GI bleeding
GI bleeding
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Term:
Hematemesis : bloody vomitus
Melena: tarry stool passage
Maroon : tarry- bloody stool
passage
Hematochezia: bloody stool
passage
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GI bleeding
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Bleeding > 5~10ml
Æ OB (+)
Bleeding > 50~100ml
Æ tarry stool
Bleeding above Treitz lig.Æ hematemesis
Bleeding above ileocecal valve Æ tarry
stool
Bleeding below ileocecal valve Æ fresh
bloody stool
1. R’t side colon Æ blood mixed inside
the stool
2. L’t side colon Æ blood coated outside
the stool
3.rectosigmoid Æ fresh bloody discharge
Common cause of acute UGI
bleeding
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Erosive, hemorrhagic gastropathy ( aspirin,
other NSAIDs) (3~11%)
Ulcer: Gastric or duodenal ulcer (35~62%)
Mallory-Weiss tear (4~13%)
Varices – portal hypertensive
gastropathy(4~31%)
Arteriovenous malformation
Maligancy (1~4%)
No source identified ( 7~25%)
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Common cause of acute LGI
bleeding
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1.
2.
3.
4.
5.
< 55 y/o
Anorectal disease
( hemorrhoid,
fissures)
Colitis (IBD,
infection)
Diverticulosis
Polys, cancer
Angiodysplasia
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1.
2.
3.
4.
5.
> 55 y/o
Anorectal disease
(hemorrhoid, fissures)
Diverticulosis
Angiodysplasia
Polys, cancer
Enterocolitic
(ischemic, infection,
IBD, radiation)
Evaluated blood loss
Blood loss %
(ml)
BP
HR
S/S
0~500
0~10%
No change
No change None
500~1000
10~20%
<120bpm
Peripheral
cool
1000~1750
20~35%
Posture
hypotension
90<SBP<120
>120bpm
+oliguria
>1750
>35%
SBP<90
<60bpm
+ shock
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Peptic ulcer
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Phase of GU, DU
Active stage:
A1: well-defined, deep ulceration;
marked bleeding from the ulcer base
marginal welling
A2: stop bleeding
Healing stage (H): H1,H2,H3
Scarred stage (S): S1( red scar), S2(white
scar)
Forrest Grade I
4
Forrest Grade
IIA
IIB
Forrest Grade
IIC
III
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Peptic ulcer
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Risk of recurrent bleeding
SRH: stigmata of recent hemorrhage
exposure vessels
adherent clots
arterial spurting or oozing
Endoscopic therapy
HSE (hypertonic saline and epinephrine),
bipolar electrocoagulation, heat probe,
hematoclip, APC
Risk factors
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> 60 y/o age
More than one comorbid illness
Blood loss > 5 units
Shock on admission
Bright-red hematemesis with hypotension
Coagulopathy
Large ( > 2cm) ulcer
Recurrent hemorrrhage ( within 72 hrs)
Requirement for emergency surgery
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GI bleeding – goals of
management
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Hemodynamic stable
Active bleeding stopped
Recurrent bleeding prevented
Hemodynamic stable
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Pulse pressure > 30 mmHg
SBP > 110 mmHg
DBP > 70 mmHg
HR < 100 bpm
Good skin turgor
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UGI bleeding -- management
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Restoration of intravascular volume
Hct: > 25%
Hct: > 30% in cardiac or pulmonary dz
Æ Vasopressors indicated ?
Vol resuscitation end-point
CVP=15 mmHg
Wedge pressure = 10 to 12 mmHg
Blood lactate < 4 mmol/ L
Base deficit –3 to +3 mmol/L
C.I. > 3L/min/m2
UGI bleeding -- management
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O2 consumption ( V O2) = Q * Hb *
(SaO2-SvO2)
Volume deficit = % loss * normal blood
volume
Males – 70 ml / kg or 3.2 L/ M2
Females – 60 ml / kg or 2.9 L/ M2
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UGI bleeding -- management
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Correction of coagulopathy
Initial infusion: FFP 2~4 u
Protamine infusion ( 1mg antagonizes
=100 u of heparin)
Vit-K (10 mg,IM): warfarin, hepatobiliary
disease
PLT transfusion: > 50000/cumm
Airway protection
PUD-- treatment
Antacids
drug interaction – Tetracyclines,
Quinolone, ketoconazole,
„ Peptic ulcer ( with evidence)
H2-blocker: Ranitidine (Zantac, Quicran)
side effect: headache, lethargy, confusion,
depression
drug interaction: Cimetidine Æ
β-blockers, Metformin, Phenytoin, Procainamide,
Theophylline, TCA and Warfarin.
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PUD -- treatment
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Peptic ulcer ( with evidence)
PPIs: Omeprazole ( Losec)
-- elder
-- intractable bleeding
-- combine with theophylline
Raise intragastric pH to 6~7
Enhance clot stablity decreased further
bleeding (but not mortality)
UGI bleeding -- treatment
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Variceal hemorrhage
1. Stabilize hemodynamic ( crystal with colloid
supply)
2. Airway patent
3. NG decompression of early detect of rebleeding
4. Octreotide: Somatostatine (Somatosan)
2Amp add N/S to 50ml Æ loading 2ml and
maintain 2ml/ hr
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UGI bleeding -- treatment
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Variceal hemorrhage
5. Endoscopic therapy with ligation
6. Sclerotherapy
7. Balloon tamponade Sengstaken-Blakemore
tube
8. Avoid hepatic encephalopathy
9. Prophylaxis: reduce portal hypertensoion
-- Inderal, nitrates
10. Surgery
Recurrent bleeding prevented
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Eradication of H.P Æ rebleeding rate < 5%
Avoid NSAIDs
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acute UGI bleeding
if no hemodynamic change and
no dropping Hb:
routine endoscopy
ulcer
hemodynamic change and
dropping Hb:
urgent endoscopy
EV
active bleeding
or visible vessel
adherent clot or flat
,pigmented spot
Endoscopic therapy
no Endoscopic therapy no Endoscopic therapy ICU for 1~2 day
ward for 2 to 3 days
ICU for 1 day
ward for 1 to 2 days
ward for 3 days
clear base
discharge
ligation or
sclerotherapy
Mallory-Weiss tear
active bleeding
no active bleeding
Endoscopic therapy
no Endoscopic therapy
ward for 1~2 days
discharge
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