Acute Gastrointestinal Bleeding
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15c – Acute gastrointestinal bleeding[edit | edit source]
Acute GI bleeding presents with :
- hematemesis (vomitting of blood) and/or
- melena (the passage of black tarry stool that has a very characteristic smell) results from the digestion of blood by enzymes and bacteria
Causes:
- peptic ulceration - 50%
- mucosal lesions (gastritis, duodenitis, erosions) 30%
- Mallory-weiss tear 5-10%
- Varices 5-10%
- Reflux oesophagitis 5%
- Angiodysplasia 2%
- Carcinoma, coagulopathies, aortoduodenal fistula, dieulafoy syndrome (rupture of a large tortuous submucosal artery on stomach)
History & examination:
- Past medical history ( peptic ulcer disease, previous bleeding, liver disease, previous surgery, coagulopathies)
- Drug history (NSAIDs, anticoagulant)
- Social history (alcohol abuse)
- Signs of acute substantial blood loss and shock (hypotension, tachycardia, tachypnea, pallor)
- Signs of liver disease and portal hypertension (spider neavi, portosystemic shunting and bruising)
- Blood test (anemia, urea, coagulation derangement)
- FBC might be normal immediately after an acute bleed but will fall once heamodilution has occurred
Management:
- Resuscitation:
- Administration high flow of oxygen
- Intravenous access + blood sample taken for cross match + iv fluid
- Nasogastric tube – to monitor the bleeding + prevent aspiration
- Urinary catheter
- Central or arterial line
- Volume replacement is gauged against pulse, blood pressure, urine output and central venous pressure
- Over or rapid transfusion with compromised cardiac function can lead to pulmonary edema
- Detection and endoscopic treatment:
- Aim: identify the bleeding point, arrest the bleeding and prevent recurrence
- Once resuscitation established, endoscopy is used to detect the site of bleeding
- Endoscopy may be used to stop or prevent further bleeding
- Risk of further bleeding : active bleeding from ulcer base, presence of visible vessel, and adherent of clot overlying the ulcer
- Sclerotherapy injection (adrenaline, sclerosant) commonly used
- Heat probs and clips
- Therapeutic endoscopy used in management of oesophageal and gastric varices and vascular malformation
- Angiography – only detect active bleeding greater 1ml/min -> selective embolization (may lead to mesenteric ischemia)
- Surgical management:
- Emergency surgery may be indicated if:
- endoscopy reveals bleeding from major artery
- attempted injection sclerotherapy is unable to control
- When bleeding recurs after therapeutic endoscopy, a further endoscopy may be able to control the bleeding
- Recurrent bleeding is associated with significant morbidity and mortality, particularly in elderly
- Continuing bleeding is particularly common in those with chronic ulcer and more common in gastric ulceration
- Duodenal ulcer :
- Simply be under-run with sutures, through a duodenectomy
- Once tolerating oral fluids, patient should be started on H.pylori eradication therapy empirically
- Gastric ulcer :
- The possibility of malignancy must be considered
- Ulcer must be biopsied to determine the nature
- Young, fit patient – ulcer should be excised completely by taking small wedge resection.
- Elderly – under-running of the ulcer may be preferable
- If confirmed malignancy – accurate staging and further treatment
- If benign – H.pylori eradication indicated
- NSAIDs should be avoided
References :
- Principles & Practise of Surgery – Chapter 17, Gastroduodenal disorders, page 232
- OHCM – Gastroenterology, page 244