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GI Bleeding, 083117_1021_LIGAMENTOFT1, Screen Shot 2020-06-27 at 14.08.39,…

- - - - usually located in the colon
        
        rarely in small bowel
        
        the most frequently affected part: left colon (descending and sigmoid)
        
        in diffused diverticulosis
        
        both descending, sigmoid, transverse and ascending colon is affected
      - usually affects older patients
      - the most common reason of lower GI bleeding
      - there can be an isolated diverticulum
      - if there are multiple diverticula in the colon: diverticular disease
      - bleeding is seen in 3-5% of the patients
      - benign lesions
      - outpouching of the wall of the gut to form a sac
        
        the mucosa layer is intact
      - Treatment
        
        endoscopic
        
        epinephrine
        
        thermal
        
        mechanic
        
        surgery
        
        if the bleeding occurs frequently
        
        all segments involved in the diverticulum are removed
    - - protruding lesions inside the lumen
      - neoplastic
        
        starts like an adenoma
        
        overtime evolves with dysplasia (low grade to high grade)
        
        finally becomes a tumor
    - - 2nd most frequent cause of GI bleeding
      - usually occurs in older patients
      - usually when it occurs in younger patients, there are concomitant situations such as vasculitis or coagulation disorder
        
        it can also happen in females that are receiving estrogen treatment
      - treatment is done by clipping
    - - when the lumens of colon and small bowel are in contact
    - - Dieulafoy lesion
        
        the bleeding of an aberrant large submucosal artery
        
        if it is not bleeding, it cannot be diagnosed because a normal mucosa is observed (artery is to deep to be seen)
        
        it is very common in proximal part of the stomach
      - Angioectasias (angiodysplasias
        
        vascular malformations
        
        usually quite big (1-10 mm)
      - Telangiectasias
        
        small red spots in the mucosa
  - - - usually it results from bleeding proximal to ileum
- - - - varices (portal hypertension)
        
        dilations of submucosal veins
        
        develop in patients suffering from long-term portal hypertension
        
        due to increased pressure in portal system, the veins that are normally collapsed in the submucosa form shunts to let blood pass, causing varices
        
        varices can rarely develop in stomach and intestine
        
        they usually develop in distal part of esophagus
        
        very prone to bleed
        
        if they rupture, they cause a very dramatic bleeding
        
        blood will be present both in the esophagus and the stomach
        
        JRSPH classification
        
        color
        
        white
        
        blue
        
        when the vein is superficial
        
        form
        
        F1: involves less than 1/3 of the lumen
        
        F2: involves up to 2/3 of the lumen
        
        F3: involves almost the whole lumen or at least 2/3
        
        presence of additional signs
        
        red wave markings
        
        longitudinal, whip-like or wormy
        
        cherry red spots
        
        small red spots
        
        hematocystic spots
        
        crimson-colored, large, blood filled projections or blister-like lesions
        
        diffuse redness
        
        high risk of bleeding
        
        localization
        
        proximal/middle/distal
        
        co-occurrence of esophagisitis
        
        a significant increase of bleeding
        
        Treatment
        
        Primary prophylaxis
        
        depends on the size, presence of additional signs and the degree of liver failıre
        
        first line treatment: non-selective beta blockers
        
        to reduce the splanchnic pressure and hence, the risk of bleeding
        
        in patients with cardiac problems, we cant use beta blockers
        
        primary prophylaxis cannot be performed with medical treatment
        
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        the most commonly used ones
        
        propranolol
        
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        nadolol
        
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        If you have active acute bleeding from the varice
        
        start antibiotic prophylaxis
        
        should be initiated immediately at the admission
        
        different options
        
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        vasoactive drugs
        
        two goals
        
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        different options
        
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        Endoscopic treatment
        
        should be performed immediately after the drug treatment
        
        especially in patients with significant bleeding or in patients with features suggesting cirrhosis
        
        There are different techniques
        
        Ligation
        
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        Injection - Sclerotherapy
        
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        Balloon Tamponade
        
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        TIPS
        
        the most definitive treatment
        
        a shunt is created between portal and hepatic veins by using a stent
        
        Secondary prophylaxis
        
        For secondary prophylaxis, same technique for the primary prophylaxis are used
        
        used when there is venous ectasia but no varices visible
      - esophagitis (hiatus hernia)
      - esophageal cancer
      - esophageal ulcer
      - Mallory-Weiss tear
        
        can happen in case of prolonged vomiting
    - - Peptic ulcer
        
        a break in the gastric or duodenal mucosa that arises when normal mucosa defensive factors are impaired or overwhelmed by aggressive luminal factors
        
        ulcers extend through the muscularis mucosae and they are usually over 5 mm in diameter
        
        most common cause of GI bleeding although significant bleeding occurs only in 10% of ulcer patients
        
