2012-9-27 HISTRORY TAKING-SYMPTOMS Gastrointestinal m Coffee ground vomiting Bleeding ■ Melena SHL Hong ch as lightheadedness, syncope, angin shock Zhongshan Hospital, Fudan University Hematemesis Coffee ground vomiting a Hematemesis is vomiting of fresh blood. a indicates that active bleeding may have m Hematemesis indicates that bleeding originates from a site proximal to the ligament of Triz. A history of fresh hematemesis usually implies a significant bleed Melena Hematochezia Melena is the passage of black tarry stool when hemoglobin is converted to a Passage of pure red blood or ble a Ingestion of as little as 200ml of blood can It usually occurs when bleeding comes from the lower gastrointestinal tract. It can also present in a massive upper nall bowel or pro elena, especially when color GI bleeding
2012-9-27 1 www.zshospital.com Gastrointestinal Bleeding SHI, Hong Zhongshan Hospital, Fudan University www.zshospital.com HISTRORY TAKING-SYMPTOMS Hematemesis Coffee ground vomiting Melena Hematochezia GI blood loss frequently is occult. Sometimes, patients may present with symptoms of blood loss, such as lightheadedness, syncope, angina, or even shock. www.zshospital.com Hematemesis Hematemesis is vomiting of fresh blood. Hematemesis indicates that bleeding originates from a site proximal to the ligament of Treiz. A history of fresh hematemesis usually implies a significant bleed www.zshospital.com Coffee ground vomiting indicates that active bleeding may have ceased. www.zshospital.com Melena Melena is the passage of black tarry stool. It occurs when hemoglobin is converted to hematin by bacterial degradation. Ingestion of as little as 200ml of blood can produce melenic stool. Although melena generally connotes bleeding proximal to the ligament of Treiz, bleeding from small bowel or proximal colon may also cause melena, especially when colonic transit is slow. www.zshospital.com Hematochezia Passage of pure red blood or blood admixed with stool. It usually occurs when bleeding comes from the lower gastrointestinal tract. It can also present in a massive upper GI bleeding
2012-9-27 Physical examination Lab exam s When GI bleeding is suspected, rapid assessment of the ■ Blood is sent to th carried out gauge the urgency of the ment of the vital signs is the best way given without delay if needed well as the depletion and absorbed blood proteins. Fecal occult blood is useful for the diagnosis Endoscopy Angiography triage patient for hospital stay or home Angiography is an important tool in the diagnosis of GI bleeding when endoscopy fails to identify the Give the most accurate diagnosis of the Assess the risk of recurrent bleeding. The potential to achieve immediate control with several atment modalities hemodynamic instability GI bleeding of obscure origIn DIAGNOSIS APPROACH tree of bleed opy in about 5% of patients. using hemobilia. nested either by presence of iron-deficteney anemia control the bleeding whe .through endoscopy or other diagnostic
2012-9-27 2 www.zshospital.com Physical examination When GI bleeding is suspected, rapid assessment of the patient is carried out gauge the urgency of the situation. – Is bleeding acute or chronic? – Is the patient hemodynamically stable or unstable? Carefully assessment of the vital signs is the best way to judge a patient’s stability. – The blood pressure and heart rate reflect the amount and rapidity of blood loss, as well as the extent of cardiac and vascular compensation. – Postural hypotension: the blood pressure is maintained on recumbency but falls more than 15 to 20 mmHg when the patient sits up. Bowel sounds are also very important for judging whether the bleeding has ceased or not. www.zshospital.com Lab Exam Blood is sent to