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GI bleeding (Lower GI bleeding (Causes (Diverticulosis (40%)
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GI bleeding
Lower GI bleeding
- Below ligament of Treitz
- acute vs. chronic
Causes
- Diverticulosis (40%)
- Angiodysplasia (40%)
- IBD, Colorectal carcinoma, Colorectal adenomatous polyps
- Ischemic colitis, Hemorrhoids, anal fissures,
Treatment
- Colonoscopy—polyp excision, , injection, laser.
- Arteriographic vasoconstrictor infusion
Upper GI bleeding
- Above ligament of Treitz (where fourth portion of the duodenum transitions to jejunum)
- 75% of GI bleeds
- acute (variceal, non variceal) vs. chronic
- 80% of episodes stop spontaneously
- esophageal varices have a 30% mortality rate
acute
- common cause for admission to hospital
- commonly caused by ulcer disease, gastritis, Mallory-Weiss syndrome, esophagitis, and gastric cancer.
- Variceal bleed is common in those with portal hypertension from cirrhosis.
Causes
above the GE junction
– oesophageal varices (10%)
– Mallory–Weiss tear (7.5%)
– Oesophagitis (6%)
– oesophageal ulcers (2%)
– oesophageal cancer
– epistaxis
Gastric
– gastritis with erosions (23%)
– gastric ulcer (22%)
– gastric cancer (3%)
– gastric varices, portal hypertensive gastropathy, gastric antral vascular ectasia, Dielafuoy lesions
Duodenal
– duodenal ulcer (24%)
– vascular malformations, including aortoenteric fistulae (common in patients with a history of aortic graft surgery.
– haemobilia (bleedingfrom the bile ductdue to liver biopsy, trauma, arteriovenous malformations, liver tumours).
coagulopathy (drugs [NSAID/Aspirin], renal disease, liver disease)
Non-variceal
treatment
– pharmacotherapy
PPI, H. pylori eradication, antiplatelet and anticoagulant agents postendoscopy
– endoscopic methods
– embolization using an angiographic catheter (for
the patient who is too unstable to undergo surgery)
– surgery
Variceal
- Develop when the hepatic venous pressure gradient (HVPG) is above 10 mm Hg (normal <5 mm Hg)
therapy
– Vasoactive therapy (Terlipressin 2 mg iv. bolus followed by 1–2 mg every 4–6 h for at least 48 h )
– Antibiotics prophylaxis (ceftriaxone, norfloxacin, ciprofloxacin tazocin)
- Balloon tamponade -Sengstaken–Blakemore tube
- Endoscopy
– Bind ligation> sclerotherapy
- TIPS, Self-expanding metal stents (SEMS), Surgery (shunt / no shunt)
Treatment
- stabilize patient (1-2 large bore IVs, IV fluids [normal saline or Ringer’s lactate.], monitor)
Forrest classification
- endoscopic predictors of rebleeding
Forrest Class \ Type of Lesion / Risk of Rebleed (%)
I / Arterial bleeding / 55-100
IIa / Visible vessel / 43
IIb / Sentinel clot / 22
IIc / Hematin covered flat spot / 10
III / No stigmata of hemorrhage / 5
Presentation
- Hematemesis—vomiting blood; upper GI bleeding (moderate to severe)
- “Coffee grounds” emesis—upper GI bleeding (low rate)
- Melena—black, tarry, loose, sticky, foul-smelling stool; upper GI bleeding 90%, if lower, the ascending colon is the most likely
can also result from bismuth, iron, spinach, charcoal.
- Hematochezia—bright red blood per rectum; lower GI source (typically left colon or rectum)
- Occult blood in stool—anywhere along GI tract
- bright red vomitus (recent bleeding)
- coffee ground (previous bleeding)
- anemia (pallor, dizziness, angina, or dyspnea)
- in order of decreasing severity of the upper GI bleed: hematochezia (brisk upper GI bleed) > hematemesis > coffee ground emesis > melena > occult blood in stool
Diagnosis
- Laboratory tests:
Hemoglobin/hematocrit level
Coagulation profile (platelet count, PT, PTT, INR).
LFTs, renal function.
- Upper endoscopy- Most accurate in evaluation of upper GI bleeding.
- Anoscopy or proctosigmoidoscopy can exclude an anal/rectal source.
- Colonoscopy
- A bleeding scan (radionuclide scanning) reveals bleeding even with a low rate of blood loss. It does not localize the lesion; it only identifies continued bleeding.
- Arteriography locates the point of bleeding.
- Hematemesis—An upper GI endoscopy is the initial test.
- Melena—Upper endoscopy is the initial test. colonoscopy if no bleeding from the endoscopy.
- Occult blood—Colonoscopy is the initial test in most cases (colon cancer is the main concern). an upper endoscopy if no bleeding from the colonoscopy.