        80% of bleeding resolves spontaneously
        
        only 20% has more severe bleeding that requires treatment
        
        location
        
        duodenal ulcers
        
        5x more common
        
        95% is in bulb or pyloric channel
        
        occurs mainly in patients aged 30-55 years
        
        they are benign
        
        gastric ulcers
        
        mostly benign
        
        however, higher risk of malignancy
        
        thats why a biopsy is done of gastric ulcers and not duodenal
        
        benign ulcers are mostly located in the antrum
        
        malignant ulcers are mostly located in the lesser curvature
        
        more common in patients aged 55-70
        
        Etiology
        
        major causes
        
        NSAIDS
        
        Chronic H Pylori infection
        
        minor causes
        
        Acid hypersecretory states
        
        f.e: Zollinger-Ellison syndrome or systemic mastocytosis
        
        CMV
        
        especially in transplant recipients
        
        Crohn disease
        
        Lymphoma
        
        medications (f.e: alendronate)
        
        Chronic medical illness
        
        cirrhosis
        
        CKD
        
        idiopathic
        
        Forrest Classification
        
        classification of upper GI hemorrhage
        
        used for purposes of comparison and selection of patients for endoscopic treatment
        
        F1: active bleeding
        
        F1a: spurting bleeding
        
        usually an arterial bleeding
        
        F1b: oozing bleeding
        
        usually an venous bleeding
        
        F2: previous bleeding
        
        F2a: non bleeding visible vessel (NBVV)
        
        erosion was deep enough to uncover it
        
        endoscopy treatment should be performed
        
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        F2b: adherent clot
        
        the clot should be removed
        
        F2c: black base
        
        there is hematin (blood residue)/ bleeding is recent
        
        low risk
        
        F3: clean base
        
        a bleeding happened a long time ago
        
        the lesion is spontaneously healing
      - Gastritis
      - Gastric varices
        
        the pathophysiology is the same as the esophageal varices
        
        different classification
        
        GOV1
        
        gastroesophageal varices extending 2-5 cam along the lesser curvature
        
        GOV2
        
        gastroesophageal varices involving the greater curvature
        
        IGV
        
        isolated gastric varices without the involvement of esophagus
        
        type I
        
        located in fundus
        
        type II
        
        located in other parts than fundus
        
        Treatment
        
        band ligation cannot be used in the stomach
        
        However, in varices that involve also esophagus, when you do band ligation at the level of the cardia, you treat both the esophageal and gastric varices
        
        the problem is when you have huge gastric varices
        
        injection therapy is used
        
        glue is injected inside to stabilize and collapse the varice
      - Gastric erosions
      - Vascular malformations
      - Gastric cancer
      - Dieulafoy's lesions
    - - Aorta-duodenal fistula
        
        very rare but very bad prognosis
        
        only treatment option: surgery
      - Duodenal ulcer
      - Hematobilia
        
        bleeding from biliary tree
      - Hemosuccus pancreaticus
        
        bleeding from pancreatic duct
      - Severe superior mesenteric artery syndrome
  - - - bleeding occurred in the stomach in a slow rare
    - - indicates rapid bleeding in esophagus
- - - - prior episodes of GI bleeding
      - known peptic ulcer disease
      - known GI malignancy
      - ingestion of drugs
      - concurrent serious conditions
      - 3️⃣ Clinical evaluation
        
        Extra-intestinal Signs and Symptoms (predictors of severity)
        
        general malaise, asthenia
        
        thirst
        
        cold, pale extremities
        
        syncope
        
        confusion
        
        shock
        
        hypotension
        
        tachycardia
        
        thready pulse
        
        tachypnea
        
        pupil dilation
        
        multi-organ failure
        
        Laboratory
        
        hemoglobin levels
        
        blood urea
        
        4️⃣ Hospital Management
        
        Vigorous resuscitation
        
        if necessary
        
        First priority: support the circulation
        
        large bore cannula
        
        infusion (if pulse > 100 bpm or systolic pressure <100 mmHg)
        
        blood transfusion (if necessary)
        
        Hb>/= 10 g dl: not requested
        
        Hb 7-10 g dl: requested
        
        depending on hemodynamic status, comorbidities, symptoms, rate of bleeding, initial and subsequent Hb levels
        
        Hb < 7g dl: requested (unless its a chronic loss)
        
        Endoscopy
        
        for active bleeding
        
        control the bleeding
        
        for non-active bleeding
        
        find the ulceration
        
        classify if it is high-risk or low-risk for re-bleeding
        
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