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Dr. Mohamed AlshekhaniProfessor in Medicine

MBChB-CABM-FRCP-EBGH2016

GIB

Introduction:• Upper :80%• Lower :15% • SIB:5%• Proximal or distal to the ligament of Treitz.

Upper Gastrointestinal Bleeding• Presents with:• Hematemesis (bright-red or “coffee-ground” emesis)• Melena (black, tarry-appearing stool)• Or very rarely hematochezia or bright red blood per rectum due to

briskly UGIB, which is associated with increased mortality.

UGIB: Causes

• 80% is due to 4 causes: • PUD• EV• Esophagitis• Mallory-Weiss tear.

• Bleeding in 80% stops spontaneously• 20% have persistent or recurrent bleeding, increasing mortality.

UGIB: Causes• Slow &/or chronic bleeding:• Suggested by history of IDA.• Typical of erosive disease: tumor, esophageal ulcer, portal

hypertensive gastropathy, Cameron lesion (5%, eroded large hiatal hernias)& angiodysplasia.

UGIB:Causes• Causes of brisk&/or severe upper GIB that increase mortality. • Peptic ulcer• Esophagogastric varices• Dieulafoy lesion• Aortoenteric fistula• Hemobilia: usually from liver or biliary procedural complication or

gallstone complications, tumors &angiodysplasia. • Hemosuccus pancreaticus: (pseudoaneurysm/aneurysm)• Neoplasm• Esophageal lesions• Gastric GIST

UGIB : evaluation by History• H/O chronic alcohol abuse: a clue to the possibility of VH. • Chronic dyspepsia: PUD.• NSAIDs use: PUD.• H/O Aortic aneurysm repair: aortoenteric fistula.

UGIB : evaluation by History• Predictors of severe GIB are:• Hematemesis• Comorbidities (such as cirrhosis or malignancy)• HD instability• Hb <8 g/dL (80 g/L). • bleeding source.

UGIB : evaluation aims• Assessing severity.• Differentiating upper from lower GIB sources. • Determining the need for interventions.

Evaluation: assessing severity• Outpatient management is usually appropriate when the following

criteria are met: • BUN<18.2 mg/dL (6.5 mmol/L)• Normal Hb• Systolic BP>109 mm Hg• PR< or equal to 100/min• Absence of: melena, Syncope,Liver disease,Cardiac failure.

Evaluation: assessing severity• Risk-stratification tools guides decisions regarding:• Hospital admission. • Discharge home from ER. • Urgent endoscopy (within 12 hours)• Non-urgent endoscopy (within 24 hours)

Evaluation: assessing severity• Severity scoring:• Best validated &most useful is Glasgow-Blatchford score (0-23), of 9

variables: BUN (0-6 points), Hb (0-6), SBP(0-3), PR(0-1), melena (0-1), syncope (0-2), hepatic disease (0-2 points)& HF(0-2).

• Has a nearly 100% NPV for severe GIB& the need for hospital-based intervention (blood transfusion, endoscopic therapy, TC arterial embolization, surgery).

• UGIB is most reliably predicted by 4 variables: melena, NGT with blood or “coffee grounds,” BUN/ Cr > 30 & absence of blood clots in the stool.

UGIB Management:

• 1. Pre-endoscopic care (resuscitation, hemodynamic monitoring, PPI therapy, attention to coagulopathy)

• 2. Early endoscopic evaluation (with excellent endoscopic vision) & treatment.

• 3. Postendoscopic care & risk reduction.

UGIB Management:• Pre-endoscopic Care:• 1.Resuscitated with crystalloids to reach physiologic endpoints (PR

<100/min, SBP>100 mm Hg&resolution of orthostasis).• 2.Blood transfusion indicated:• A. HD instability &ongoing bleeding or susceptibility to

complications from hypoxia (for example IHD).• B. Target Hb < 7 g/dL, if HD stable with no active or massive

bleeding. • 3.Early (pre-endoscopic) PPI does not improve clinical outcomes

(bleeding, surgery, mortality) but is safe & reduces the likelihood of detecting ulcers with high-risk stigmata & need for endoscopic trt.

