GI BLEEDING - NEVADA UNIVERSITY

8/7/2019 GI BLEEDING - NEVADA UNIVERSITY

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Gastrointestinal BleedingGastrointestinal Bleeding

HematemesisHematemesis-- Vomiting of bright redVomiting of bright redbloodblood

usually represents bleeding proximal tousually represents bleeding proximal tothe ligament of Treitzthe ligament of Treitz

HematocheziaHematochezia-- bright red blood perbright red blood per

rectumrectum indicates a lower GI source of bleedingindicates a lower GI source of bleeding

Blood has a laxative effect so with massiveBlood has a laxative effect so with massivebleeding the stool may be bright redbleeding the stool may be bright red


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Blood streaks on the stool indicates anal outletBlood streaks on the stool indicates anal outletbleedingbleeding

Blood mixed with stool indicates bleeding sourceBlood mixed with stool indicates bleeding sourcehigher than the rectumhigher than the rectum

Blood with mucus indicates an infectious orBlood with mucus indicates an infectious orinflammatory diseaseinflammatory disease

Currant jellyCurrant jelly--like material indicates vascularlike material indicates vascularcongestion and hyperemia (intussusception orcongestion and hyperemia (intussusception ormidgut volvulus)midgut volvulus)


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MaroonMaroon--colored stools indicate voluminouscolored stools indicate voluminousbleeding proximal to the rectosigmoid areableeding proximal to the rectosigmoid area

Melena, passage of black, sticky (tarry)Melena, passage of black, sticky (tarry)stools suggests upper GI tract bleeding,stools suggests upper GI tract bleeding,but can be as distal as the right colonbut can be as distal as the right colon

Hematemesis suggests a large bleed withHematemesis suggests a large bleed withpossible recurrence, melena alonepossible recurrence, melena aloneindicates less voluminous bleedingindicates less voluminous bleeding


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Causes of Upper GI BleedingCauses of Upper GI Bleeding

CommonCommon

NasopharyngealNasopharyngeal

bleedingbleeding

Erosive EsophagitisErosive Esophagitis

Peptic ulcerPeptic ulcer

Gastritis (H. pylori)Gastritis (H. pylori) MalloryMallory--Weiss tearWeiss tear

Prolapse gastropathyProlapse gastropathy

Less CommonLess Common

Bleeding disordersBleeding disorders

Duplication cystDuplication cyst

Foreign bodyForeign body

Tube traumaTube trauma

Vascular malformationVascular malformation Esophageal varicesEsophageal varices


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Causes of Lower GI BleedingCauses of Lower GI Bleeding

CommonCommon

Anal fissureAnal fissure

Infectious colitisInfectious colitisSalmonella, Shigella,Salmonella, Shigella,Campylobacter, C.diffCampylobacter, C.diff

Inflammatory bowelInflammatory boweldiseasedisease

IntussusceptionIntussusception

Upper GI sourceUpper GI source

Less CommonLess Common

Meckels diverticulumMeckels diverticulum

Duplication cystDuplication cyst

HirschsprungsHirschsprungsenterocolitisenterocolitis

Gangrenous intestineGangrenous intestine Vascular malformationVascular malformation


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Clinical Findings in PUDClinical Findings in PUD

Neonatal PeriodNeonatal Period Gastric ulcers are more common thanGastric ulcers are more common than

duodenal ulcers in neonatesduodenal ulcers in neonates

Spontaneous Perforation is a moreSpontaneous Perforation is a morecommon presentation than bleedingcommon presentation than bleeding

Frequently associated with:Frequently associated with:

Hypoxia, Sepsis, RDS, CNS disorderHypoxia, Sepsis, RDS, CNS disorder


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Infants and ToddlersInfants and Toddlers Presenting symptoms:Presenting symptoms:

VomitingVomiting

Poor feedingPoor feeding

Irritability during and after eatingIrritability during and after eating

Abdominal distentionAbdominal distention

Hematemesis, melenaHematemesis, melena

Commonly associated with underlyingCommonly associated with underlyingdisease in this age groupdisease in this age group


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PrePre--SchoolersSchoolers Periumbilical or generalized abdominalPeriumbilical or generalized abdominal

painpain

Vomiting after eatingVomiting after eating

Nocturnal or early morning painNocturnal or early morning pain

Gastric ulcers are as common as duodenalGastric ulcers are as common as duodenalulcersulcers

