Acute GI Hemorrhage Flashcards
What % of pts hospitalized for bleeding require an operation?
5-10 % of pts
Most pts with an acute GI bleed will what?
stop bleeding spontaneously
15% of cases, the bleeding will persist
Mortality from acute GI bleed?
> 5%
Bleeding can occur anywhere along the GI tract and is classified based on its location relative to the;
ligament of treitz
Most cases of acute bleeding originate where?
proximal to the ligament of Treitz (>80%)
Upper GI hemorrhage, bleeding proximal to the ligament of treitz, accounts for > 80% of cases of GI hemorrhage, what are most common?
PUD
variceal bleeding
Most lower GI bleeding, distal to the ligament of treitz, is from ?
the colon
Most lower GI bleeding is from the colon, with common causes being?
diverticula
angiodysplasias
Most lower GI bleeding comes from colon, what % comes from the small bowel?
5%
What is obscure vs occult bleeding?
obscure—> hemorrhage that recurs or persists after negative endoscopy
occult—> not apparent to pts until they present with symptoms of anemia
Initial approach to a pt with GI hemorrhage?
airway and breathing take first priority
then we focus on pt’s hemodynamics
The severity of bleeding can be based on clinical parameters, what do we see with hemorrhagic shock?
SBP < 90
cool clammy extremities
obtundant
agitated
In regards to GI bleeding, what signs do we see with 20-40% blood loss?
HR >100 beats/min
decreased pulse pressure
Hemodynamic signs of bleeding are less reliable in which pts?
elderly
pts taking beta-blockers
What is the BLEED scoring system for GI hemorrhage?
it’s a model that predicts risk of recurrent hemorrhage
need for surgical intervention or even death
What 5 criteria do we take into account with BLEED model?
ongoing bleeding SBP < 100 mmHg PT > 1.2x normal AMS comorbid conditions requiring ICU admission
if any of these criteria present, model predicts 3 fold increase in recurrent hemorrhage, need for surgery, death
Leading cause of morbidity and mortality in pts with acute GI bleeding?
multiorgan failure due to inadequate initial resuscitation
How do we resuscitate a pt with acute GI bleeding?
intubate and ventilate if concern for resp compromise
two large bore IVs placed
unstable pts give 2L bolus of LR
send labs
insert Foley
triple lumen, A-line if needed, ICU admission if needed
In pts that receive >10 U of blood, what else should they receive empirically?
FFP
platelets
calcium
What are the most common manifestations of acute hemorrhage?
hematemesis
melena
hematochezia
Hematemesis is vomiting blood usually caused by ?
bleeding from upper GI tract
What’s melena?
passage of dark, tarry stools
** usually indicative of bleeding from upper GI
hbg degraded to hematin by stomach acid
What hematochezia?
bright red blood per rectum
usually lower GI source
upper GI bleeds can produce hematochezia if large or brisk enough
Older pts tend to bleed from what?
angiodysplasia
cancer
diverticula
ischemic colitis
Younger pts tend to bleed from?
peptic ulcers
varices
Meckel’s
Why do we place an NG tube in a pt suspected of acute GI hemorrhage?
although melena usually an upper GI problem, it can be from colon and small bowel
although hematochezia is a lower GI problem, it can be caused by upper GI bleed
NG tube helps lavage the stomach and see what kind of contents are inside
can help see rate of bleeding, helps remove old blood from stomach
If we have an NGT in place and aspirate shows red blood or coffee ground fluid, what does this mean?
we have an upper GI bleed
** return of bile from NGT shows that duodenum has been sampled and can rule out an upper GI source in most cases
NGT aspirate is helpful most of the time, regardless these pts should still have what done?
upper endoscopy
When do we perform an endoscopy, time-wise?
should be performed within 24 hrs
proven to reduce transfusion requirements, resource use, and hospital stay
EGD in the emergent/urgent setting is associated with what?
reduced accuracy
poor visualization
increased complication rate
Morbidity and mortality increases significantly in pts who have losts how many units?
if they have lost > 6 units
Are most GI hemorrhage upper or lower?
upper
>80% occur proximal to the ligament of Treitz
More than 80% of acute GI hemorrhages occur where?
proximal to ligament of Treitz (upper)
Causes of upper GI bleeding?
non-variceal sources (80%) ** PUD most commonly
variceal sources
This is the foundation for diagnosis and management of an upper GI bleed:
upper endoscopy
In general what % of pts undergoing an upper GI endoscopy will require intervention?