• 4.Coagulopathy (INR >1.5) corrected with FRP not vit K (delayed full therapeutic effect) in actively bleeding receiving anticoags.

• 5.Octreotide & antibiotics should be given before endoscopy for suspected variceal bleeding.

UGIB Management:

• NGT is not required for diagnosis, prognosis, visualization, or therapeutic effect.

• Routine use of prokinetics is not recommended except when patients are suspected of having large amounts of blood in the UGIT; in such cases, erythromycin can be given prior to upper endoscopy.

UGIB Management:

• Endoscopic treatment:• Upper endoscopy within 24 hours of presentation in patients with

features of UGIB.• Endoscopy within 12 hours is generally recommended only for

patients with suspected variceal bleeding.• Low-risk ulcers not requiring endoscopic intervention are clean-

based or have a non-protuberant pigmented spot.• Intermediate-risk ulcers have adherent clots & should be vigorously

irrigated to dislodge the clot & reclassified based on appearance. • High-risk ulcers that require endoscopic treatment: active arterial

spurting or a non-bleeding visible vessel &.• Routine second-look endoscopy is not required after UGIB unless

rebleeding occurs or the initial examination was incomplete.

UGIB Management:

• Post-endoscopic Care & Risk Reduction:• Post endoscopic PPI improves outcome after endoscopic

interventions.• PUD tested for H pylori &If positive, eradication done &confirmed.• If negative, retesting done with an alternative method BZ of false-

negative results with bleeding, PPI, or concomitant antibiotics.• Aspirin should be resumed within 3 - 5 days for patients with

established CVD. • Long-term PPI may not be necessary for aspirin users who undergo

H. pylori testing &eradication.• Long-term, daily PPI should be offered to aspirin users who are H.

pylori negative or those who use concomitant NSAIDs, anticoagulants, glucocorticoids, or other antiplatelets.

Variceal bleeding Management:

• Octreotide / telipresin infusion & antibiotics are given even if this is suspected.

• FLuid resuscitation is preferred with crystaloids.• Endoscopic intervention can be done safely even with INR up to 2.5

& above that, correction done with FFP.• Endoscopic band ligation is preferred over sclerotherpay for acute

esophageal variceal bleeding.• For bleeding gastric varices cyanoacrylate sclerotherpay is preferred

over band ligation.• When the above measures fail, temponade with esophgeal balloons

as Baltimore-Sengestaken tube is used as bridge to more definitive therapies as TIPS or surgery.

• NS Beta-blockers are used after the control of the bleeding.

LGIB:

• Typically occurs in elderly.• Presents with hematochezi; acute bright red blood per rectum or

red- or maroon-colored stool. • HD instability is less common but, if present, raises the possibility of

a briskly bleeding UGI source.

LGIB:

• Causes:• Diverticulosis 30%• Colitis 24%• Ischemic 12%• IBD 9%• Radiation 3%• Hemorrhoids 14%• Postpolypectomy 8%• Colon polyps or cancer 6%• Rectal ulcer 6%• Angiodysplasia 3%• Other 6%.

LGIB:

• Causes of severe LGIB:• Diverticulosis• Aortoenteric fistula• Colonic or rectal varices• Dieulafoy lesions• Neoplasm• Colitis• Ischemic• IBD• Infectious• Intussusception• Meckel diverticulum• Angiodysplasia

SIB or Obscure GIB

• Relatively uncommon ; 5–10% of GIB. • with advances in SI imaging(VCE, deep enteroscopy& radioimaging)

the cause of bleeding in SI identified in most patients. • OGIB should be reserved for patients in whom a source of bleeding

cannot be identified anywhere in the GI tract. • SIB should be considered in patients with GI bleeding after

performance of a normal upper & lower endoscopic exams. • Second-look exams using upper endoscopy, push enteroscopy&/or

colonoscopy can be performed if indicated before SB evaluation. • VCE should be considered a first-line procedure for SIB& should be

performed before deep enteroscopy if there is no contraindication. • Any method of deep enteroscopy can be used when endoscopic

evaluation& therapy are required.

