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GIT Bleeding
GIT Bleeding
to
GIT bleeding
Ben Jugmohan
19 November 2017
Outline
• Introduction
• Definitions
• Differential diagnoses and Outcomes
• The 3 O’s
• Queries
• Summary
Not covered
• Anatomy
• Physiology
• How to resuscitate
Introduction
• Common problem in all settings
• Potentially fatal
• Frequently managed on an out-patient basis
• Prompt resuscitation, risk evaluation, provisional diagnosis and
further investigation
Definitions
• Traditional
• Upper GI
• Lower GI
• Newer anatomical definitions
• Upper
• Mid
• Ampulla of Vater to ileo-caecal
valve
• Lower
Definitions
• Overt
• Haematemesis, melaena
• haematochezia
• Occult
• Fe deficiency anaemia
• Positive stool occult blood
• Obscure
• No obvious cause after standard investigation
• Usually warrants investigation of the small bowel
Differential Diagnosis – Upper GIB
• Peptic ulcer disease Most
• Gastroesophageal varices common
• Erosive esophagitis/gastritis/duodenitis
• Mallory Weiss tear
• Vascular ectasia
• Neoplasm
• Dieulafoy’s lesion Rare, but cannot
• Aortoenteric fistula afford to miss
Am J Gastroenterol
2004;99:619
Initial Assessment
• Always remember to assess A,B,C’s
• Assess degree of hypovolemic shock
• 921 pts
• Liberal (9g/dl) vs restrictive (7g/dl)
• Haemodynamically stable
• 6 week survival, rebleeding rates, other adverse outcomes
• Better outcomes for restrictive strategey
Approach to Overt GI bleeding
• Resuscitation
• ? Transfusion
• How and when to investigate ?
Non-responder
• Transfer to theatre
• Senior personnel
• Endoscopy and all adjuncts
• Be prepared to operate
Responder
• Upper GI
• Variceal
• Gastroscopy within 12 hours
• Non-variceal
• Gastroscopy within 24 hours
• Lower GI
• Gastroscopy within 24 hours
• Colonoscopy and/ or radiological imaging
Approach to Overt GI bleeding
• Resuscitation
• ? Transfusion
• How and when to investigate ?
• Therapy
Non-variceal UGIB
• PUD/ Gastritis/ MW
• PPI
• NPO
• ?NGT
• Bloods
• Stratify
• Endoscopy
• Re-stratify
Rockall Scoring System
• Validated predictor of mortality in patients with UGIB
• 2 components: clinical + endoscopic
Variable 0 1 2 3
Gut 1996;38:316
Clinical Rockall Score – Mortality Rates
60%
50%
40%
30%
20%
10%
0%
0 1 2 3 4 5 6 7
AIMS65
• Simple risk score that predicts in-hospital mortality, LOS, cost in
patients with acute UGIB
lbumin <3.0
NR > 1.5
ental status altered
ystolic BP <90
+ years old
Gastrointest Endosc 2011;74:1215
AIMS65
Gastrointest Endosc
2011;74:1215
Blatchford Score
Lancet
2000;356:1318
Forrest Classification
Endoscopic Observation Rebleeding Chance %
60%
40% 55
43
20%
22
0% 5 10
Clean base Flat spot Adherent Nonbleeding Active
clot visible vessel bleeding
Am J Gastroenterol 2005;100:2395
Urgent Colonoscopy – RCT#2
• 85 patients with serious hematochezia (hemodynamically significant,
Hgb drop > 1.5 g/dL, blood transfusion)
• EGD performed within 6 hours
• If EGD negative, randomized to urgent (<12 hr) or elective (36-60 hr)
colonoscopy
• Primary endpoint = further bleeding
• No evidence of improved outcomes
Am J Gastroenterol 2010;105:2636
Radiographic Studies
Multi-Detector CT (CT angio)
• Readily available, can be
performed in ER within 10
minutes
• Can detect bleeding rate of 0.5
ml/min
• Can localize site of bleeding (must
be active) and provide info on
etiology
• Useful in the actively bleeding but
hemodynamically stable patient
Gastrointest Endosc 2010;72:402
Occult bleeding
benjugmohan@gmail.com
076 371 5120