Primary ulcers are as common asPrimary ulcers are as common assecondary ulcerssecondary ulcers


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School AgeSchool Age Male: Female ratio is 3:1Male: Female ratio is 3:1

Burning epigastric painBurning epigastric pain

Nocturnal painNocturnal pain

Melena, hematemesis, fecal occult bloodMelena, hematemesis, fecal occult blood

Primary ulcers are more common thanPrimary ulcers are more common thansecondary ulcerssecondary ulcers


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Pathophysiology of GI BleedingPathophysiology of GI Bleeding

Mucosal lesionsMucosal lesions

AcidAcid--peptic disease, drugpeptic disease, drug--induced (NSAIDs),induced (NSAIDs),Infectious (H. pylori), inflammatory bowel dzInfectious (H. pylori), inflammatory bowel dz

Portal hypertensionPortal hypertension

Esophageal varices, hypertensive gastropathyEsophageal varices, hypertensive gastropathy

CoagulopathyCoagulopathy -- Hemophilia, hepaticHemophilia, hepaticcoagulopathy, CHF w/hepatic congestioncoagulopathy, CHF w/hepatic congestion

Vascular lesionsVascular lesions -- hemangiomashemangiomas


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Causes and Effects of HCauses and Effects of H++ IonIon

BackdiffusionBackdiffusionLowflow states Drugs, EtOH Stress H. pylori Bile Reflux

Mucosal Barrier Break

Parietal Cells

Release of histamine + Vasodilatation

Increased HCl and Pepsin Secretion

H+


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Peptic Ulcer DiseasePeptic Ulcer Disease

Diagnostic EvaluationDiagnostic Evaluation History (medications, family history)History (medications, family history)

Physical exam (include Hemoccult)Physical exam (include Hemoccult)

CBC, type & screen for GI bleedingCBC, type & screen for GI bleeding

PT, PTTPT, PTT

H. pyloriH. pylori antibody, fasting gastrin levelantibody, fasting gastrin level Upper GI SeriesUpper GI Series

EGDEGD


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Indications for EGDIndications for EGD

Hematemesis, Melena, Heme (+) stoolHematemesis, Melena, Heme (+) stool

Severe pain, weight lossSevere pain, weight loss

Unexplained anemiaUnexplained anemia

Symptoms persist despite trial ofSymptoms persist despite trial ofantisecretory therapyantisecretory therapy

Evaluation of abnormal UGI seriesEvaluation of abnormal UGI series

Evaluation of status ofEvaluation of status of H. pyloriH. pylori


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Case #1Case #1 UGI BleedingUGI Bleeding

12 YOWF with S/P splenectomy 2 yr ago for12 YOWF with S/P splenectomy 2 yr ago forEvans syndromeEvans syndrome

Weakness, pallor, melana x 2 daysWeakness, pallor, melana x 2 days ExamExam HRHR-- 128, BP128, BP--86/54, tachycardic, pale,86/54, tachycardic, pale,

abdomen nontender, nondistended, noabdomen nontender, nondistended, nohepatomegalyhepatomegaly

LabLab H/H=6.8/19.1, WBC, 5.7; platelets,H/H=6.8/19.1, WBC, 5.7; platelets,115,000, PT=13.2 sec; AST, 38; ALT, 45; T.bili,115,000, PT=13.2 sec; AST, 38; ALT, 45; T.bili,0.5; alk phos, 2270.5; alk phos, 227


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Esophageal varicesEsophageal varices


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Case #2Case #2 UGI BleedingUGI Bleeding

11 YOWM previously healthy with 1 day h/o11 YOWM previously healthy with 1 day h/ofever, vomiting and diarrheafever, vomiting and diarrhea

Emesis x 6 over past 24 hr, w/blood last 2 timesEmesis x 6 over past 24 hr, w/blood last 2 times ExamExam HRHR-- 84, BP84, BP--116/74, abdomen116/74, abdomen

nontender, nondistended, no hepatomegalynontender, nondistended, no hepatomegaly

LabLab H/H=13.8/39.1, WBC, 8.7; platelets,H/H=13.8/39.1, WBC, 8.7; platelets,235,000, PT=12.2 sec235,000, PT=12.2 sec


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Prolapse GastropathyProlapse Gastropathy


