خونریزیهای حاد دستگاه گوارش

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Acute Gastrointestinal Hemorrhage خونریزیهایحاد دستگام گکوار ون 

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GI Bleeding Maybe classified into: Upper Gi bleeding (proximal to Dj flexure) Variceal bleeding Non-variceal bleeding (Peptic ulcer , ... ) Lower GI bleeding (distal to Dj flexure) Colon (diverticula , angiodysplasias, ...) small intestine * Obscure bleeding Occult bleeding » Upper GI bleeding 4x more common wer GI bleeding 

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GI Bleeding In past 20 years > Increased use of NSAIDs* & SSRIs**[]1TGI bleeding > use of PPIs*** & anti H.pylori [JJJGI bleeding prer The overall result>> | 4% *nonsteroidal anti-inflammatory drugs **selective serotonin reuptake inhibitors proton pump inhibitors a 

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GI Bleeding » Management of these patients is frequently multidisciplinary emergency medicine gastroenterology intensive care Surgery interventional radiology “Emergency resuscitation is Same _ for upper and lower GI bleeds 

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Emegency Resuscitation initial assessment and resuscitation Assess airway, breathing, and circulation (ABCs) Assess magnitude of bleeding Initiate appropriate monitoring Laboratory evaluation History and exam Identify risk factors Previous surgery Medications Localize bleeding Endoscopy Possible nasogastric tube aspirate Other studies as needed Pharmacologic Endoscopic Angiographic Surgical 011111 1 1 1 1111111117 

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Emegency Resuscitation Takes priority over determining the diagnosis/cause ۶ ABC (main focus is ‘C’) » Oxygen: 15L/m Non-rebreath mask > AV Line (2 large bore cannulae into both ante-cubital fossae ) Take bloods at same time for CBC, Urea & Electrolytes, LFT, PT, PTT, Clotting, cross match 6 Units » Urine Catheter » IV Fluid initially (a 2-liter bolus of crystalloid solution, usually lactated Ringer ) » then blood as soon as available (depending on urgency : O- « Group specific « fully cross-matched) depends to (response to the IV fluid, age, concomitant cardiopulmonary disease, bleeding continues) » Monitor response to resuscitation frequently (HR, BP, urine output, level of consciousness, peripheral temperature) » Stop anti-coagulants and correct any clotting derrangement + NG tube and aspiration (will help differentiate upper from lower GI bleed) » Organise definitive treatment (endoscopic/radiological/surgical) 

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Estimating Degree of Blood Loss » RR, HR, and BP can be used to estimate degree of blood loss/hypovolaemia oyun Loss 0-750 750-1500 1500-2000 <0 oe (%) 0-15 15-0 30-40 >%40 RR 14-20 20-30 30-40 >40 HR <100 >100 >120 >140 BP Unchanged Unchanged Reduced Reduced Tilt test (+) <90mm Hg Urine >30 20-30 5-15) Anuric Output SS (mI/hr) Mental Restless Anxious Anxious/ Confused/ State confused lethargic 

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History and Examination Aim of history and examination 1. Identify likely source - upper or lower potential cause 2. Determine severity of bleeding 3. Identify precipitants (e.g. Drugs) PO ee 

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History > CC/PI Duration, frequency, and volume of bleeding (indicate severity of bleeding) Nature of bleeding: will point to source Haematemesis (fresh or coffee ground)/melaena suggest upper GI bleed. © -bleeing from nose or pharynx « distal small bowel or right colon Hematochezia (passage of fresh blood through the anus, usually in or with stools) suggests colon * brisk upper Gl bleeding can present with dark or bright rectal bleeding Fresh rectal bleeding suggests rectum, anus If Rectal bleeding, blood being passed alone or with bowel opening (ifalone suggests heavier bleeding) If with bowel opening , blood mixed with the stool (colonic), coating the stool (colonic/rectal), in the toilet water (anal), on wiping (anal) ‘Ask about associated upper or lower GI symptoms that may point to underlying cause Upper abdominal pain/dyspeptic symptoms suggest upper GI cause such as peptic ulcer lower abd. pain, bowel symptoms such as diarrhoea or a background f change in bowel habit suggest lower Gl cause ( Colitis, cancer) © Previou: of bleeding and cause 

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History PMH “ History of any diseases that can result in GI bleeding, ( Peptic ulcer disease, diverticular disease, liver disease/cirrhosis) “ Bleeding disorders ( haemophilia) ! Drug Anti-platelets or anti-coagulants can exacerbate bleeding “ NSAIDs, SSRIs and steroids may point to PUD | Alcohol (risk of liver disease and variceal bleeding) moking (peptic ulcer disease) 