20-35% need intervention
5-10 % need surgery
In what % of pts with upper GI hemorrhage, is EGD not able to localize source of bleeding because of excessive blood impairing visualization of mucosal surface?
1-2%
How can we improve visualization of upper GI with EGD?
flush stomach w/NS
IV erythromycin to promote gastric emptying
PUD accounts for majority of UGI bleed, what % of cases?
40%
In pts with PUD what’s the most frequent cause of death and most frequent indication for operation?
bleeding
Why do we see bleeding with PUD?
peptic acid erodes mucosal surface
major bleeding seen when erodes into artery (gastroduodenal or left gastric arteries)
Pts with evidence of GI bleed should receive endoscopy within 24 hrs, whole waiting this they should be on?
PPI
What’s the Forrest classification system?
developed to assess risks based on endoscopic findings for GI bleed
Which pts under Forest classification system do we initiate endoscopic therapy?
IA; active pulsatile bleeding (have high rebleed risk)
IB: active, non-pulsatile bleed (high rebleed risk)
IIA: non-bleeding visible vessel (high rebleed risk)
IIB: adherent clot–> remove clot and evaluate ulcer base, clean base or black spot not treated
What are some meds that are ulcerogenic?
NSAIDs
SSRIs
Once a bleeding ulcer has been identified, how do we tackle the bleeder endoscopically?
epi inj
heater probes
coagulation
clips
Epi injections as an endoscopic tool to prevent bleeding?
1:10,000 to all 4 quadrants of the lesion
> 13 cc of epi is assc/w better hemostasis
- epi inj alone assc w high rebleed rate
- epi + thermal energy control 90% of PUD bleeding
After 1st endoscopic attempt at controlling bleeding, pt rebeleeds, what do we do?
endoscopy again
After a 1st endoscopic attempt at controlling bleeding, the pt bleeds again, thus a 2nd attempt at endoscopic control is warranted, what % of bleeders are controlled with this second attempt?
75%
***25% will need surgery
At the time of endoscopy, Forrest classification is most important indicator of rebleeding risk, but ulcer size and location also important;
ulcers > 2 cm
posterior duodenal ulcers
gastric ulcers
**have higher risk of re-bleed
What blood transfusion requirements necessitate surgical intervention?
ongoing blood transfusion requirement > 6 units in older pts
8-10 units in younger pts
What are the indications for surgery in someone with GI hemorrhage?
hemodynamic instability despite resuscitation (>6 U)
2 failed endoscopic attempts
shock due to recurrent hemorrhage
continued slow bleed with transfusion requirement > 3 U a day
If bleeding is from duodenal ulcer, mostly are found in duodenal bulb, how do we tackle it surgically?
expose via longitudinal duodenotomy
bleeding can be controlled with pressure then suture ligation w/non-absorbable suture
Most frequently used operation for a bleeding duodenal ulcer?
pyloroplasty with truncal vagotomy
For gastric ulcer bleeding, why is gastric ulcer resection generally indicated?
10% risk of malignancy
For bleeding gastric ulcers, operation we normally perform?
simple excision assc with 20% rebleed so distal gastrectomy performed
These are mucosal and submucosal tears that occur near the GE junction:
Mallory-Weiss tears
seen in pts after intense retching
can occur in pts w/repeated emesis
MOA that causes Mallory-Weiss tears?
forced abdominal contractions against an unrelaxed cardia
get mucosal laceration of cardia due to increased gastric pressure
Mallory-Weiss tears account for what % of upper GI bleeding?
