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    GI Bleeding - Nurses

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    GI bleeding is a common medical issue that requires rapid assessment and treatment. Upper GI bleeding has various potential causes like peptic ulcers or varices, while lower GI bleeding is often due to diverticulosis, angiodysplasia, or neoplasms. Early endoscopy within 24 hours is the gold standard for diagnosis and treatment, allowing for therapies like cauterization or ligation to stop bleeding. Cirrhosis patients with variceal bleeding have a higher mortality and require specialized management including antibiotics, vasoconstrictors, band ligation, or TIPS procedure. Proper resuscitation, endoscopic localization of bleeding source, and prevention of rebleeding are key to optimizing outcomes from GI hemorrh

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    GI Bleeding - Nurses

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    GI bleeding is a common medical issue that requires rapid assessment and treatment. Upper GI bleeding has various potential causes like peptic ulcers or varices, while lower GI bleeding is often due to diverticulosis, angiodysplasia, or neoplasms. Early endoscopy within 24 hours is the gold standard for diagnosis and treatment, allowing for therapies like cauterization or ligation to stop bleeding. Cirrhosis patients with variceal bleeding have a higher mortality and require specialized management including antibiotics, vasoconstrictors, band ligation, or TIPS procedure. Proper resuscitation, endoscopic localization of bleeding source, and prevention of rebleeding are key to optimizing outcomes from GI hemorrh

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    GI bleeding is a common medical issue that requires rapid assessment and treatment. Upper GI bleeding has various potential causes like peptic ulcers or varices, while lower GI bleeding is often due to diverticulosis, angiodysplasia, or neoplasms. Early endoscopy within 24 hours is the gold standard for diagnosis and treatment, allowing for therapies like cauterization or ligation to stop bleeding. Cirrhosis patients with variceal bleeding have a higher mortality and require specialized management including antibiotics, vasoconstrictors, band ligation, or TIPS procedure. Proper resuscitation, endoscopic localization of bleeding source, and prevention of rebleeding are key to optimizing outcomes from GI hemorrh

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    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    5K views71 pages

    GI Bleeding - Nurses

    Uploaded by

    api-3760283
    GI bleeding is a common medical issue that requires rapid assessment and treatment. Upper GI bleeding has various potential causes like peptic ulcers or varices, while lower GI bleeding is often due to diverticulosis, angiodysplasia, or neoplasms. Early endoscopy within 24 hours is the gold standard for diagnosis and treatment, allowing for therapies like cauterization or ligation to stop bleeding. Cirrhosis patients with variceal bleeding have a higher mortality and require specialized management including antibiotics, vasoconstrictors, band ligation, or TIPS procedure. Proper resuscitation, endoscopic localization of bleeding source, and prevention of rebleeding are key to optimizing outcomes from GI hemorrh

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    of 71

    Gastrointestinal Bleeding

    Dr Christopher Khor
    Senior Consultant Gastroenterologist
    Division of Gastroenterology & Hepatology
    National University Hospital
    GI Bleeding

    Introduction
    Causes of GI Bleeding
    Management Principles
    Assessment
    Management
    Introduction

    Common: UGIB 30-100/100,000 vs. LGIB


    20/100,000 (5x less common)
    Risk increased in aspirin (dose-related) & NSAID
    Decreased hosp stays due to endoscopy, 25%
    therapeutic endoscopy
    Reductions in surgery, rebleed, mortality
    Introduction
    Upper GI Bleeding (UGIB)
    Non-Variceal Bleeding
    Variceal Bleeding

    Lower GI Bleeding (LGIB)


    ‘Obscure’ cause 5%
    Small bowel
    Introduction
    Non-variceal Bleeding
    Mortality 3.5-14%

    Variceal Bleeding
    Mortality 30-50%
    2/3 die within 1 year
    Introduction

    80% stop spontaneously


    Mortality correlated with
    comorbidity
    Diagnosis facilitates endotherapy,
    lowers mortality
    Causes of GI Bleeding
    Upper GI Bleeding- Etiology

    3 major causes:
    Peptic Ulcer
    Gastric Erosions
    Varices

    No diagnosis in 10-15%,
    >1 in 20-30%
    Diagnosis of UGIB in 2225 patients

    Duod ulcer 24.30%


    Gastric erosions 23.40%
    Gastric ulcer 21.30%
    Varices 10.30%
    Mallory-Weiss tear 7.20%
    Esophagitis 6.30%
    Erosive duodenitis 5.80%
    Neoplasm 2.90%
    Stomal ulcer 1.80%
    Esophageal ulcer 1.70%
    Misc 6.80%

    Silverstein FE et al, GI Endosc 1981; 21:73


    Peptic Ulcer Bleeding
    Variceal Bleeding
    Rarer causes of UGIB
    Angiodysplasia
    Aortoenteric fistula
    Dieulafoy disease
    Hemobilia
    Hemosuccus pancreaticus
    Factitious bleeding or non-GI source
    Lower GI Bleeding- Causes

    Diverticulosis 43%
    Angiodysplasia 20%
    Undetermined 12%
    Neoplasia 9%
    Colitis 9%
    Other 7%

    Boley SJ et al Am J Surg 1979


    Diverticular Bleeding
    Evaluation & Management
    of GI Bleeding
    Management Principles
    Rapid, accurate assessment
    Severity
    Site
    ? Variceal
    NSAID use