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= Ph. Examination » Reduced level of consiousness < Pale and 012۳0۳0۷ ‏سرد ومرطوب‎ ( ۶ Cool peripheries Tilt test* )TPruise rate >20 bpm: or Wt systolc blood pressure >10 mmHg) *postural changes should be elicited by allowing the patient to sit up with the legs dangling for 5 minutes.A fall in blood pressure of more than 10 mm Hg or an elevation of the pulse of more than 20 beats/min again reflects at least a 20% blood loss » Tachcardic and thready pulse » Hypotensive with narrow pulse pressure » The oropharynx and nose should always be examined (simulate distal source) » Tenderness on abdominal examination may point to underlying CAUSE e.g. Epigastric [} peptic ulcer < Stigmata of chronic liver disease (palmer erythema,, dupuytrens contracture, asterixis, jaundice, spider naevi, gynacomastia, shifting dullness/ascites) rectal examination may reveal melaena, dark red blood, bright red blood 

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owe gesoneaina hemormaze Fon ac rye sora 1 | ‘Upper Gi bles conn ds ‏كا‎ ] ee 1 ۱-1 ‏م‎ ‎Diagnostic. Non-Diagnostic 1 1 مم و مدق | موه و ‎operon‏ FIGURE 46-2 Localization “early” endoscopy (within 24 hours) » Increasing data, however, have shown that an NG tube is unreliable in localizing the bleeding site, and virtually all patients with significant bleeding should undergo upper endoscopy for direct 

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Presentation » Acute Upper GI bleeding presents as: " Haematemesis (vomiting of fresh blood) ‘ Coffee ground vomit (partially digested blood) | Melaena (black tarry stools) ~ If bleeding very brisk and severe) fresh rectal bleeding 7 If bleeding very slow and occult] iron deficiency anaemia 

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Causes of Upper GI Hemorrhage Gastric and 30%- Gastroesophageal varices >90% duodenal ulcers 40% Gastritis or 20% Hypertensive portal <5% duodenitis gastropathy Esophagitis 5%-10% Isolated gastric varices Rare Mallory-Weiss tears 5%-10% Arteriovenous 5% malformations ‏لاما ف مس ساف لعفب اوعس فل‎ rick Por (Dieulafoy lesion.) 2 ۱ ‏وس‎ ‎Tumors 2% ceonnt Por ww» BO% of bows Others 5% = 

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Management (Non- variceal) 1) Emergency resuscitation as already described 2) Pharmacology PPI (infusion) - pH >6 stabilises clots and reduces| risk of re-bleeding following endoscopic haemostasis If H pylori positive then for eradication therapy Stop{] NSAIDs/SSRIs/aspirin/clopidogrel/warfarin/steroids if safe to do so (risk:benefit analysis) 

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Management (Non- variceal) 3) Endoscopy Urgent EGD (within 24h) diagnostic & therepeutic ‘Treatment administered if active bleeding, visible vessel, adherent blood clot ‘Treatment options(endoscopic hemostatic therapy ) injection (adrenaline), thermal therapy {heater probes, monopolar or bipolar electracoagulaton, and laser or argon plasma coagulation (APC)} clipping " If re-bleeds then arrange urgent repeat EGD (successful in 75% of patients) 25100 emergent surgery 

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| £5 sire ponte usw Boscng 1 1 600 class featon (a bla tb gee PM nace UR Endoscopic Findings and Rebleeding Risks in Peptic Ulcer Disease Grtela وه ‎SK ۳‏ ات ...ان تج ۳ امسا وب ‎ctv, nonpulsatile bleeding High ASE‏ أن ات وا ‎Norleedngvistlevesse High‏ Adherert clot Intermediate Ulcer with blak spot Low Clean, notesing veer bed Low **In adherent clot (Forrest IIb), the clot is moved and the underlying lesion evaluate: Ged b Gre lla Grate lb Grade lke ‏اانا‎ 

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Endoscopic Clipping 

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Management (Non- variceal) 4) Surgical management (10%) Reserved for patients with failed medical management (ongoing bleeding despite 2x OGD) ۶ 1) Indications: 1) massive hemorrhage unresponsive to endoscopic control ‎transfusion requirement of >6 -8 units of blood, despite attempts at endoscopic‏ رد ‎control.‏ ‎2) lack of availability of a therapeutic endoscopist, ‎) Jack of availability of blood for transfusion ‎recurrent hemorrhage after one or more attempts at endoscopic control,‏ رد ‎| repeat hospitalization for bleeding ulcer ‎concurrent indications for surgery such as perforation or obstruction, malignancy‏ زر ‎۶ ۱۱( Secondary or relative indications: ‎“rare blood type or difficult crossmatch, refusal of transfusion, ‎“shock on presentation, ‎“advanced age, ‎“severe comorbid disease, bleeding chronic gastric ulcer for which malignancy is a concern ‎ ‎ 

