Gastrointestinal bleeding

(1)

Gastrointestinal bleeding

• ..is the reason in 2 % of all admissions to hospital

• 85.000 cases/year in the US. The incidence of

urgent upper GI bleeding: 145/100.000

inhabitant/year in Hungary

( Nagy Gy. MBA Suppl 2002/3)

• Average mortality rate: 8%

• FORMS:

Haemathemesis

: red or black( coffee

ground appearance);

Melaena

(the stool is black

and tarry and always diarrhoea as blood is

(2)

Site of GI bleeding

85-95% from upper tract

2% from small intestine

5-18% large intestine

(3)

Clinical signs depend on the site and

severity of the bleeding

• Localisation

Proximal source

Distal source

• Reasons

Ulcer, erosion, varicies,

Mallory–Weiss,

tumour, IBD,

ischaemic vascular lesions

,

angiodysplasia,

altered hemostasis

(4)

DIAGNOSTIC APPROACH

• History

• Physical examination

• Laboratory parameters

• Endoscopy

• Isotope scan

• Angiography

(5)

TAKING HISTORY

• Onset of complains (sudden or chronic)

• Pain location and characteristics

• Weight loss, weekness, changing bowel habit

• Characteristics of the stool and vomit

• Abdominal cramps

• Drug, alkohol abuse, diet

• Fever

(6)

PHYSICAL EXAMINATION-1

• Examination of the oropharyngs, nasal

cavity: to exclude swallowed blood

• Presence of blood in the bowel causes

hypermotility (on auscultation)

• Palpation of defence ( ileus,intestinal

infarct)

(7)

PHYSICAL EXAMINATION-2.

• skin: jaundice, pale,cold, vet

• Anxiety, restlessness, lightheadidnes

• Systolic BP< 100 mmHg , puls rate > 100: visual distrubances, collaps while changing position: postural hypotension

• 10-20/min difference in pulse rate or 10-20 mmHg in BP between supine and sitting position = blood loss more than 20% of total blood volume (or 1-2 units of whole blood)

• Blood loss <500 ml rarely associated with systemic signs

• More intensive bleeding (40% of total volume) results in decreased venous return to the heart, decreased cardiac output, increased

(8)

LABORATORY FINDINGS

• Hemoccult test: for screening, for early diagnosis of tumours casuing chr. occult bleeding.

• PCV starts to decline after 6 hrs of onset because of hemodilution, so the PCV is not sensitive indicator of acute blood loss, since it may take 12-24 h to completely equilibrate with the vascular compartments.

• Leukocytosis, thrombocytosis

• BUN > 40 mg/dl in acute an severe bleeding (Nitrogen overload due to brakedown of blood proteins to urea by intestinal bacteria)

• BUN/kreatinin ratio>100 in upper GI bleeding • BUN/kreatinin ratio <50 in lower GI bleeding

• Hypovolaemic shock caused by massive GI bleeding will be the

consequence of centrilobular hepatic necrosis leading to elevation of hepatic enzymes SGOT and SGPT and myocardial infarction in elderly

(9)

Signs of upper GI bleeding

• Vomiting

of blood or coffee-ground

material (blood that has been in the stomach

for at least several minutes)

• Blood per nasogastric tube

• Melaena:

as little as 100 ml of blood can

produce melaena

• Maroon-colored stools meaning brisky

bleeding of upper GI source

(10)

Bleeding from the small intestine

• Rare, painless, hard to localize

• Only tool for diagnosis: angiography+CT ,

izotope (technetium pertechnecate)scan

and lately: capsullar endoscopy

• Origin: angiodysplasia (in 40%), Meckel

divericula, bening tumors

(11)

Bleeding from the lower GI tract

• Fresh blood and clots.

• Reason: rectal varicies, hemmorhoids,

tumour: polyps or carcinoma, fissures,

diverticulosis (in 50% of elderly cases),

angiodysplasia

• Slower rates of bleeding, more proximal in

the colon, can present with maroon-colored

or „currant jelly” stools

(12)

(13)

DIAGNOSTIC PROCEDURES

• Gastroscopy: for identification of the site and reason of

bleeding: timing the best within 12-24 hours after the

bleeding episode.

• Urgent endoscopy for variceal hemorrhage!

• Colonoscopy

• Mesenteric angiography

• Capsullar enteroscopy

• CT - MR enterography

radioisotop scan

The bleeding source remains obscure in 52 % even after

upper and lower endoscopic examination had been

performed!

(14)

(15)

(16)

angiography

(17)

(18)

Emergency quidelines: patients with

active or severe bleeding should be

managed in intesive care unit (ICU)

• When patient first seen in shock: prior taking history: vital

signs should be noted, blood sent for typing and large bore

(14-18 gauge) iv.line (catheter) placed for early fluid

supply.

• Urine output should also be monitored and airways should

be protected

• PCV<25, BTT

• GI bleeding in 85% usually stop within the first 24-48

hours spontaneously.

• Surgical consultation and intervention is needed in approx.

10% of the cases.

(19)

(20)

TREATMENT GUIDELINES-1

• Maintain intravascular volume and hemodynamic

stability

• Stop bleeding: local measures: nasogastric lavage

with cold tap water, sclerotherapy of varicies,

electrocoagulation for ulcers and angiodysplasia,

• systemic: H2 blocker, protonpump INH, antacids

to maintain gastric ph near 7.0

• Surgical intervention indicated in cases where 24

h of adequate measures the blood loss is more than

6 units, and the bleeding returns

(21)

TREATMENT GUIDELINES-2

• Blood replacement

: packed red cells

should be given to maintain PCV at 30%,

central venous pressure at 8-15 cm water,

and systolic BP at greater than 100 mm Hg.

• Each unit of blood should raise the PCV

(22)

(23)

(24)

(25)

Thalidomide for the treatment of chronic gastrointestinal

bleeding from angiodysplasias: a case series. Eur J

Gastroenterol Hepatol. 2009.

• BACKGROUND: Mucosal angiodysplasias, either inherited or

acquired, can cause gastrointestinal bleeding, sometimes refractory to treatment and requiring ongoing transfusion.

• Thalidomide was started with 50 mg/day and then increased

incrementally by 50 mg every week up to 200 mg/day, if tolerated, and continued for 6 months. Patients who continued 100-200 mg/day of thalidomide for 6 months did not require any transfusions during the 6 months of medication. During 6-months posttreatment of these three patients, one maintained response without any transfusion for 2

months, then required 1 U of blood every 4 weeks, one patient required 2 U of blood every 3-4 weeks, and one patient died from diabetes

complications.

• CONCLUSION: Thalidomide should be considered as a therapeutic option in patients who are resistant to conventional therapy, but it has a high discontinuation rate because of its side-effects.