5-10
How do we diagnose Mallory-Weiss tears?
diagnosed by history
endoscopy frequently used to confirm diagnosis
**retroflexion maneuver needs to be performed to view area underneath GE junction
Most Mallory-Weiss tears occur where ?
lesser curve (less common on greater curve)
Tx for Mallory-Weiss tears?
supportive tx is effective bc 90% of bleeding episodes are self-limited
mucosa often heals within 72 hrs
Recurrent bleeding from a Mallory-Weiss tear?
uncommon
IF conservative tx fails to manage Mallory-Weiss tears, what do we do?
endoscopic tx w/injection or electrocautery
angiography used if endoscopy fails
surgery–> high gastrotomy with suture of mucosal tear
This is characterized by multiple superficial erosions of entire stomach, commonly the body;
stress related gastritis
Cause of stress gastritis?
combo of pepsin and acid injury in context of ischemia from hypoperfusion states
These are solitary lesions due to acid hypersecretion, that appear in pts with severe head injuries:
Cushing’s ulcer
When stress ulcers are associated with burn’s these ulcers are called?
Curling ulcers
In the ICU what factors increase risk of hemorrhage from stress gastritis?
ventilator dependence > 48 hrs
coagulopathy
These are vascular malformations primarily along the lesser curve of stomach, within 6 cm of GE junction;
Dieulafoy’s lesions
What are Dieulafoy’s lesions?
vascular malformations seen along lesser curve
represent rupture of large vessels in gastric submucosa
erosion of gastric mucosa overlying these vessels leads to bleeding
Why can bleeding from Dieulafoy’s lesions be massive?
due to rupture of large vessels in gastric submucosa (usually 1-3 mm)
Tx for Dieulafoy’s lesion?
endoscopic control usually successful
if fails angiographic coil embolization may be used
surgery if all fails (endoscopic tattooing helps identify lesion) –> gastrostomy performed, lesion oversewed
if all else fails–> partial gastrectomy
What is watermelon stomach?
gastric antrum vascular ectasia
What is Gastric Antrum Vascular Ectasia?
watermelon stomach
dilated venules that appear as linear red streaks meeting on the antrum
How do pts with GAVE present?
acute severe bleeding is rare
present with chronic anemia, FOBT
Tx for GAVE ?
endoscopy successful in 90% of pts
if fails–> antrectomy
Do malignancies of the upper GI tract present with acute bleeding or other symptoms?
assc w/chronic anemia, FOBT
don’t present with episodes of significant hemorrhage
What is an aorto-duodenal fistula as cause of massive upper GI bleeding?
rare
develop in setting of previous AAA repair
can also be seen in 1% of aortic graft cases
Time frame of when aorto-duodenal fistulas present?
3 yrs
MOA of aorto-duodenal fistula?
pseudo-aneurysm at proximal anastomotic suture line
fistulization into overlying duodenum
What type of bleeding pattern do we see in someone with an aorto-enteric fistula?
sentinel bleed which heralds next massive bleed
How do we diagnose aorto-enteric fistula?
emergent EGD, bleeding seen in 3/4th part of duodenum
Surgical tx for an aorto-enteric fistula?
aorta ligated proximal to the graft
graft removed
extra-anatomic bypass
duodenal defect repair primarily
This is an unusual cause of upper GI bleed and pts present with hemorrhage, RUQ pain, jaundice;
hemobilia
usually due to trauma or instrumentation of biliary tree
How do we diagnose and treat hemobilia?
angiography
angiographi embolization is preferred tx
Bleeding related to portal HTN is a result of?
esophageal varices
Esophageal varices are common where in the esophagus?
distal esophagus
varices seen in 30% of pts with cirrhosis, and of this group 30% will bleed
Why do we give pts with variceal bleeding a 7 day course of broad spectrum abx like FQs?
will lower the risk of rebleed
What is the vasoactive medication of choice for pts with esophageal varices?
somatostatins (ocreotide)
** helps buy time for resuscitation
Effectiveness of endoscopy in treating esophageal varices?
90% are treated effectively
Endoscopic therapy of choice for esophageal varices?
banding
In pts where pharmacologic therapy or endoscopy fails what do we do for varices?
