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GI Hemorrhage October 11, 2014 David Hughes Slide 2 Incidence 1-2% of all hospital admissions Most common diagnosis of new ICU admits 5-12% mortality 40% for recurrent bleeders 85% stop sponateously Those with massive bleeding need urgent intervention Only 5-10% need operative intervention after endoscopic interventions Slide 3 Site Upper Esophageal Stomach Doudenum Hepatic Pancreatic Lower Small bowel Colon Anus Slide 4 Etiology 85% are due to: Peptic ulcer disease Variceal hemorrhage Colonic diverticulosis Angiodysplasia Slide 5 Chain of events 1. Recognize severity 2. Establish access for resusitation 3. Resusitate 4. Identify source 5. Intervention Slide 6 Question #1 JB a 30 y/o with hematemesis presents with orthostatic hypotension, clammy hands, but without tachycardia. How much blood has he lost? a) >40% b) 20-40% c) 10-20% d) 6 units over 24 hours Earlier for elderly, multiple co-morbidities Slide 30 Peptic ulcer hemorrhage Anti-secretory surgery?? Indicated for NSAID pts who need to continued meds H. pylori ulcer disease controversial Only 0.2% of pts every require surgery for bleeding ulcer Surgery pts had lower than average H. pylori positivity Oversewing and antibiotics still leave 50% at high risk for rebleeding Bottom line: still recommended but without definitive evidence Slide 31 Peptic ulcer hemorrhage Doudenal ulcer Expose ulcer with duodenotomy or duodenopyloromyotomy Direct suture ligation, four quadrent ligation, ligation of gastroduodenal artery Anti-secretory procedure Truncal, parietal cell vagotomy If unstable can use meds Slide 32 Peptic ulcer hemorrhage Gastric ulcer 10% are maliganant 30% will rebleed with simple ligation Need Resection Distal gastrectomy with Bilroth I or II Subtotal gastrectomy for 10% high on lesser curve Slide 33 Variceal hemorrhage Cirrhotics usually 25% mortality for each bleeding episode 75% will rebleed 50% mortality with surgery Based on Childs class Slide 34 Somatostatin or vasopressin w/wo NTG Slide 35 Shunt procedures Sugiura procedure TIPS Slide 36 Other sources of UGI hemorrhage Mucosal lesions Gastritis, ischemia, stress ulceration Key is prevention with acid supression Surgery often requires resection and Roux-en-Y due to multiple bleeding sites >50% mortality with surgery Mallory-Weiss 10% will have significant bleeding 90% stop spontaneously Surgery rare, but gastrotomy with oversewing effective Dieulafoys Wedge rxn after endoscopic marking Aortoenteric fistula 1% of AAA repair patients Herald bleed preceeds exsangunation by hours to days Endoscopy and if negative CT scan and if negative angiography Surgery graft removal and extraanatomic bypass Slide 37 LGI hemorrhage Sites Colon 95-97% Small bowel 3-5% Only 15% of massive GI bleeding Finding the site Intermittent bleeding common Up to 42% have multiple sites Slide 38 Slide 39 Bleeding diverticulosis Slide 40 Colonic angiodysplasia Slide 41 LGI hemorrhage Etiology Diverticulosis 40-55% Right sided lesions > left 90% stop spontaneously 10% rebleed in 1 st year and 25% at 4 years Angiodysplasia 3-20% Most common cause of SB bleeding in >50 y/o >50% are in right colon Neoplasia Typically bleed slowly Inflammatory conditions 15% of UC patients, 1% of chrons patients Radiation, infectious, AIDS rarely Vascular Hemorrhoids >50% have hemorrhoids, but only 2% of bleeding attributed to them Others Slide 42 LGI hemorrhage Evaluation Same for UGI bleed If unstable with hematochezia need EGD 1st After stable Rectal Anoscopy for hemorrhoids Slide 43 LGI hemorrhage diagnostics Colonoscopy Within 12 hours in stable patients without large amounts of bleeding Selective viseral angiography Need >0.5 ml/min bleeding 40-75% sensitive if bleeding at time of exam Tagged RBC scan Can detect bleeding at 0.1 ml/min 85% sensitive if bleeding at time of exam Not accurate in defining left vs right colon Slide 44 Meckels Diverticulum Cecal angiodysplasia with extravasation Small bowel ulceration due to NSAIDS Slide 45 Slide 46 LGI hemorrhage treatment Endoscopy Great for angiodysplasia and polypectomy sites Angiographic Selective embolization for poor surgical candidates Can lead to ischemic sites requiring later resection Surgery Ongoing hemorrhage, >6 units or ongoing transfusion requirement Site selection Blind segmental will rebleed in 75% Based on TRBC scan will rebleed in 35% Slide 47 GI hemorrhage from unknown source Only 2-5% are not upper or lower Average patient 26 month duration of intermittent bleeding 1-20 diagnostic tests Average of 20 units transfused Slide 48 Localization of GIHOUS CT scan Tumors, inflammation, diverticuli Enteroclysis Ulcerations, inflammation Only 10-20% yeild (SBFT is 0-6%) Meckels scan Initial test for patients