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Management (Non- variceal) 4) Surgery > Ill) high risk patient (closer monitoring and possibly considered for early operation ) » Shock and a low hemoglobin level at presentatior 6 ۶ Blood requiring > >4units in 24h >Bunits in 48h Peptic Ulcer Disease ~ >60 years of age, » Endoscopic finding: > high-risk lesions( erosion of artery) eg: > posterior duodenal ulcer (gastroduodenal a. ) > lesser curvature gastric ulcer (left gastric a. ( > Forrest classification -Ilb (Active bleeding or visible vessel) > ulcers >2 cm in diameter 

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Management (Non- variceal) > 4) Surgery » Operation for Bleeding Peptic Ulcer | Duodenal Ulcer 1. oversewing (+ Vagotomy) 2. Vagotomy + Antrectomy * +subsequent treatment for H. pylori infection 4 Gastric Ulcer 1. oversewing & biopsy (30% rebleeding) Distal gastric resection 2. 3. ulcer excision+Vagotomy and Drainage Patients who are in shock or medically unstable should not hav gastric resection. a 

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Management (Non- variceal) » vagotomy سس ‎setecive‏ © لاقم العام امعم ‎selene,‏ 0۳ ‎cet)‏ هه 

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Management (Non-variceal) 4 Stress gastritis multiple superficial erosions of the entire stomach, most commonly in the body ~ pathogenesis: acid and pepsin injury + ischemia (hypoperfusion states), in critically ill patients * although NSAIDs produce a similar appearance when stress ulceration is associated with major burns [)Curling ulcers ~ management: acid suppressive therapy (often successful) octreotide or vasopressin, endoscopic therapy angiographic embolization. surgical choices included vagotomy and pyloroplasty with oversewing ar-total gastrectomy. 

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Management (Non- variceal) Dieulafoy lesion. » vascular malformations (in lesser curve within 6 cm of the g.e junction) » pathogenesis: unusually large vessels (1 to 3 mm)[Jerosion of the gastric mucosa[] massive bleeding » Management: endoscopic control angiographic embolization surgical intervention (prior endoscopic tattooing )f gastrostomy +oversewing partial gastrectomy 

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Variceal Bleeding 0 Suspect if upper GI bleed in patient with history ot chronic liver disease/cirrhosis or stigmata on clinical examination Liver Cirrhosis results in portal hypertension and development of porto-systemic anastamosis Sites of porto-systemic anastamosis include: Oesophagus (P= eosophageal branch of L gastric v, S= oesophageal branch of azygous v) Umbilicus (P= para-umbilical v, S= infeior epigastric v) Retroperitoneal (P= right/middle/left colic v, S= renal/supra- renal/gonadal v) Rectal (P= superior rectal v, S= middle/inferior rectal v) Furthermore, clotting derrangement in those with chronic liver disease can worsen bleeding 

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Management of Variceal bleeds » Emergency resuscitation as already described » Drugs Somatostatin/octreotide - vasoconstricts splanchnic circulation and reduces pressure in portal system Terlipressin - vasoconstricts splanchnic circulation and reduces pressure in portal system ۲ Propanolol - used only in context of primary prevention (in those found to have varices to reduce risk of first bleed) » Endoscopy Band ligation !) Injection sclerotherapy 

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Management of Variceal bleeds * Balloon tamponade - sengstaken-blakemore tube Rarely used now and usually only as temporary measure if falled endoscopic management » Radiological procedure - used if failed medical/endoscopic Mx Selective catheterisation and embolisation of vessels feeding the varices TIPSS procedure: transjugular intrahepatic porto-systemic shunt shunt between hepatic vein and portal vein branch to reduce portal pressure and bleeding trom varices} performed i failed medical and endoscopic management Can worsen hepatic encephalopathy ۶ Surgical Surgical porto-systemic shunts (often spleno-renal) Liver transplantation (patients often given TIPP/surgical shunt whilst awaiting this) 

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۳۶ 6 Esophageal Gastric ال ‎Nasal‏ اا ‎Peavey‏ ل ير ار ا ‎Pharynx‏ ‎‘Esophagus‏ ‏عم ‎aspiration ©‏ ‎port stomach‏ Esophageal baloon ۳ © Gastric baloon (inflated) | Gast content aspiration openings Genny 00 Debor 

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Lower Gl Bleeding robes 

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Lower GI bleeding » Lower Gl bleed refers to bleeding arising distal to the 1 ۳ 1 ligament of Treitz (DJ flexure) h / Less common than upper GI bleeding Although this includes jejunum and ileum bleeding from these sites is rare (<5%) Vast majority of lower GI bleeding arises from colon/rectum/anus 

