U G I Bleedingg

Faisal Al-MashatD f S Dep of Surgery

KAUH & KAHOC

“Massive UGIB can shake the Equanimity of the most experienced clinician”

fDefinitions

■ Haematemesis: vomiting up of blood■ Haematemesis: vomiting up of bloodProximal to ligament of Trietz

■ Bright red: rapid and sizeable bleeding

■ Coffee-ground: smaller bleed■ Coffee ground: smaller bleed

■ Melaena: Black tarry stool ( > 60 ml )y ( )

O i ll h h i j j ■ Occasionally hemorrhage into jejunum, ileum & right colon can cause melaena if transit is low Contact time 8 h

■ Massive UGIH may cause haematochezia if transit is rapid

E id i lEpidemiologyIncidence:

USA: 100 per 100,000 / yearUK : 103 per 100,000 / yearUK : 103 per 100,000 / year

M li 10 15%Mortality: 10 - 15%Almost all deaths:

1- Elderly2- Medical problemsp

CCauses

Di ib i i■ Distribution varies■ Cause° 10 15%■ Cause : 10 - 15%■ Multiple causes: 20 - 30%■ Multiple causes: 20 - 30%

Th 3 M t C CThe 3 Most Common Causes

1 O i1- Oes varices2 Gastritis / Erosions 2- Gastritis / Erosions 3- DU3 DU

Oes:■ Varices■ Mallory - Weiss tear Duod / Juju:y■ Ca■ Reflux■ Foreign body

■ Peptic ulcer■ Erosions / duodenitis■ Vascular malformations

H bili

Stom:P i l

■ Haemobilia■ Polyps (including Peutz-Jeghers syndrome and other polyposis

d )■ Peptic ulcer■ Erosions / gastritis■ Varices

l h h

syndromes)■ Aorto - enteric fistula

Idiopathic■ Portal hypertensive gastropathy■ Ca■ Lymphoma

Idiopathic

y p■ Leiomyoma■ Angiodysplasis (including Osler’s disease)d sease)■ Dieulafoy’s

Massive UGIB

1 O / i1- Oes / gas varices2- Gas ulcer2 Gas ulcer3- DU4- Stress5- Dieulafoy’s5- Dieulafoy s 6- Aorto - enteric fistula

Bleeding with Cutaneous Stigmata

di h h i l i i (1- Hereditary haemorrhagic telangiectasia (R-O-W Syndrome)y )

2- Pseudoxanthoma elasticum3 Ehl D l S d3- Ehlers - Danlos Syndrome4- Degos’ Diseaseg5- Peutz - Jeghers Syndrome

R O W SyndromeR-O-W Syndrome

Upper G I Toxicity of NSAIDUpper G I Toxicity of NSAID

Relative RiskRelative Risk■ Ibuprofen +■ Fenoprofen +■ Aspirin +■ Diclofenac +■ Sulindac ++■ Sulindac ++■ Diflunisal ++■ Naproxen ++

I d h i■ Indomethacin ++■ Tolmetin +++■ Piroxicam +++■ Ketoprofen +++■ Azopropazone ++++ l ++ di +++ hi h+, low; ++ medium; +++, high

H hernia

Oes varices

Gas ca

Oes ca

D diverticulum

D U

G Gas ca

D diverticulum

Oes ca

B d R f A t Bl diBody Response of Acute Bleeding

1- Significant:Syncope, p hypotension, pallor, tach & JVP

2- 500 ml loss: changes° except:g pa- Elderlyb Existing anemiab- Existing anemiac- Cardiovascular disease

3- Tach & postural fall >20 mmHg The most sensitive signs of hypovolaemiag yp

Clinical Presentation

D d ODepends On:

