Gastrointestinal Hemorrhage

Dr J.M. Adotey
Dept of Surgery
University of Port Harcourt Teaching
Hospital
1st September 2008

Gastrointestinal Bleeding
Types - Upper
- Lower
Acute - immediately life threatening/profuse
Chronic - slow bleed anemia
Causes
1. Upper
Common - Ulcers - DU
- GU

- Erosions - Gastric
- Duodenal
- Esophageal
- Mallory Weiss tear
Rare

- Esophageal Varices
- Tumor - benign
- malignant

-Vascular lesion- Deulafoys

(AV malformation)

- Stress ulcer
- Diffuse antral vascular ectasia
(watermelon stomach)
- Chemotherapy - 2-tumor necrosis

- angiodysplasia

-Thrombocytopenia

- aorto-enteric fistula
Very rare

- duodenal diverticula
- hereditary hgic
telengiectasia

2. Lower
Common - sigmoid diverticular disease
- ulcerated angiodysplasia of
submucosa of R colon
Less common - hemorrhoid spontaneous large
lesion
- post hdectomy 2/52
- severe colitis
- occasionally Meckels
- major upper GI hge
- typhoid

- colonic tumors
Patient - usually middle-aged or elderly.

Upper GI bleeding - common emergency

- attracts mortality of about 5%
- esophagogashoduodenoscopy
is investigation of choice
- medical Rx is ineffective
- therapeutic endoscopy may be
useful
- elderly (and unfit) patients need
more urgent surgery

Management
- combined approach - surgeon
-physician(gastroenterologist)
- 3 cardinal steps
1 Vigorous resuscitation of initial bleed
restore hdynamic stability
- IV access
- Gp & Xmateh blood
- plasma/ plasma expanders
- crystalloids - N/saline
- D/saline

- screened whole blood

- CVP line
- Urethral catheterisation
monitor for re-bleed & treat
NG tube
O2 by mask
Confusion/ restlessness - 2o - hypoxemia
- hyporolemia

2 Prompt - History
- Exam

- Investigation
Upper GI endoscopy
emergency mesenteric angiography
small bowel enteroscopy
colonoscopy - unhelpful
flexible sigmoidoscopy (out enema)
NB Angiography - helpful if blood loss
> 0.5 - 1 ml/min
3 Measures to arrest hige & prevent further/rebleed
- correct any coagulopathy ( FFP)

- Therapeutic endoscopy - injection- adrenaline

-sclerosant
- laser photocoagulation
- bipolar diathermy coag.
Repeat endoscopic intervention - dangerous
- mortality
- Surgery - major initial bleed
- large vessel in ulcer base
- re bleed in hospital
- advanced age
- > 6 units blood

- preceded by upper GI endoscopy

- identify site
- except torrential bleed
- then after induction

Type of Surgery
Depends on cause
DU - arrest hge (ligate/undersew nonabsorb) +
Vagotomy
- monitor for rebleed especially in 72 hrs
postoperative.
GU - undersew small Dieulafoys lesion
- subtotal gastrectomy + (excision of ulcer)
- some always gastrectomy in all cases

b/c - re bleed
- fear of malignancy
- Bilroth I or II anastom
- high lesser curve ulcer-PAUCHET
manoeuvre
- since most patients elderly
- minimum surgery
- inhibit acid pharmacologicaly
- eradicate H. pylori to prevent recurrence
- NSAIDS - withdraw
- give antisecretory agents

- ZE - proton pump inhibitors in long term

- surgery - if gastrinoma can be
adequately removed.

Esophageal variceal bleeding:

Endoscopy - exclude other causes - DU
- gastritis
A. Nonsurgical
- Endoscopic Sclerorx- alchohol, ethano
- Banding (as effective
Problems expertise reqd, recurrence
- esoph. Ulceration, perf, stricture
- mediastinitis
- bacteremia
- endocarditis
- pneumoperitoneum
- portal vein thrombosis

- Balloon tamponade Sengs/ Blakemore

- Linton
- 12 24 hours
- Problems Secretions aspiration
- Perforation esoph
- headward slide of esoph. balloon
- linear ulcer in esoph. bleed
- Drugs
-Vasopressin
- Glypressin
- Terlipressin
- for both initial control and prophy
- Somatostatin
- Octreotide
- Propranolol prevention after intial Rx

B. Surgical Rx
- about 85% controlled by non Surg Rx
- continuing bleed/or recurrence after intial control
- majority high risk
- Esoph. transection (stapled) Childs A/good B
- Portosystemic shunt Childs A/good B
- Hepatic transplant Childs C
- Recently TIPSS

Childs classification of hepatocellular function in

liver disease
Group designation

Bilirubin (mg dl-1)

< 2.0
2.0-3.0
> 3.0
Albumin (g dl-1)
_> 3.5
3.0-3.5
< 3.0
Ascites
None Easily controlled poorly controlled
Neurological disorder None
Minimal
Advanced
Nutrition
Excellent Good
Wasting

- oral neomycin & lactulose

N2 absorption
incidence of enceph
TIPPS - transjugular intrahepatic portosystemic stent
shunt (interventional radiologic procedure)
- extrahepatic vascular anatomy preserved
- hepatic transplant therefore remains an option
- technically demanding
- contraindication - portal vein occlusion
- complication- liver capsular rupture
- fatal hge
- stent stenosis

Open surgical shunt

- in area out - facilities/skills
- most will avoid acute surgery
- b/c increased op mortality
- b/c liver transplant/TIPPS surg shunt
- rarely for Rx of acute variceal bleed b/c
mortality
- main indication is Child A patient
- effective for re-bleed
- selective (splenorenal) -low incidence of PSE
- preserves h. blood flow

Mallory- Weiss - longitudinal tear below GEJ

- sometimes extends into lower end
esophagus
- many dont bleed
- mid-age alcoholic
- repetitive,strenuous vomiting
(retching)
- endoscopy - may be missed (because
difficult U turn)
- gastrotomy + under-run
- 90% subside spontaneously

Lower GIB - if no pre-op cause found

Reaction - subtotal colectomy + ileostomy
- 2nd surgery ileo rectal anast.
- in between any hge easily
identified
OR
- transverse split colostomy
- later a hemicolectomy