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Presentation » Lower GI bleeding presents as : ° hematochezia " Bright red blood - more distal bleeding point(e.g. rectum, anus) 7 Dark red blood- more proximal bleeding point (e.g. Distal small bowel, colon) “ Old clot * melena (slower or from a more proximal source) * rectal bleeding maybe: mixed or separate from the stool * mixed suggests more proximal bleeding separate from the stool " coating the stool (colonic/rectal), * in the toilet water (anal), * on wiping (anal) Passed with motion or alone (if alone suggests heavier bleeding) ding very slow and occult then can present with iron deficiency 

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TABLE 46-3 Differential Diagnosis of ‏تلا کی ات یت‎ Beet SMALL BOWEL BLEEDING 5% ‘Angiodyspiasias Erosions or ulcers (potassium, NSAIDs) Crohns disease Radiation Mecke!'s diverticulum Neoplasia ‘Acrtoenterc stule 95% 0%-40% 58-15% 510% 10% 58% 3 354 3 1 15 10 COLONIC BLEEDING Diverticular disease Poorectal disease Ischemia Neoplasia Infectious colts Post polypectomy Inflammatory bowel disease Angiodyspiasia Radiation colits or proctitis her Internal hemorrhoid External hemorrhoids Ethiology Intussusception In the pediatric population Meckel’s diverticulum in the young adult more than one potential source in 40% Slayer eee vaca بين ته سيو وی سیر و 7 

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Diagnosis and managemen Ralls lover gastiomissinal inaaing | YS | Assess tor anorectal outlet bieeaing ۲ ‏ا ل‎ ule out Upper Gi Bleeding, er’ 5 ‏ماه‎ ar EGD po و 

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Diagnosis and management » Emergency resuscitation as already described © NGT(...Jjreturn of bile?) » Endoscopic “ OGD (15% severe acute rectal bleeding Tupper GI source!) " Colonoscopy (within24h) > rapid bowel preparation (over 4-6 hours) 4‘ diagnostic and therepeutic (injection, diathermy, clipping) ropriate for minimal to moderate bleeding 

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RBC scan Nuclear Scintigraphy (Radionuclide Scanning /RBC scan) » technetium labelled own red blood cells reinjected: diagnostic only » Determines site of bleeding only (not cause) » detect bleeding as slow as 0.1 mL/min * more than 90% sensitive (most sensitive but least accurate method) + a guide for angiography 

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Diagnosis and management ~ Radiological CT angiogram diagnostic only (non-invasive ,extremely sensitive as little as 0.1 mL/min) Determines site and cause of bleeding In he ‏لحي‎ )0( xl OP recererveten (©), Sige oP ‏رسمه ( 0 منم یط مه مدا سوت‎ Brow bar opie cri (arrose © ). 

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Diagnosis and management » Mesenteric Angiogram | diagnostic and therepeutic (but invasive) ‘ can detect hemorrhage in the range of 0.5 to 1.0 mL/min / ۱ | Determines site of bleeding and ‏تسيا‎ ‎allows embolisation of bleeding vessel (Can result in colonic ischaemia - reserved for patients whose underlying condition precludes surgical therapy) 5 significant risk of complications (hematomas, arterial thrombosis, Contrast dye reactions, and acute renal 

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Management > Surgical » Last resort in management as very difficult to determine bleeding point at laparotomy Segmental colectomy - “ where site of bleeding is known Subtotal colectomy - 0 very rarely be required in a patient who is hemodynamically unstable with ongoing colonic hemorrhage of an unknown source » Beware of small bowel bleeding - always embarassing when bleeding continues after large bowel removed ! (by intra-operative colonoscopy/enteroscopy) » Beware of rectal bleeding (by anoscopy/rectoscopy) 

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Management Flow Chart for Severe lower GI bleeding Resuscitate OGD (to exclude upper Gi cause for severe PR bleeding) CT angiogram (to identify Mesenteric angiogram (to site and cause of | —__> _ identify site of bleeding and bleeding) treat bleeding by embolisation — of vessel). <7 

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Management » As 85% of lower Gl bleeds will settle spontaneously the interventions mentioned on previous slide are reserved for: ' Severe/Life threatening bleeds » In the 85% where bleeding settles spontaneously Outpatient Department investigation is required to determine underlying cause: | Endoscopy: flexible sigmoidoscopy, colonoscopy 0 Barium enema 

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The End Ref: 1)Dr. Mohammad Mobasheri (https://www.sgsu.org.uk/pageassets/societies/society/ois/resources/GI-bleed. ppt) 2)Schwartz's Principles of Surgery 2014 3)Sabiston 2016 .