Sengstaken-Blakemore tube
has a gastric and esophageal balloon which are both inflated
Complications of balloon tamponade therapies?
aspiration
esophageal rupture
misplacement
rebleed in 50% of cases
For esophageal varices that don’t respond to medicine, endoscopy or baloon tamponade, what do we do?
TIPS (required in 10% of pts with varices)
Success rate of TIPS in controlling variceal bleeding?
95%
Rebleeding from TIPS is seen in 20% of pts within what time frame?
1st month
Lower GI bleeds account for what % of GI bleeds?
20 %
seen in older pts
LGI bleeds tend to be seen in what patient populations?
elderly pts
> 95 % of pts with LGIB, the source is the ?
colon
IN pediatric pts, cause of LGBI?
intussussception
How does LGIB typically present ?
hematochezia
sometimes as melena if bleeding is slow or from a proximal source
What makes LGIB more complicated that UGIB?
40% of pts with LGIB have more than 1 source of bleeding
25% of pts, the bleeding source is never identified
Once resuscitation is initiated in a pt with LGIB, what’s the next step?
r/o anorectal bleeding with digital rectal exam, anoscopy or sigmoidoscopy
also need to rule out UGIB by placing NG tube–> if bilious or no blood rules out UGIB source
Colonoscopy is considered mainstay in LGIB, and these act as adjuncts:
tagged RBC study
angiography
RBC tagged scans can detect bleeding as slow as ?
0.1 mL/min
difficult to diagnose right sided vs left sided bleeding
Selective angiography can detect bleeding as slow as?
0.5 cc- 1 cc/min
Some complications of angiography?
hematoma
arterial thrombosis
contrast reaction
kidney failure
MCC of significant LGIB?
diverticula
MCC of LGIB?
diverticula
What % of pts with diverticulosis experience bleeding?
3-15%
What is the cause of LGIB from diverticulosis?
bleeding occurs from neck of diverticula
due to bleeding vasa recti as they penetrate the submucosa
In terms of diverticulosis, what part of colon do we see bleeding more commonly?
diverticula are more common on left colon
but bleeding occurs more often from right colon
- **75% stop spontaenously
- **10 % rebleed within 1 year
- ** 50% rebeleed withn 10 yrs
What are angiodysplasias of the intestines?
AV malformations
acquired lesions from progressive dilation of normal blood vessels in submucosa of intestine
In what age group do we find angiodysplasias?
pts > 50
These lesions, as sources of LGIB in pts > 50%, are often assc w/ aortic stenosis and renal failure;
angiodysplasias
Hemorrhage from angiodysplasias tend to occur from right side of colon most often, with what part of colon commonly affected?
cecum
During colonoscopy these lesions appear as red stellate lesions with a surrounding rim of pale mucosa and can be tx with sclerotherapy or electrocautery;
angiodysplasias
If angiodysplasias are discovered incidentally what do we do?
nothing
if active bleeding can be treated with vasopressin, gelfoam, electrocautery, sclerosing agents, r-hemi as last resort
In this source of LGBI, the bleeding is usually painless, intermittent, slow in nature, and often assc with Fe-deficiency anemia;
colon ca
Hemorrhoids account for what % of acute LGIB?
5-10%
How do we distinguish bleeding from hemorrhoids vs anal fissure?
hemorrhoids as source of LGIB–> usually painless, from internal hemorrhoids, blood on toiler paper
anal fissure—> painful blood on toilet paper
Tx for anal fissures?
stool bulking agents–psyllium
increased water intake
topical nitroglycerin
diltiazem to relax sphincter
UC vs Crohn’s, which one do we see LGIB more often?
UC more often (15%)
CD (1%)
Tx for c. diff colitis?
d/c antibiotics
supportive care
PO/IV flagyl or PO vanco
When flex sigmoidoscopy shows bleeding telangiectasias what is on the differential as source of GI bleed?
radiation proctitis as source
MCC of small intestinal bleeding?
angiodysplasias
**commonly in jejunum