SIB or Obscure GIB

• CTE should be performed in patients with suspected obstruction before VCE or after negative VCE exams.

• When there is acute overt hemorrhage in the unstable patient, angiography should be performed emergently.

• In patients with occult hemorrhage or stable patients with active overt bleeding, multiphasic computed tomography should be performed after VCE or CTE to identify the source of bleeding & guide further management.

• If a source of bleeding is identified in the small bowel that is associated with significant ongoing anemia and/or active bleeding, the patient should be managed with endoscopic therapy.

• Conservative management is recommended for patients without a source found after SB investigation, whereas repeat diagnostic investigations are recommended for patients with initial negative SB evaluations & ongoing overt or occult bleeding.

BO5:1

• 1.The most common type of GIB is:• Upper.• SIB.• Lower.• Obscure.• None of the above.

BO5:2

• 2.The least common type of GIB is:• Upper.• SIB.• Lower.• Overt.• None of the above.

BO5:3

• 3.The most common presentation of UGIB is:• Fresh hematemesis.• Melena.• Hematochesia.• Cofee-ground vomiting.• None of the above.

BO5:4

• 4.The most common presentation of LGIB is:• Fresh hematemesis.• Melena.• Hematochesia.• Cofee-ground vomiting.• None of the above.

BO5:5

• 5.The following can be a presentation of UGIB except:

• Fresh hematemesis.• Melena.• Hematochesia.• Cofee-ground vomiting.• None of the above.

BO5:6

• 6.The following are essential component of significant UGIB except:

• IV access.• PPI.• Upper endoscopy.• NG Tube.• Blood grouping and cross match.

BO5:7

• 7.The prokinetic of choice in severe upper GIB is:

• IV metochlorpromide.• IV erythromycin.• Oral erythromycin.• Oral domperidone.• None of the above.

BO5:8

• 8.Interventions that improve survival in severe upper GIB include all except:

• Endoscopic hemostasis if indicated.• Pre-endoscopy PPI.• Post-endoscopic PPI.• Radiological intervention.• Surgery.

BO5:9

• 9.The need for endoscopic intervention is decided by:

• Forrest classification.• Blackford scoring.• Glasgo scoring.• Apgar scoring.• Non of the above.

BO5:10

• 10.The following endoscopic lesions warrants endoscopic intervention during UGIB except:

• Spurting vessel.• Oozing lesion.• Visible vessel.• Adherent clot.• Ulcer with pigmentation.

BO5:11

• 11.The endoscopic intervention of choice for severe UGIB is:

• Single.• Dual.• Triple.• All.• None.

BO5:12

• 12.H Pylori testing during UGIB is frequently:• False positive.• False negative.• Accurate.• Need need not to be repeated.• All of the above.

BO5:13

• 13.The first step in managing severe LGIB is:• Colonoscopy.• Exclude upper GI source.• Surgery.• IV PPI.• All of the above.

BO5:14

• 14.The best approach in managing severe LGIB which can not be hemoynamicly be stabilized is:

• Angiographic intervention.• Colonoscopy.• Surgery.• IV PPI.• All of the above.

BO5:15

• 15.Endoscopy in non-variceal UGIB is indicated within:

• 12 hours.• 24 hours.• 36 hours.• 48 hours.• 72 hours.

BO5:16

• 16.Endoscopy in variceal UGIB is indicated within:

• 12 hours.• 24 hours.• 36 hours.• 48 hours.• 72 hours.

BO5:17

• 17.The following should be given in suspected variceal UGIB except:

• Somatostatin.• Telepressin.• PPI.• Antibiotics.• Crystaloides.