Pharmacological and surgical management of GI bleeding
Upper GIT bleeding
General Principles
1. Resuscitation/Maintain ABC (airway, breathing, CIRCULATION)
2. Endoscopy (diagnosis and management) – within 24 hours in most patients*
3. Medical intervention
4. Remove risk factors – i.e. NSAIDS
Resuscitation/ Maintain ABC
Emergency management of Acute Gastrointestinal Bleeding
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Rapid history and examination, note age.
Monitor pulse and BP every 30 mins
Take blood for haemoglobin, urea, electrolytes and grouping
Establish IV access
Give blood transfusion/colloid if necessary
o Indications – 1. If in shock: BP<100, pulse >100bpm 2.haemoglobin<10g/dL
Oxygen therapy for shocked patients
Endoscopy
 Urgent endoscopy (after resus) should be done in patients with shock, suspected liver
disease or continued bleeding.
 “Dual modality” endoscopic technique is currently used on lesions– adrenaline injections
and thermal coagulation. Laser therapy and ‘metallic clips’ may also be applied.
o Adrenaline injections (diluted 1 to 10 000): a vasoactive agent that works by
constricting blood vessels and reducing blood flow to area.
o Thermal coagulation: a heat probe applies direct pressure and heat to stop bleeding.
 These methods effective, but re-bleeding still occurs in 20% within 72 hours.
 NB: acute oesophageal varices are mainly treated with band ligation and sclerotherapy
(sclerosant solutions stop bleeding by causing necrosis, thrombosis and inflammation of
injected sites)
Medical Intervention
 Vasopressin (synthetic analogue – terlipressin), somatostatin (synthetic analogues –
octreotide and vapreotide) reduce variceal bleeding by lowering portal venous pressure.
 Their merit remains unclear, but they may improve bleeding control during endoscopic
management.
 Vasopressin (ADH) causes increased vasoconstriction in splanchnic, portal, coronary,
cerebral, peripheral, pulmonary, and intrahepatic vessels – helps reduce portal venous
hypertension.
 PPIs and H2 receptor antagonists use doesn’t have evidence of affecting mortality rates of GI
haemorrhage, but PPI are given to all patients with peptic ulcers due to long term benefits.
 During endoscopy, if there is stigmata of high risk of ulceration, high dose of intra-venous
PPI therapy (omeprazole) may be given.
References:
Kumar and Clark 2005
http://emedicine.medscape.com/article/196561-treatment#TreatmentSurgicaltherapy
http://www.australianprescriber.com/magazine/28/3/62/6/
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* - Cooper et al, Study showed endoscopy performed within 24 hours reduced length of stay
in hospital, rate of recurrent bleeding and the need for emergent surgical intervention.
Lower GIT bleeding
“Massive bleeding from lower GI tract is rare... usually due to diverticular disease or ischaemic
colitis... small bleeds from haemorrhoids occurs very commonly” Kumar and Clark
General principles
1. Resuscitation and initial assessment – same as in upper GIT bleeding
2. Localization of the bleeding site – using investigations such as rectal examination,
proctoscopy, sigmoidoscopy, colonoscopy, etc)
3. Therapeutic intervention to stop bleeding at the site.
Surgical management – indicated in patients who have a persistent bleed.
 Once the bleeding site has been preoperatively determined, intra-arterial vasopressin is
injected to try to reduce blood flow, and a segmental colectomy is performed.
 If the bleeding site is not localized, a subtotal colectomy with ileoproctostomy is performed,
but this has a significantly higher mortality rate.
http://emedicine.medscape.com/article/188478-treatment