GI bleeding short note by S.

Wichien (SNG KKU)

UGIB Cause 1.PUDU>GU (elderlyGU>DU) 2.varice,gastritis,duodenitis,esophagitis,AVM Varice -painless -hematemesis -chronic liver -tachycardia -hypoT Non varice pain or painless hematemesis/melena no chronic liver vary vary Prognosis factor 1.clinical prognosis factor -> 60 yr -shock? -underlying? -PRC > 6 u -active bleeding 2.endoscopic finding Forrest class 1a-spurting 1b-oozing 2a-NBVV /end on A 2b-adherent clot 2c-pigment spot 3-clean base

Melena -black, tarry stool -50 cc = melena -10 cc = FOBT +ve -bleed from smb/colon if stasis > 12 hr :can melena Hematochezia -bleed from LGI 175 cc -bleed from UGI must > 750-1000 cc NSAIDs & ASA -can ulcer along GI tract Large hiatal hernia -Cameron ulcer AAA -aortoduodenal fistula

%rebleed 100 50 40 20 10 5

endo Tx must must must +/observe observe

3.clinical+endoscopic finding Rockall score 0 1 2 3 1.age <60 60-79 >80 2.shock no PR>100 SBP<100 3.comorbid IHD,HF RF,LF 4.EGD mallory PU CA 5.EGD clean base blood clot spot spurting <3=good prognosis >8=hi risk motality Blatchford score (Score 0-23) 1SBP 100-109=1 90-99=2 <90=3 2.BUN 6.5-7.9=2 8-9.9=3 10-24.9=4 >25=6 3.Hb Men : 12-12.9=1 10-11.9=3 <10=6 Women : 10-11.9=1 <10=6 4.other pulse >100=1 melena=1 syncope=2 hepatic ds=2 HF=2

GI bleeding short note by S.Wichien (SNG KKU)

Endoscopy -low risk+stable=elective case -hi risk+stable=early in 24 hr Adherant clot 2 option 1.removed clot -adrenalin before remove -if NBVVTx 2.no Tx -PPI 80mg iv then 8mg/hr Technique 1.injection -tamponade effect -adrenalin 1:10000,glue,NSS -4 point0.5cc/point -then clip or heater probe 2.Thermal coagulation -monopolar/bipolar/laser/heater probe -argon plasma coagulator 3.mechanical technique -hemoclip Sx management I/C for Sx 1.persist hypoT 2.failed 2nd endo Tx 3.PRC >6 u in 24 hr 4.no blood/endoscopist Bleeding DU 1.Suture ligation (3 point ligation) -1&2=upper&lower stitchcontrol GDA -3=U-stitchcontrol transverse panc A 2.Additional procedure (stable pt) recur 1.TV&D 10% 2.TV&A <1% 3.HSV 10-20% Bleeding GU Low risk -Type1,4partial gastrectomy include ulcer -Type2,3as above+TV Hi risk -suture ligate+biopsy -rebleed 20-40% Stress ulcer -dec blood flow (not hyperacid or H.pylori) -often fundus -burncurling ulcer ICHcushing ulcer Mallory weiss synd -linear partial taer lesser curve below EGJ -90% can spon stop -<5% can not stop by scope :prox gastrotomy :not acid reducing sx Dieulafoy lesion -submucosal artery -protrude via mucosal erosion -5 cm from EGJ -chronic intermittent bleeding -male, middle age -endoscope findings :flat/protudeberant vv, arterial bleeding Tx (not acid reducing sx) 1.endo injection 2.embolize2nd lne 3.suture ligate/wedge resection Watermelon stomach -vascular ectasia -female, elderly -antrum -venous bleeding -chronic blood loss -endoscope findingsas portal gastropathy Tx 1.endoscopic Tx 2.if need sx=antrectomy Leiomyoma & sarcoma -submucosa -bleed from central ulceration Tx -wedge resection margin 2-3 cm -if invade local organ=en bloc resection Aorto-enteric fistula Tx -open+remove graft -closed fistula tract -extra anatomical bypass or ATB impregnated in situ graft Hemobilia Tx--angiographic embolization

GI bleeding short note by S.Wichien (SNG KKU)

LGIB UGIB : LGIB : OGIB = 75:20:5 Definition -acute LGIB within 3d -chronic LGIB >3d -massive LGIB--PRC>=4u/d -occult LGIBFOBT+ve -obscure LGIBunknown cause Location -colon 80-85% -anorectal 10% -smb 5% -unknown Etiology Young adult 1=meckel 2=IBD & polyp Adult-60 year 1=colon diverticulum 2=IBD & tumor >60 year 1=angiodysplasia 2=colon diverti & tumor Diagnostic modality 1.NG tube -r/o UGIB 2.colonoscope -can localize 70-90% -can urgent colonoscope 3.RBC scan -screening test (for angiogram?) -detect bleed 0.1 cc/min -poor localization 4.selective mesenteric angiography -detect bleed > 0.5-1 cc/min -femoral approach -SMAIMAceliac -can Tx by embolization or vasopressin Approach 1.no active bleed or stop -bowel prepcolonoscope 2.active or continuous bleed Stable -moderate bleedRBC scan -active bleedshift to angiogram -urgent colonoscope Unstable -EL/intra op endoscope Operative Tx 1.unknown bleeding site -lithotomy -midline incision -colonoscope (+/- nss irrigate via appendix) +vesegmental resection -ve/unstablesubtotal colectomy 2.Known bleeding site Post polypectomy -endoscopic Tx Diverticulosis -active bleeding : rt > lt 1.endoscopic Tx 2.angiographic embolization 3.open Sx Angiodysplasia -degenerative lesion -venous bleeding -rt > lt -endoscopic tx Rectal dieulafoy -pulsatile A bleeding -endoscopic Tx Radiation proctitis -formalin chemical coagulation

GI bleeding short note by S.Wichien (SNG KKU)

Obscure GIB -5% GIB -intermittent bleeding -smb lesion Etiology >50 year 1.angiodysplasia 2.tumor, telangiectasia 30-50 year 1.tumor 2.UC <30 year 1.meckel 2.Peutz jegher syndrome Osler Weber Randau Approach 1.DDx 2.repaet upper & lower scope 3.Push enteroscope 4.capsule endoscope 5.RBC scan or angiogram (active bleed) 6.intraop endoscope *enteroclysis & GI follow through -if not suspect tumor/polypshould not do -+ve only <20% OGIB Tx 1.endoscopic Txvascular lesion 2.sx resectiontumor, meckel, fail1 *dont EL if not know lesion except severe bleeding/unstable