Upper Gi Bleed And Lower Gi Bleed

Front 1

Definition

Back 1

• bleeding proximal to the ligament of Treitz (75% of GI bleeds) ligament of Treitz: suspensory ligament where fourth portion of the duodenum transitions tojejunum

Front 2

Etiology

Back 2

Above GE jn

stomach

duodenum

coagulopathy

vascular malformation

Front 3

Above GE jn

Back 3

• epistaxis
  
• esophageal varices (10-30%)
  
• esophagitis
  
• esophageal cancer
• Mallory-Weiss tear (10%)

Front 4

Stomach

Back 4

• gastric ulcer (20%) (see Peptic Ulcer Disease, G12)
  
• gastritis (e.g. from alcohol or post-surgery) (20%)
  
• gastric cancer
  
• gastric antral vascular ectasia (rare, associated with cirrhosis and CTD)
• Dieulafoy's lesion (very rare)

Front 5

Duodenum

Back 5

Ulcer in bulb (25%)

aortoenteric fistula: usually only if previous aortic graft

Front 6

coagulopathies

Back 6

drugs

renal disease

liver disease

Front 7

Vascular malformation

Back 7

dieulafoy's lesion

AVM

Front 8

Clinical features

Back 8

in order of decreasing severity of the bleed: hematochezia > hematemesis > coffee ground emesis > melena > occult blood in stool

Front 9

Management (initial) of upper GI bleed?

Back 9

• stabilization
  
• send blood for CBC, cross and type, platelets, PT, PTT, electrolytes, BUN, Cr, LFTs
  
• keep NPO
  
• consider NG tube to determine U vs L bleed
  
• endoscopy
  
• IV PPI
  
• for variceal bleeds, octreotide 50 mcg loading dose followed by constant infusion 50 mcg/hr
  
• consider IV erythro
  

Front 10

Prognosis of U GI bleed?

Back 10

80% stop spontaneously

• peptic ulcer bleeding: low mortality (2%) unless rebleeding occurs (25% of patients, 10% mortality)

• endoscopic predictors of rebleeding: spurt or ooze, visible vessel, fibrin clot• can send home if clinically stable, bleed is minor, no comorbidities, endoscopy shows clean ulcerwith no predictors of rebleeding

• H2-antagonists have little impact on rebleeding rates and need for surgery

• esophageal varices have a high rebleeding rate (55%) and mortality (29%)

Front 11

Definition of lower GI bleed

Back 11

bleed distal to ligament of treitz

Front 12

etiology of lower GI bleed

Back 12

• • if blood per rectum with hemodynamic instability, rule out upper GI source
  
• • diverticular (60% from right colon)
  
• • vascular angiodysplasia anorectal (hemorrhoids, fissures)
  
• • neoplasm cancer polyps
  
• • inflammation colitis (ulcerative, infectious, radiation, ischemic)
• • post-polypectomy

Front 13

Clinical features of lower GI bleed?

Back 13

• hematochezia
  
• anemia
  
• occult blood in stool
  
• rarely melena
  

Front 14

Management of GI bleed?

Back 14

Treat underlying causes

Front 15

How to approach hematochezia? (fresh blood through anus)

Back 15

1. assess hemodynamicaly stable

2. resuscitate (IV fluids +/- blood transfusion)

3. assess coagulation status (CBC, INR/PTT)

4. determine site of bleeding

Front 16

What to do if massive bleed/hemodynamically unstable? And clinical suspicion of UGIB?

Back 16

colonoscopy and OGD

Front 17

What to do if hemodynamically stable, no UGIB risk factors?

Back 17

colonoscopy only

Front 18

What to do for slow bleed?

Back 18

radionucleotide Tc 99 m tagged RBC scan

Front 19

What to do for RAPID bleed?

Back 19

angiography +/- embolization