to 30 cm from the anal verge while the fibreoptic sigmoidoscope can reach up to 70 cm and so it can diagnose most of the lesions of the rectum, sigmoid colon and descending colon.
Colonoscopy can visualize the whole colon but it needs proper preparation of the colon by repeated enemas before the procedure. In patients with massive colonic bleeding, the blood will obscure the field and so it is better to postpone the procedure in these situations. Colonoscopy is the investigation of choice for chronic blood loss.
Angiography. This invasive investigation is performed when colonoscopy cannot be performed because of massive bleeding or when colonoscopy cannot pinpoint the source of bleeding, e.g. in angiomatous malformations of the colon. Selective catheterization of the superior or inferior mesenteric artery will usually succeed in localizing the site of bleeding provided that the rate of bleeding is ml or more per minute. If angiography succeeds in localizing the source of bleeding, an attempt can be made to stop the bleeding by injection of vasoconstrictors or gel foam through the angiography catheter. Angiography is not an easy investigation and it is not available except in special centres.

37. IIb Acute LGI Bleeding Evaluation
The following pictures will show you the common causes of massive bleeding per rectum in adults as they show on colonoscopy
Angiodysplasia (usually Rt colon)

38. IIb Acute LGI Bleeding Evaluation
Diverticula (usually Lt colon)

39. IIb Acute LGI Bleeding Evaluation
Normal colon UC

40. IIb Acute LGI Bleeding Evaluation
Ischemic colitis (usually splenic flexure)

41. IIb Acute LGI Bleeding Evaluation
Diverticula (usually Lt colon)

42. After treatment and follow-up
IIb Acute LGI Bleeding Management
1. 80% of bleeding cases stop spontaneously
2. Arteriography & embolization
Angiodyaplasia Argon beam coagulation
3. Urgent surgery
Preoperative localization Resection
No localization + I.O. colonoscopy High failure
After treatment and follow-up
Notice that surgery occupies last place.
Failure of localization may end in total colectomy
Again lower GI bleeding deserves more, probably a lecture of its own. Howver, we have to shift to the following and last segment

43. III Bleeding of obscure origin Definition
the cause of the bleeding has not been determined after an initial gastrointestinal evaluation
May be occult or manifest

44. III Bleeding of obscure origin Sources
In 38% of patients the source of bleeding is located in the distal duodenum and proximal jejunum
Duodeno-jejunal arteriovenous malformations (AVMs) are the most common cause for bleeding

45. III Bleeding of obscure origin Management steps
Repeat upper and/or lower GI endoscopy
Enteroscopy
Push enteroscopy. can be advanced as much as 100 cm past the ligament of Treitz
Sonde enteroscopy, a tube is advanced by peristalsis into the small intestine. Lengthy and uncomfortable
Swallowed capsule endoscopy
Although endoscopy is an excellent test to determine the source of gastrointestinal bleeding, like any other test, it is not 100% sensitive. A spastic duodenal bulb may make a small duodenal ulcer difficult to identify. Occasionally a small ulcer located in a large hiatal hernia (Cameron's ulcer) may be overlooked. A vascular ectasia in a less than optimally prepared colon can easily be missed. In addition, on occasion large polyps or even cancer of the colon may escape detection.
The patient swallows a small capsule that has a self-contained light source as well as a transmitter. The capsule is allowed to pass through the GIT by normal peristalsis and eventually passes in the stool. The data (images of the small bowel mucosa) are collected by and contained in the receiver, which is worn about the waist while the capsule is traversing the small bowel. The data in the receiver are then analyzed by a special computer program, which can indicate images that show suspicious lesions and their location within the small bowel. The images can then be examined by a gastroenterologist.

46. III Bleeding of obscure origin Management steps
Isotope-labelled RBCs scan ( ml/min)
Mesenteric angiography (>0.5ml/min)
Meckel’s scan
Barium meal for chronic cases (limited value in AVM)
intraoperative enteroscopy
Although intraoperative enteroscopy identifies specific mucosal abnormalities in 70% of patients, the therapeutic efficacy in preventing recurrent hemorrhage is only 41%.

47. Individualize management Don’t hesitate to TRANSFER
Application
Case variation
Surgeon’s experience
Hospital facilities
The outline of this lecture is clear ………………may be
The pictures were illustrative ……………………probably
The information correct ………………………….quite possibly
But one thing is for sure……………………….....It is also absolutely useless, of no value, just vacant words,…if, ……………if you don’t put it to actual use on our patients.
Many of you might by now be telling themselves that it is all theoretical. How can we apply this
Cases vary greatly and no rigid scheme will suit them all
The experience of one surgeon varies from another
And above all we don’t all have the same up to date facilities in our hospitals, ICUs, emergency mesenteric arteriography, not to mention emergency isotope scanning.
Therefore, the message is
Individualize management according to patient’s condition and facilities
Don’t hesitate to transfer to specialized centers, preferably after hemodynamic stabilization
Individualize management
Don’t hesitate to TRANSFER