1- Amount2 R2- Rate3- General health

1- Haematemesis +/- Melaena2- Shock3- Chronic anaemia

4- M I , C V A

EvaluationEvaluation

Hi t 50 %History : 50 %

1- Dyspepsia2- Heart burn 7- Chronic liver disease

8 NSAID3- Dysphagia & weight loss4- Peptic ulcer5- Vomiting / retching followed

8- NSAID9- Anticoagulants10- Bruises11 A i f

g gby haematemesis

6- Recent high alcohol

11- Aortic graft

ExaminationExamination

1- Shock: Pallor, Pulse, BP, P. hypotension2- Stigmata of cirrhosis2 Stigmata of cirrhosis3- Purpura, pigmentaion, Telangiectasia4 Abdomen:4- Abdomen:

■ TendernessM■ Masses

■ Hepato, spleno, dilated veins, ascites5- Jaun + abd pain + melaena: Haemobilia6- DRE

InvestigationsInvestigations

1- CBC : “Hb poor indicator of volume loss”2- U & Es3- LFTs3 LFTs4- INR , PTT5 G i & X hi5- Grouping & X-matching6- ABG7- CXR8 ECG8- ECG

Specific Investigationsp g

1- Endo: All2- B Meal3- Radionuclide 4- Angio

OGD I ti ti f Ch iOGD Investigation of Choice

1 Diagnostic1- Diagnostic

2- Therapeutic

3 P di f i / 3- Predictor of continuous / recurrence

E d C i i f ↑Endo Criteria of ↑Risk Bleed in Oes Varices1 Diff d1- Diffuse redness2- Haematocystic spoty p3- Large tortous varicesvarices4- Proximal extension5- Oesophagitis

Endo Criteria of d aCont/Rec DU Bleed

1- Arterial spurter1- Arterial spurter2- Vessel in base of ulcer

Adh l3- Adherent clot

Complications of OGD

1- Aspiration1 Aspiration2- Bleeding3- Perforation4 F4- Fever5- Respiratory depression5- Respiratory depression6- Reactions to sedatives

Relationship Between Clin and Endo Diag and Risk of p gRecu Bleed (MacLeod & Mills, 1982)

Clinical Rebleed Rate (%)

History of recent Negative 15Alcohol Positive 30Shock Present 69Shock Present 69

Absent 21Age <60 18

>60 34>60 34Endo Varies 42

DU 32GU 48Oesophagitis/gastritis/ 6-14duodenitisMallory-Weiss 13

Relationship Between Endo Stigmata of Recent Bleed and Re-Bleed Rate

Stigma Re-Bleed ( )(%)

Actively spurting vessel 75 - 85y p gVisible vessel, not actively bleeding 50Flat, red/black spot 8 - 10Flat, red/black spot 8 10

No stigmata 0 - 5

B MealB Meal

1- ↓ diag accuracy

2- Obscures endo & angio studies2 Obscures endo & angio studies

3- Chronic cases

4- Diagnostic

Predictors of Poor Prognosis

1- Age > 60 y2 Sh k ( > 6 it )2- Shock ( > 6 units )3- Endo stigmata of recent bleed4- Pathology5- Concomitant disease5 Concomitant disease

TreatmentTreatment

1- Bed rest2- I V fluids3- O2: 5-10 l/min4- Transfusion

l5- Folye’s6- Lavage7 T d7- Tamponade8- CVP9 H antagonist: no role9- H2 antagonist: no role

■ Prevent errosive gastritis■ Prevent stress ulcer ? Re-bleed■ Prevent stress ulcer, ? Re-bleed

TamponadeTamponade

L N tube S B tubeL N tube S B tube

Outcome of ResuscitationOutcome of Resuscitation

■ 80 % stopp■ 20 %:

C i bl d1 - Continue to bleed2 - Re-bleed within 48 h of adm2 Re bleed within 48 h of adm

Non operative ManagementNon- operative Management1 Endo:1- Endo:

■ Nd - YAG■ Monopolar BICAP heater probe APC■ Monopolar, BICAP, heater probe, APC■ Injection: sclerosants, alcohol, vasoconstrictors,

adrenaline, thrombin, fibrin glueg■ Banding■ Haemoclip

2- Radio:■ Emoblization (varices, gastritis, angiodysplasia)■ TIPS

3- Pharma: Vasopressin, Somatostatin , β-Blockers

Endo modalities for UGIH

Injection Thermal Mechanical

Adrenaline (1:10,000 or 1:20,000) Heater probe Haemoclips

Fibrin glue Bicap probe Banding

Human thrombin Gold probe Endoloops

Sclerosants APC Staples/sutur

Alcohol Laser

E b li tiEmbolization

Pre Post

TIPS

After placement, collaterals are less

UGIB

Continuing massive h h

Recent hemorrhage, d t l it t d

Hemorrhage >3 days t blhemorrhage adequately resuscitated

bleeding stoppedstable

Emergency endoscopy E l dNon-urgent endoscopy

Emergency endoscopy

D fi it bl di l i

Early endoscopy

N t bl d l

Recent bleeding but no lesion OR recurrent

Definite bleeding lesion No recent bleed, normal endoscopy

bleeder of uncertain cause OR actively

bleeding but normal

ManageObserve endoscopy

99m Tc-labelled RBC scan

NegativePositive

Angio

Laparotomy & Perioperative endoscopy

g

Erosive Gastritis

AntacidsH2-anta / PPIH2 anta / PPIGastric lavage

Eliminae underlying cause

No hemorrhage Continued hemorrhage

Endoscopic hemostasisI t t i l iMedical management

Antacids

H2 t / PPI

Intraarterial vasopressin

H2-anta / PPI

sucralfateOperative treatment

H PyloriH . Pylori

Peptic ulcerPeptic ulcer

■ 80 %: stops sponta■ 80 %: stops sponta■ 25 %: intervention■ Rx:1- Endo: Nd - YAG, Bipolar, Heat

probes, Adrenaline, Sclerosant, Cli ( h i i )Clips (no technique superior)

2- Surgery:DU suturing vago + pyloropDU : suturing, vago + pylorop

All receive anti H PyloriGastric: resection P gastrecGastric: resection, P gastrec

Bleeding Peptic UlcerBleeding Peptic Ulcer

Low risk of rebleeding Active bleeding or high risk of Low risk of rebleeding

M it

g grebleeding (shock, visible vessel)

Monitor Endoscopic therapy

Rebleed Unable to control bleedingNo further bleeding

Repeat endoscopic therapy

SurgeryRebleed

Bleeding Oes Varices

1 90 % portal hypertension have varices1- 90 % portal hypertension have varices2- 30 % with varices will bleed3- 80 % comes from varices4- 70 % rebleed5- Mortality : 50 % 6 Survival depends on degree of hepatic impairement6- Survival depends on degree of hepatic impairement

Treatment

1- Vasopressin & Octreotidep2- Tamponade: 90 % suc. 50 % re-bleed within 24 h removal3- Endo: banding , sclerog ,4- Tipss: re-bleed but enceph

Morta 1 %Morta 1 %5- Surgery: transection , devascularization , shunting

Emergency shunting: 20 % morta & 50 %encephenceph

Bleeding Esophageal Varices

Sclerotherapy

No further bleeding Continued hemorrhageNo further bleeding

D fi iti t t t

g

Temporizing methodsDefinitive treatment

Sclerotherapy

Devascularization

Vasopressin

Balloon tamponadeDevascularization

Shunt

Liver transplantationSclerotherapy

Liver transplantation

No further bleeding Continued hemorrhage

TIPSOperative

Bleeding Gas VaricesBleeding Gas Varices

1- Endo:Sclero:

■ Ethonalamine oleate & Polidocanal: poor results

■ Ethonalamine oleate & N-butyl-2-cyanoacrylate (NC): successful ? E b liEmbolism

ligation (EVL)2- Radio:

ll l d d d■ Balloon-occluded retrograde transvenous obliteration

■ Transjugular retrograde obliteration■ TIPS

3- Surgical:DevascularizationResection of upper stomach

Prevention bleed varices

A- Primary :y

1 β blockers: bleed by 40 50 %1- β- blockers: bleed by 40 – 50 %

2- Banding: may be considered

3- Sclero / shunting: Ineffective

B S dB – Secondary:1- 70 % variceal bleed re-bleed2- β – Blockers

Li i3- Ligation4- Sclero4 Sclero5- TIPS6- Surgery

Dieulafoy’s lesion

■ Rare■ Large s/m artery protruding through ■ Large s/m artery protruding through

m■ Within 6 cm of G - O junction on

l lesser ■ Rx: injection, thermal, clipping,

bandinggSingle: 50 % rebleedingCombined: 20 % rebleed. 90 % sucsses

I di ti f SIndications for Surgery

1- Continuing bleed2- Re-bleed3- Failure of endo 4- Pathology:

■ Chronic posterior DU with clot adherent to a large artery

■ Gastric ulcer: Re-bleed is common5- Fitness: elderly or ill6- Loss > 30% blood volume

Unknown Source of BleedUnknown Source of Bleed

l f il d bl di OGD & Colonoscopy fail to detect bleeding :S. bowel lesions are often responsible

1- Haemobilia2- Ulcerating panc / duod tumours2 Ulcerating panc / duod tumours3- Aorto / cavo duod fistula4- Meckel’s5- Polyps6- Smooth muscle tumours6 Smooth muscle tumours7- Angiodysplasia8- Lymphoma9- TB10- Crohn’s 0 C o s 11- Cavernous haemangioma12- Hamartoma13- Duplication cyst14- Chronic pancreatitisp

GIT Lymhoma Jejunal CA

Mickel’sMickel sLymhoma

I ti tiInvestigations

1- Small bowel enema: most useful2 R di lid2- Radionuclide3- Sel S M angio

T4- CT, MRI, MRA, MRCP5- Capsule endoscopy6- Lapa + Intraop enteroscopy

(IOE)

Radionuclide Studies

1 M i L G I bl d1- More in L G I bleed

2- Bleed rate: 0.1 ml/min

3- Of value in intermittent bleed

Radionuclide Scanning

■ Technetium Pertechnetate (99Tcm)

■ Sulphur-colloid (TcSc): emergency

■ Technetium labeled autologous red cells ■ Technetium-labeled autologous red cells (intermitent bleeding) long time

M k l’Meckel’s

Angiography

1- Bleed rate > 0.5 - 1.0 ml/m2- Diagno & Therap3 A 90 %3- Accuracy: 90 %4- Complication: 2%

■ Catheter■ Catheter■ Contrast■ With embolization → perforation

Conclusion

1- Collaboration of Gastroentero, Radio & surgeon2 NSAID i 2- NSAID important cause3- Only 10 - 20% require intervention

E l d4- Early endoscopy5- Variceal bleed has a significantly higher mortality than

thothers

Angiographic Therapy of UGIHg g p pyProcedure Success Rate in

Arresting Hemorrhage (%)

1. Mallory-Weiss tear

Vasopressin infusion into left gastric artery

77

Gelfoam embolization 88Gelfoam embolization of left gastric artery

88

2. Stress ulceration Vasopressin infusion 75-84into left gastric arteryGelfoam embolization of left gastric artery

80of left gastric artery

3. Gastric ulcer Vasopression infusion 65-70Embolization 79

4. Duodenal ulcer Vasopressin infusion 33-62Embolization 79

d f l bl d l k fEndoscopic stigmata of ulcer bleeding : prevalence, risks of rebleeding and reduced risk of rebleeding following endoscopic

Endoscopic l (%)

Rebleed Rate with success

Rebleed Rate with Endoscopic

Appearance Prevalence (%) with success Endoscopic

Stigmata

with Endoscopic

treatment (%)Active arterial Active arterial

bleeding 12 90 15-30

Visible Vessel 22 50 15-30Adherent clot 10 33 5Oozong without

stigmata 14 10 Not availablestigmataFlat spot 10 7 Not available

Clean base ulcer 32 3 Not available

Endoscopic Management of Continuous or Recurrent DU BleedingContinuous or Recurrent DU Bleeding

1- Diluted adrenaline 1 : 10,000

2- 3 - 4 injections of 0.5-2 ml of edgesj g

3 1 i j ti f 0 5 2 l i t b3- 1 injection of 0.5 - 2 ml into base