GI Hemorrhage* David HughesIncidencel1-2% of all hospital admissionslMost common diagnosis of new ICU admitsl5-12% mortalityl40% for recurrent bleedersl85% stop sponateouslylThose with massive bleeding need urgent interventionlOnly 5-10% need operative intervention after endoscopic interventionsSitelUpperlEsophageallStomachlDoudenumlHepaticlPancreaticlLowerlSmall bowellColonlAnusEtiologyl85% are due to:lPeptic ulcer diseaselVariceal hemorrhagelColonic diverticulosislAngiodysplasiaChain of eventslRecognize severitylEstablish access for resusitationlResusitatelIdentify sourcelInterventionQuestion #1lJB a 30 y/o with hematemesis presents with orthostatic hypotension, clammy hands, but without tachycardia. How much blood has he lost?l40%l20-40%l10-20%l6 units over 24 hoursEarlier for elderly, multiple co-morbiditiesPeptic ulcer hemorrhagelAnti-secretory surgery?lIndicated for NSAID pts who need to continued medslH. pylori ulcer disease controversialOnly 0.2% of pts every require surgery for bleeding ulcerSurgery pts had lower than average H. pylori positivityOversewing and antibiotics still leave 50% at high risk for rebleedinglBottom line: still recommended but without definitive evidencePeptic ulcer hemorrhagelDoudenal ulcerExpose ulcer with duodenotomy or duodenopyloromyotomy Direct suture ligation, four quadrent ligation, ligation of gastroduodenal arteryAnti-secretory procedurelTruncal, parietal cell vagotomylIf unstable can use medsPeptic ulcer hemorrhagelGastric ulcer10% are maliganant30% will rebleed with simple ligationlNeed ResectionlDistal gastrectomy with Bilroth I or II lSubtotal gastrectomy for 10% high on lesser curveVariceal hemorrhagelCirrhotics usuallyl25% mortality for each bleeding episodel75% will rebleedl50% mortality with surgerylBased on Childs classSomatostatin or vasopressin w/wo NTGShunt proceduresSugiura procedureTIPSOther sources of UGI hemorrhageMucosal lesionsGastritis, ischemia, stress ulceration Key is prevention with acid supression Surgery often requires resection and Roux-en-Y due to multiple bleeding sites 50% mortality with surgeryMallory-Weiss10% will have significant bleeding 90% stop spontaneously Surgery rare, but gastrotomy with oversewing effectiveDieulafoys Wedge rxn after endoscopic markingAortoenteric fistula1% of AAA repair patients Herald bleed preceeds exsangunation by hours to days Endoscopy and if negative CT scan and if negative angiography Surgery graft removal and extraanatomic bypassLGI hemorrhagelSiteslColon 95-97%lSmall bowel 3-5%lOnly 15% of massive GI bleedinglFinding the sitelIntermittent bleeding commonlUp to 42% have multiple sitesBleeding diverticulosisBleeding diverticulosisColonic angiodysplasiaLGI hemorrhagelEtiologyDiverticulosis 40-55%Right sided lesions left 90% stop spontaneously 10% rebleed in 1st year and 25% at 4 yearsAngiodysplasia 3-20%Most common cause of SB bleeding in 50 y/o 50% are in right colonNeoplasiaTypically bleed slowlyInflammatory conditions15% of UC patients, 1% of chrons patients Radiation, infectious, AIDS rarelyVascularHemorrhoids 50% have hemorrhoids, but only 2% of bleeding attributed to themOthersLGI hemorrhagelEvaluationlSame for UGI bleedlIf unstable with hematochezia need EGD 1stlAfter stablelRectallAnoscopy for hemorrhoidsLGI hemorrhage diagnosticslColonoscopylWithin 12 hours in stable patients without large amounts of bleedinglSelective viseral angiographylNeed 0.5 ml/min bleedingl40-75% sensitive if bleeding at time of examlTagged RBC scanlCan detect bleeding at 0.1 ml/minl85% sensitive if bleeding at time of examlNot accurate in defining left vs right colonMeckels DiverticulumCecal angiodysplasia with extravasationSmall bowel ulcerationdue to NSAIDSLGI hemorrhage treatmentlEndoscopyGreat for angiodysplasia and polypectomy siteslAngiographicSelective embolization for poor surgical candidatesCan lead to ischemic sites requiring later resectionlSurgeryOngoing hemorrhage, 6 units or ongoing transfusion requirementSite selection lBlind segmental will rebleed in 75%lBased on TRBC scan will rebleed in 35%GI hemorrhage from unknown sourcelOnly 2-5% are not upper or lowerlAverage patient26 month duration of intermittent bleeding1-20 diagnostic testsAverage of 20 units transfusedLocalization of GIHOUSlCT scanTumors, inflammation, diverticulilEnteroclysisUlcerations, inflammationOnly 10-20% yeild (SBFT is 0-6%)lMeckels scanInitial test for patients 30 years oldlEndoscopyPush or pull endoscopyVideo capsule endoscopyIntraoperative endoscopy 70% successfulEtiology of GIHOUSlArteriovenous malformation 40lSmall bowel leiomyoma 11lSmall bowel adenocarcinoma 7lSmall bowel lymphoma 6lCrohns disease 6l“Watermelon” stomach 4lMeckels diverticulum 4lSmall bowel leiomyosarcoma 3lMetastatic colon carcinoma to small bowel 3lSmall bowel varices 3lSmall bowel melanoma 3lOthers 10Szold A, Katz L, Lewis B: Surgical approach to occult gastroint