the laboratory for complete blood count, routine chemistries, and clotting studies. Blood for typing and crossmatching is sent to the blood bank so that the transfusions can be given without delay if needed. A rise in the BUN after major upper GI bleeding episodes results from volume depletion and absorbed blood proteins. Fecal occult blood is useful for the diagnosis of occult bleeding. www.zshospital.com Hong Shi, Department of Gastroenterology & Hepatology, Zhongshan Hospital 复 旦 大 学 附 属 中 山 医 院 消 化 科 Endoscopy Endoscopic examination is the best tool to triage patient for hospital stay or home. Functions – Give the most accurate diagnosis of the source of bleeding. – Assess the risk of recurrent bleeding. – Offer endoscopic therapy when a source of bleeding is found (endoscopic hemostasis). Endoscopic examination should be made available to the patient within 24 hours or when the patient is stabilized from his hemodynamic instability. www.zshospital.com Hong Shi, Department of Gastroenterology & Hepatology, Zhongshan Hospital 复 旦 大 学 附 属 中 山 医 院 消 化 科 Angiography Angiography is an important tool in the diagnosis of GI bleeding when endoscopy fails to identify the source. Advantages – Accurate localizaion of rapidly bleeding lesions – The potential to achieve immediate control with several treatment modalities. www.zshospital.com Hong Shi, Department of Gastroenterology & Hepatology, Zhongshan Hospital 复 旦 大 学 附 属 中 山 医 院 消 化 科 GI bleeding of obscure origin The source of bleeding remains unidentified after gastroscopy and colonoscopy in about 5% of patients. The most common causes include angiodysplasia, small bowel neoplasms, Meckel’s diverticulum, ectopic varices and conditions causing hemobilia. Capsule endoscopy is better tolerated by the patients. Double balloon enteroscopy offers an opportunity to control the bleeding when a source is found. www.zshospital.com Hong Shi, Department of Gastroenterology & Hepatology, Zhongshan Hospital 复 旦 大 学 附 属 中 山 医 院 消 化 科 DIAGNOSIS APPROACH Recognition of hemorrhage – In most cases, the doctors recognize hemorrhage through history taking and physical examination. – Occult bleeding is manifested either by a positive finding of a test for fecal occult blood or by the presence of iron-deficiency anemia. Assessment of severity Differentiation of upper from lower GI hemorrage – The approximate site of bleeding can usually be predicted by the manner of presentation. – When the location of bleeding is in question, a nasogastric tube may be placed. Etiology -through endoscopy or other diagnostic tests
2012-9-27 Etiology High risk patients GI bleeding lificant GI bleeding olie blood pressure below 100mmHg Vascular malformation Rectal Admitted for other medical problems and developed GI bleeding during hospitalization High risk peptic ulcers RESUSCITATION Localized active bleeding s Vital signs and urine output should be carefully monitored replacemare peripheral drip should be inserted for fluid m A central line would be useful for patients in shock. Evidence of substantial volume loss- blood transfusion s A joint team of gastroenterologists, GI surgeons and tervention radiologists should manage a patient with GI rrhage are important predictors of recurred THERAPY PHARMOCOLOGICAL THEI Pharmacological therapy ceptor antaganists a Radiological therapy mp inhibitors(PPI): omeprazole, est Surgery otide)red ntifibrinolytic agents(recombinant activated factor VIl) n Antibiotics- variceal bleeding halospurin