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Meckels ScanMeckels Scan

99m99mTcTc--Pertechnetate ScanPertechnetate Scan -- injected IV andinjected IV andaccumulates in gastric tissueaccumulates in gastric tissue -- RLQ uptakeRLQ uptake

is diagnostic of Meckels diverticulumis diagnostic of Meckels diverticulum False (+)False (+) -- bleeding lesions such asbleeding lesions such as

Crohns disease, intussusception,Crohns disease, intussusception,hemangioma, PUDhemangioma, PUD

False (False (--)) -- Barium, bladder overdistention,Barium, bladder overdistention,no gastric mucosa in diverticulumno gastric mucosa in diverticulum


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99m99mTcTc-- Labeled Red Cell ScanLabeled Red Cell Scan

99m99mTcTc--sulfur colloid is added to a sample ofsulfur colloid is added to a sample ofthe patients blood cells and rethe patients blood cells and re--infused IVinfused IV--

patient is scanned with gamma camerapatient is scanned with gamma camera

HalfHalf--life is short (2.5 min) so that after 10life is short (2.5 min) so that after 10minutes only 10% is left in the circulationminutes only 10% is left in the circulation

99m99mTc accumulates at the bleeding site andTc accumulates at the bleeding site andlights up on scanlights up on scan -- can detect 0.1 ml/mincan detect 0.1 ml/min


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GI BleedingGI Bleeding -- TreatmentTreatment

ABCsABCs -- protect airway with hematemesis inprotect airway with hematemesis inan obtunded patientan obtunded patient

IV accessIV access -- two lines (0.9% NS in one line,two lines (0.9% NS in one line,PRBCs not compatible with dextrose)PRBCs not compatible with dextrose)

Transfuse for Hgb < 8 w/active bleedingTransfuse for Hgb < 8 w/active bleeding

NG lavageNG lavage Antacids (1 ml/kg up to 30 ml q 2 hr)Antacids (1 ml/kg up to 30 ml q 2 hr)

PPI 2 mg/kg loading dose, then 1PPI 2 mg/kg loading dose, then 1mg/kg/day IVmg/kg/day IV


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Drug Efficacy in Healing UlcersDrug Efficacy in Healing Ulcers

DrugDrug RegimenRegimen Ulcers HealedUlcers Healed

H2RAH2RA 4 weeks4 weeks 8 weeks8 weeks

CimetidineCimetidine 40 mg/k/d40 mg/k/d 80%80% 90%90% RanitidineRanitidine 44--8 mg/k/d8 mg/k/d

FamotidineFamotidine 11--2 mg/k/d2 mg/k/d

PPIsPPIs

OmeprazoleOmeprazole 0.70.7--3 mg/k/d3 mg/k/d85%85% 95%95% LansoprazoleLansoprazole 0.70.7--4 mg/k/d4 mg/k/d

SucralfateSucralfate 4040--80 mg/k/d80 mg/k/d 75%75% 86%86%


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ATLS Classification of ShockATLS Classification of Shock

ClassClass BloodBlood

LossLoss

BPBP HR HR CapCap

refillrefill

NeuroNeuro

11 150 > 3 sec> 3 sec AlertAlert

33 3030 35%35% DecreasedDecreased >150>150 > 3 sec> 3 sec LethargicLethargic

44 4040 45%45% NotNot

palpablepalpable

>150>150 > 3 sec> 3 sec ObtundedObtunded


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ManagementManagement

Class 1, no anemia, no active bleeding onClass 1, no anemia, no active bleeding onlavage, may be followed up as outpatientlavage, may be followed up as outpatient

Class 2, mild anemia, active bleeding mayClass 2, mild anemia, active bleeding maybe monitored on wardsbe monitored on wards

Class 3 or 4 admit to PICU, central line,Class 3 or 4 admit to PICU, central line,

arterial linearterial line

IVF boluses, transfusion as neededIVF boluses, transfusion as needed


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ManagementManagement

Iced saline?Iced saline? -- with cooling, bleeding timewith cooling, bleeding timeincreases to 3 x control, clotting timeincreases to 3 x control, clotting time

increases up to 60%, and PT can increaseincreases up to 60%, and PT can increaseto 2 x control, and can cause hypothermiato 2 x control, and can cause hypothermia