    Resuscitation
    Stabilize before diagnosis, therapy & rebleeding
    prevention
    Endoscopic therapy
    Gold standard
    Suspect Variceal Bleeding if:
    Prior history
    Ethanol abuse
    Jaundice or stigmata of liver disease
    Poor Prognostic Features
    Severity of initial bleed
    Transfusion, BRB in NG aspirate, hypotension, tachycardia

    Age >60
    Comorbid disease
    Onset of bleeding in hospital
    Mortality 25% vs. 4%, Hb drop >1g/day

    Emergency surgery
    Mortality up to 30%
    Bleeding Site (Upper vs. Lower)

    NG tube
    Significance of negative aspirate

    Stool color
    Melena
    Rectal bleed: massive UGI vs LGI

    Mild elevation in Urea


    Resuscitation
    IV access
    Large-bore x 2, CVP, +-S-G catheter

    Replete volume with NS


    PCT ASAP
    When to transfuse?
    Age, comorbidity, ongoing bleed
    Resuscitation
    Correct coagulopathy
    >6 Units bld consider FFP, plt, Ca

    Close monitoring (+-in ICU)


    Protect airway
    If massive hematemesis

    Other
    IV Omeprazole
    IV Somatostatin / Octreotide
    • Suspicion of variceal bleeding
    Non-endoscopic Treatment:
    Nonvariceal Bleeding

    IV Omeprazole
    Evidence for benefit

    No benefit
    IV H2RA
    Iced saline lavage
    Non-endoscopic Treatment:
    Variceal Bleeding

    IV Somatostatin / Octreotide
    Suspicion of variceal bleeding

    Sengstaken-Blakemore tube
    IV Antibiotics
    Gram neg coverage
    Ceftriaxone, Ciprofloxacin
    Endoscopy
    Within 24 hrs
    Diagnostic & therapeutic benefit
    Reduction in rebleed, surgery, mortality
    • Cook et al Gastroenterol 1992

    Early endoscopy
    Ongoing bleed after resuscitation
    Suspicion of variceal bleeding
    Poor prognostic factors

    OGD, colonoscopy
    Small bowel evaluation
    Non-endoscopic evaluation

    Radionuclide scan
    Angiography
    Enteroclysis
    Capsule Endoscopy
    Tagged Red Cell Scan
    Mesenteric Angiography &
    Embolization
    Enteroclysis
    Enteroscopy
    Capsule Endoscopy
    Now the gold standard for small
    bowel evaluation
    Double-Balloon Enteroscopy
    Double-Balloon Enteroscopy
    Endo stigmata & rebleeding
    90%

    50%

    30%

    18%
    7% Post-Tx
    3%

    Clean Base Flat Spot Adherent Visible Arterial


    Clot Vessel Bleed
    Endoscopic Therapy

    Thermal methods
    heater probe
    electrocoagulation
    Nd:YAG laser
    Argon Plasma Coagulation (APC)
    Electrocoagulation
    Electrocoagulation
    Heater Probe
    Argon Plasma Coagulator (APC)
    APC
    Endoscopic Therapy
    Non-thermal
    Injection therapy
    Sclerosants: ulcer and variceal bleed
    Vasoconstrictors: ulcer eg. Adrenaline
    Histoacryl: variceal bleed
    Endoscopic variceal ligation for bleeding
    esophageal varices
    Endoscopic Accessories
    Bleeding Duodenal Ulcer
    Double-Balloon Enteroscopy
    Variceal Bleeding
    Different pathophysiology
    Portal Venous HPT >12mmHg due to
    cirrhosis
    Varices most commonly in
    esophagus, gastric fundus/cardia
    Bleeding risk related to varix size
    Variceal Bleeding
    Treatment of Variceal Bleeding
    IV antibiotics
    IV Octreotide / Somatostatin
    Esophageal
    Ligation vs. sclerotherapy vs. histoacryl injection

    Sengstaken tube

    TIPS

    Gastric
    Histoacryl injection

    TIPS
    Esophageal Varices
    Band Ligation
    of Varices
    Multi-band Ligator
    Variceal Ligation
    Portal Hypertensive Gastropathy
    Gastric Varices
    Histoacryl injection
    Sengstaken
    Tube
    Transjugular Intrahepatic Porto-Systemic
    Shunt (TIPS)
    Bleeding in Cirrhosis
    Lower GI Bleeding-
    Causes
    43%
    Diverticulosis
    20%
    Angiodysplasia
    12%
    Undetermined
    9%
    Neoplasia
    9%
    Colitis
    7%
    Other

    Boley SJ et al Am J Surg 1979


    Diverticular Bleeding
    Lower GI
    Bleed
    Post-endoscopy care

    Vital signs
    Urine output
    Continued/recurrent bleed
    Repeat FBC- when?
    ? Repeat endoscopy
    Summary
    GI bleeding is common
    Variceal bleeding has different
    pathophysiology, a/w increased
    mortality
    Evaluation & management are key
    Endoscopic Mx is definitive for most
    When to call the surgeon
    Only with Registrar/GI approval, prompt
    decision
    First approach with endotherapy
    Continued bleed > 24 hrs
    > 6 unit transfusion
    Recurrent bleed despite endotherapy
    Gastric Angiodysplasia
    Dieulafoy Lesion- Prepyloric
    Bleeding Duodenal Diverticulum
    Bleeding Duodenal Diverticulum
    Hemosuccus Pancreaticus
    Aorto-Enteric Fistula
    Gastric Cancer
    Gastric Cancer

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