2012-9-27 3 www.zshospital.com Hong Shi, Department of Gastroenterology & Hepatology, Zhongshan Hospital 复 旦 大 学 附 属 中 山 医 院 消 化 科 Etiology Upper GI bleeding Lower GI bleeding Common Gastric/duodenal ulcer Esophageal/gastric varices Angiodysplasia Hemorrhoids Less common Gastroduodenal erosions Esophagitis Mallory Weiss tear Colonic neoplasms IBD Ischemic colitis Radiation colitis Diverticular disease Rare Upper GI malignancy Vascular malformation Colonic ulcers Rectal varices www.zshospital.com Hong Shi, Department of Gastroenterology & Hepatology, Zhongshan Hospital 复 旦 大 学 附 属 中 山 医 院 消 化 科 High risk patients Significant GI bleeding – Syncope – Haematemesis – Systolic blood pressure below 100mmHg – Postural hypotension – 4 units of blood have to be transfused in 12 hours to maintain blood pressure Patients over 60 years old and with multiple underlying diseases Admitted for other medical problems and developed GI bleeding during hospitalization www.zshospital.com Hong Shi, Department of Gastroenterology & Hepatology, Zhongshan Hospital 复 旦 大 学 附 属 中 山 医 院 消 化 科 High risk peptic ulcers High risk peptic ulcers and those actively bleeding or have bled recently may show stigmata of haemorrhage on endoscopy. – Locoalized active bleeding Pulsatile Arteiral spurting Simple oozing – Have bled recently Adherent blood clot Protuberant vessel Flat pigmented spot on the ulcer base Stigmata of haemorrhage are important predictors of recurrent bleeding. www.zshospital.com Hong Shi, Department of Gastroenterology & Hepatology, Zhongshan Hospital 复 旦 大 学 附 属 中 山 医 院 消 化 科 RESUSCITATION Irrespective of the underlying cause of gastrointestinal bleeding, a patient should be resuscitated. Vital signs and urine output should be carefully monitored. A large bore peripheral drip should be inserted for fluid replacement. A central line would be useful for patients in shock. Evidence of substantial volume loss- blood transfusion. A joint team of gastroenterologists, GI surgeons and intervention radiologists should manage a patient with GI bleeding. www.zshospital.com Hong Shi, Department of Gastroenterology & Hepatology, Zhongshan Hospital 复 旦 大 学 附 属 中 山 医 院 消 化 科 THERAPY Pharmacological therapy Endoscopic hemostasis Radiological therapy Surgery www.zshospital.com Hong Shi, Department of Gastroenterology & Hepatology, Zhongshan Hospital 复 旦 大 学 附 属 中 山 医 院 消 化 科 PHARMOCOLOGICAL THERAPY Acid-suppressing drugs -effective drugs to promote ulcer healing H2-receptor antagonists Proton pump inhibitors (PPI) : omeprazole, esomeprazole and pantoprazole Vasoactive agents vasopressin (cardiac ischaemia, worsening coagulopathy) Terlipressin (used in combination with glyceryl trinitrate) Somatostatin (octreotide, vapreotide) reduces portal blood pressure and azygous blood flow Antifibrinolytic agents (recombinant activated factor VII) Antibiotics- variceal bleeding Cephalosporin quinolone
2012-9-27 Endoscopic hemostasis Radiological therapy a Highly-selective coil embolization for tion therapy using epinephrine or other sclerosants bleeding ulcer and vascular malforn lation atin sponge pledgets hageal varices ligation using single or multiple band ligators Polyvinyl alcohol particles cyanoacrylate for gastrie varices a Trans-jugular Intrahepatic Portal-Systemic ormation Shunts (TIPss) for gastric or esophageal Hemostatic clips Surgery common causes of acute GI bleeding urgery remains the most definitive method ding that cannot be controlled by fusion(i.e total of 6-8 units of blood Evidence suggestive of GI perfora GI Bleeding Case G,I, Bleeding Case ■58-year-0 BP 130/80mmHg HR 100 beats/min a Black unformed stools, nausea cated BP 100/80mmHg, HR 120 beats/ min epigastric pain. n HEENT: funduscopic examination shows arterial s 10 years ago he had an ulcer Chest: clear He has a daily alcohol intake of two bears s Extremities: no cyanosis or edema. He has been taking one enteric-coated m Stool: melenic, fecal occult blood test positive. aspirin each day