NG tube is useful to monitor bleeding, butNG tube is useful to monitor bleeding, but

not in treatmentnot in treatment Therapeutic endoscopy (sclerotherapy)Therapeutic endoscopy (sclerotherapy)

useful in variceal hemorrhageuseful in variceal hemorrhage


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ManagementManagement -- OctreotideOctreotide

Somatostatin analogSomatostatin analog -- octreotide has a longeroctreotide has a longerhalfhalf--life than somatostatinlife than somatostatin

Decreases splanchnic blood flow andDecreases splanchnic blood flow andgastrointestinal secretiongastrointestinal secretion

Make a 1Make a 1 QQg/ml dripg/ml drip -- begin drip at a rate of 0.1begin drip at a rate of 0.1QQg/kg/ming/kg/min -- increase to 0.5increase to 0.5 QQg/kg/min untilg/kg/min until

bleeding stops, then wean ratebleeding stops, then wean rate Side effectsSide effects -- nausea, gas, hyperglycemia,nausea, gas, hyperglycemia,

gallstones, elevated liver enzymesgallstones, elevated liver enzymes


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GI BleedingGI Bleeding SummarySummary

Remember your abCsRemember your abCs

IV access if bleeding is significantIV access if bleeding is significant

Plan diagnostic workPlan diagnostic work--up based onup based onpresentationpresentation

Consider nonConsider non--GI causes of blood in the GIGI causes of blood in the GI

tract (e.g., swallowed blood)tract (e.g., swallowed blood)


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Question #1Question #1 An 18An 18--monthmonth--old boy passed a dark red stool four hours ago andold boy passed a dark red stool four hours ago and

another bloody stool during physical examination. He has no fever,another bloody stool during physical examination. He has no fever,vomiting, diarrhea, or constipation. His growth and developmentvomiting, diarrhea, or constipation. His growth and developmenthave been normal. On physical examination, his pulse is 140/min,have been normal. On physical examination, his pulse is 140/min,respiratory rate 24/min, and blood pressure is 86/54 mmHg. Therespiratory rate 24/min, and blood pressure is 86/54 mmHg. Theabdomen is soft and nontender. Rectal examination reveals maroonabdomen is soft and nontender. Rectal examination reveals maroon--

colored stool that is guaiac positive. The remainder of the physicalcolored stool that is guaiac positive. The remainder of the physicalexamination is normal. Gastric aspirate is negative for blood.examination is normal. Gastric aspirate is negative for blood.Laboratory evaluation reveals hemoglobin 8 g/dL, hematocrit 26%.Laboratory evaluation reveals hemoglobin 8 g/dL, hematocrit 26%.Prothrombin time, partial thromboplastin time, and INR wereProthrombin time, partial thromboplastin time, and INR werenormal. After intravenous fluid administration and erythrocytenormal. After intravenous fluid administration and erythrocytetransfusion, which of the following is most likely to be diagnostic?transfusion, which of the following is most likely to be diagnostic?

A. Barium enemaA. Barium enemaB. Meckel radionuclide scanB. Meckel radionuclide scanC. Computerized tomography (CT scan) of the abdomenC. Computerized tomography (CT scan) of the abdomenD. Upper gastrointestinal series with small bowel follow throughD. Upper gastrointestinal series with small bowel follow throughE. Abdominal angiographyE. Abdominal angiography


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Question #2Question #2

A 6A 6--weekweek--old infant has done well since birth until blood and mucusold infant has done well since birth until blood and mucusappeared in the stool for the past 3 days. He is taking his usual fourappeared in the stool for the past 3 days. He is taking his usual fourounces of cowounces of cow--milk formula per feeding without vomiting. He ismilk formula per feeding without vomiting. He ismore irritable during defecation. Physical examination reveals thatmore irritable during defecation. Physical examination reveals that

the abdomen is soft and not distended. The hemoglobin is 10 g/dL.the abdomen is soft and not distended. The hemoglobin is 10 g/dL.

Which of the following is the most likely explanation for the findingsWhich of the following is the most likely explanation for the findingsin this infant?in this infant?

A. Hirschsprung diseaseA. Hirschsprung disease

B. Meckel diverticulumB. Meckel diverticulumC. Anal fissureC. Anal fissureD. CowD. Cow--milk protein colitismilk protein colitisE. Midgut volvulusE. Midgut volvulus

GI BLEEDING - NEVADA UNIVERSITY

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