GIT Bleeding:
VGIB
LGIB
Dr. Mohamed Shekhani
CABM-FRCP
1
Variceal bleeding:
Common lethal complication of
cirrhosis(50% at diagnosis, 7%/year),
particularly with:
Esophageal varices
Portal hypertensive
Biliopathy
Types
Clinical decompensation
(i.e., ascites, encephalopathy,a previous
episode of hemorrhage, or jaundice).
Gastric fundal varices
Or GEV
Portal hypertensive
gastropathy
1
Variceal bleeding:
Common lethal complication of
cirrhosis(50% at diagnosis, 7%/year),
particularly with:
Primary prophylaxis
to prevent a first
episode of VH.
MANAGEMENT
Clinical decompensation
(i.e., ascites, encephalopathy,a previous
episode of hemorrhage, or jaundice).
Treatment of the acute
bleeding episode:
Mortality 15-20%
Secondary prophylaxis
(prevention of recurrent VH).
60%/year.
VARICES INCREASE IN DIAMETER PROGRESSIVELY
Varices Increase in Diameter Progressively
No varices
Small varices
7-8%/year
Merli et al. J Hepatol 2003;38:266
Large varices
7-8%/year
PROGNOSTIC INDICATORS OF FIRST VARICEAL HEMORRHAGE
Variceal hemorrhage
Predictors of hemorrhage:
 Variceal size
 Red signs
 Child B/C
NIEC. N Engl J Med 1988; 319:983
Varix with red signs
Class A: 5-6
Class B: 7-9
Class C: 10-15
2
Portal HT Risk stratification
Decompensated liver cirrhosis:
Child-Pough or MELD class
( Model of end stage liver
disease)
Gastroesophageal varices.
Varices or colaterlas detected on
imaging studies as Abd
U/S,EUS,Dopler
Portal
HT
Risk stratification
Plateletes/spleen maximal
bipolar diameter<909
Varices on VCE
Fibroscan measuring liver
stiffness predicts portal HT
HVPG: gold standard&Best
predictor of PHT & EV, but
invasive &not widely available.
>5 mm Hg PHT
>10 mm Hg clinically significant
Primary prophylaxis of bleeding eso varices:
Propranolol 20mgm*2
untill PR 55/min
Indefinite
Nadolol 40mgm once daily
Untill PR 55/min
Indefinite
Propranolol
EBL
Sessions every
4 weeks
Or
Endoscopic band ligation
Evey 4 weeks untill total obliteration
Follow up: 3 /12 for 1 year, yearly
PP of EV
bleed
Nadolol
FU OGD after
Obliteration:
3 MONTHLY
For 1 year
Then
Yearly
Indefintely.
3
Management of acute variceal bleeding:
Antibiotics:
Ceftriaxone
Ciprofloxacin
5 days
Vasoconstrictor
Octreotite
Somatostatin
Telipresin
5 days
Endoscopic
Intervention
EBL
Sclerotherapy
Acute variceal
Bleeding.
Cyanoacrylate
Injection
Sclerotherapy
For gastric
Varices.
Sigestaken
Tube temponade
Esophageal
stenting
4
Secondary prophylaxis( prevention of
recurrent) of bleeding EV:
5
Propranolol
Same as for primary prophylaxis.
propranolo
Nadolol
Isosorbide
Nadolol
Same as for primary prophylaxis.
Isosorbide dinitrate
10 mgm*10-20 mgm*2
EBL
Same as for primary prophylaxis.
Cyanoacrylate injection
sclerotherapy or IR for gastric
varices not EBL.
Secondary prophylaxis
EBL for
EV
Cyanoacrylate
for GV
Interventional
Radiology for
GV
Portal Hypertensive Gastropathy
Definition:
Predictors of its presence
•PHT- related ectatic gastric mucosal vessels mostly in fundus
& body of the stomach.
GEV , Child class& prior variceal endoscopic therapy
Prsentation
Chronic blood loss leading to IDA rather than acute bleeding
Treatment:
Iron supplementation;BB,Shunt therapy(surgeryorTIPS)
Prophylaxis
Same.
14
Acute Lower Gastrointestinal Bleeding
Bleeding distal to the ligament of Treitz for <less than 3 days.
The colon is the most common site of bleeding.
The incidence increases with age, with mean of 63-77 years.
LGIB accounts for 20% of all episodes of GIB.
Most episodes of LGIB will stop without intervention.
The most common causes of acute LGIB are diverticulosis, angiectasia,
ischemic colitis, perianal disease.
The most frequent causes of chronic LGIB are neoplasms, angiectasia, IBD.
Causes in Our locality:
Perianal diseases(piles/Fissure)
IBD(UC>CD)
Infectious colitis
Neoplasms(adenoma or cancer)
Solitary rectal ulcer syndrome
(SRUS)
Meckel’s diverticulum.
Ischemic colitis.
Angiodysplasia
Hemorrhoids/ fissures:
Piles
1
2
Bleeding after/or with
defecation
Fissure
Pain & bleeding with
defecation
Careful perianal exam+ anoscopy
assist in the diagnosis
Acute LGIB: Management algorythm
Initial evaluation/ resuscitation
Triage to OP vs Ward vs ICU
Mild scanty bleeding
Anorectal pathology
susspected
Rigid Anoscopy or
sigmoidoscopy to
confirm diagnosis
Outpatient
management
Anorectal pathology(piles/fissure) is the most common pathology in our locality
But this should be diagnosed on solid basis not to miss serious pathologies as IBD or
cancer.
Acute LGIB: Management algorythm
Severe bleeding
Severe exanguinating
bleeding
Emergency
angiography for
bleeding control by
gel form or coils
Or emergency surgical
consult.
If emergency angio
succeeded just
observe for
recurrence but if
fails refer to surgery
SURGERY
Severe exanguinating bleeding needs urgent action either emergency surgery or
emegency therapeutic interventional radiology.
Acute LGIB: Management algorythm
Moderate severe bleeding
Consider NGT aspirate
Bloody NGT aspirate
Risk for UGIB
OGD
If +ve treat
accordingly
Most of the cases of LGIB fall in this category & require 1st NGT aspiration & if
+ve bloody aspirate , urgent upper GIT endoscopy.
Acute LGIB: Management algorythm
Moderate severe bleeding
NGT not done or –ve
aspirate
Polyethelene
glycol(PEG) solution
laxative for
preparation for
emergency
colonoscopy in few
hours.
Colonoscopy within
12-24 hours
Manage according to
colonoscopic findings
If the NGT aspirate is not bloody or NGT was not inserted, urgent prep with PEG
is needed for urgent colonoscopy within12-24 hours.
Acute LGIB: Management algorythm
Moderate severe bleeding
On colonoscopy
bleeding site &
cause is identified
so treat as
appropriate.
If the colonoscopy identifies the site/cause of bleeding the problem is solved
Acute LGIB: Management algorythm
Moderate severe bleeding
If On colonoscopy
there is visual
impairment because
of ongoing bleeding
Angiography.
If on colonoscopy there was visual impairment due to bloody field urgent
angiography is indicated fordiagnosis & therapy.
Acute LGIB: Management algorythm
Moderate severe bleeding
On colonoscopy
bleeding site not
identified but
bleeding had
stopped
OGD
Or
Repeat colonoscopy
Or
SI evaluation
/Or
Others( RBC
scan,angiography)
for rebleeding.
If on colonoscopy the bleeding had stopped & no lesion was identified, upper
GI endoscopy is considered(if had already been done) or RBC scan/angigraphy
Is done fordiagnosis/treatment specially if bleeding recurred.