2012-9-27 4 www.zshospital.com Hong Shi, Department of Gastroenterology & Hepatology, Zhongshan Hospital 复 旦 大 学 附 属 中 山 医 院 消 化 科 Endoscopic hemostasis For peptic ulcers (either actively bleeding or showing protuberant vessel or fresh clot) – injection therapy using epinephrine or other sclerosants – thermocoagulation using heater probe or electrocoagulation – Hemostatic clips For gastric or esophageal varices – Injection of sclerosant (ethanolamine, STD) – Banding ligation using single or multiple band ligators – Injection of cyanoacrylate for gastric varices For vascular malformation – Argon plasma coagulation – Hemostatic clips www.zshospital.com Hong Shi, Department of Gastroenterology & Hepatology, Zhongshan Hospital 复 旦 大 学 附 属 中 山 医 院 消 化 科 Radiological therapy Highly-selective coil embolization for bleeding ulcer and vascular malformation using: – Gelatin sponge pledgets – Micorcoils – Polyvinyl alcohol particles Trans-jugular Intrahepatic Portal-Systemic Shunts (TIPSS) for gastric or esophageal varices www.zshospital.com Hong Shi, Department of Gastroenterology & Hepatology, Zhongshan Hospital 复 旦 大 学 附 属 中 山 医 院 消 化 科 Surgery Surgery remains the most definitive method of stopping hemorrhage. Indications – Arterial bleeding that cannot be controlled by endoscopic haemostasis. – Massive transfusion (i.e. total of 6-8 units of blood) required to maintain blood pressure. – Recurrent clinical bleeding after initial success in endoscopic and/or angiographic hemostasis – Evidence suggestive of GI perforation www.zshospital.com Hong Shi, Department of Gastroenterology & Hepatology, Zhongshan Hospital 复 旦 大 学 附 属 中 山 医 院 消 化 科 Algorithm in the management of common causes of acute GI bleeding www.zshospital.com Hong Shi, Department of Gastroenterology & Hepatology, Zhongshan Hospital 复 旦 大 学 附 属 中 山 医 院 消 化 科 G.I. Bleeding Case 58-year-old man Black unformed stools, nausea, epigastric pain. 10 years ago he had an ulcer. He has a daily alcohol intake of two bears. He has been taking one enteric-coated aspirin each day. www.zshospital.com Hong Shi, Department of Gastroenterology & Hepatology, Zhongshan Hospital 复 旦 大 学 附 属 中 山 医 院 消 化 科 G.I. Bleeding Case Vital signs – Supine BP 130/80mmHg, HR 100 beats/min – Seated BP 100/80mmHg, HR 120 beats/min HEENT: funduscopic examination shows arterial narrowing Chest: clear Abdomen: active bowel sounds, no masses or tenderness, spleen is not palpables. Extremities: no cyanosis or edema. Stool: melenic, fecal occult blood test positive
2012-9-27 Questions Vignette follow-up Whether gi bleeding exists? VA is admitted to the hospital and m Severity of the hemorrhage receives a three-unit transfuse m The amount of gi tract blood los copy reve cer Source of hemorrhage Upper or lower GI No rebleeding occurs with medical bleeding management. s He has not had recurrent symptoms or m Ceased or not? evidence of bleeding during one year of ■ How to treat? follow-up. 划! 石虹 Email: shi hong@zs-hospital shcn
2012-9-27 5 www.zshospital.com Hong Shi, Department of Gastroenterology & Hepatology, Zhongshan Hospital 复 旦 大 学 附 属 中 山 医 院 消 化 科 Questions Whether GI bleeding exists? Severity of the hemorrhage? The amount of GI tract blood loss? Source of hemorrhage? Upper or lower GI bleeding? Etiology? Diagnosis? Ceased or not? How to treat? www.zshospital.com Hong Shi, Department of Gastroenterology & Hepatology, Zhongshan Hospital 复 旦 大 学 附 属 中 山 医 院 消 化 科 Vignette follow-up VA is admitted to the hospital and receives a three-unit transfusion. Endoscopy reveals a duodenal ulcer. No rebleeding occurs with medical management. He has not had recurrent symptoms or evidence of bleeding during one year of follow-up. www.zshospital.com 谢 谢 ！ 石 虹 Email：shi.hong@zs-hospital.sh.cn