GI Bleed

Question 1

What are the types of GI bleed

Answer 1

1. Acute or Overt GI Bleeding:
   
   • Hematemeis: Vomiting blood, which can appear bright red or like coffee grounds.
   • Melena: Black, tarry stools, usually indicating upper GI bleeding.
   • Hematochezia: Passage of fresh blood through the anus, typically indicative of lower GI bleeding, though it can sometimes result from massive upper GI bleeding.
2. Chronic or Occult GI Bleeding:
   
   • Occult Bleeding: Not visible to the patient but can be detected through tests such as fecal occult blood tests (FOBT) or by identifying iron deficiency anemia.
   • Chronic Bleeding: Gradual blood loss over time, often leading to anemia without overt signs of bleeding.
3. Obscure GI Bleeding:
   
   • Definition: Persistent or recurrent bleeding with an unidentified source after upper endoscopy and colonoscopy. This often points to a bleeding site in the small intestine.

Question 2

What are the classifications of GI Bleed?

Answer 2

1. Upper GI Bleeding:
   
   • Location: Originates from the esophagus down to the ligament of Treitz, which is located at the duodenojejunal flexure.
   • Common Causes: Peptic ulcer disease, esophageal varices, portal gastropathy, gastric erosions/gastritis, esophagitis, duodenitis, upper GI cancers, Mallory-Weiss tear, and use of certain medications like NSAIDs, steroids, and anticoagulants.
2. Lower GI Bleeding:
   
   • Location: Originates distal to the ligament of Treitz.
   • Common Causes: Although not detailed here, lower GI bleeding commonly arises from conditions such as diverticulosis, colorectal cancer, hemorrhoids, and inflammatory bowel disease.

The Ligament of Treitz is an anatomical landmark that defines the boundary between the upper and lower GI tract. It is a thin muscle connecting the junction of the duodenum and jejunum to the diaphragm. Clinically, this ligament is essential in distinguishing the source of GI bleeding.

Question 3

• Incidence: 100 per 100,000 people.
• Comparison to Lower GI Bleeding: UGIB is five times more common than lower GI tract bleeding.
• Emergency Admissions: Accounts for 5% of emergency admissions.
• Natural Course: 80% of UGIB cases stop bleeding spontaneously.
• Mortality Rate: 7-10% of cases result in death.
• Re-bleeding: Increases mortality by 10 times, highlighting the importance of monitoring and preventing re-bleeding episodes.

Question 4

What are the causes of upper GI Bleed

Answer 4

1. Peptic Ulcer Disease (PUD): Accounts for 25-50% of UGIB cases. Ulcers in the stomach or duodenum can erode into blood vessels, causing significant bleeding.
2. Esophageal Varices: These are enlarged veins in the esophagus, often due to liver cirrhosis, and are responsible for 80% of the mortality related to UGIB.
3. Portal Gastropathy: A condition associated with liver disease where the stomach lining becomes congested with blood and prone to bleeding.
4. Gastric Erosions/Gastritis: Inflammation or erosion of the stomach lining can cause bleeding.
5. Esophagitis: Inflammation of the esophagus, often due to acid reflux, can lead to bleeding.
6. Duodenitis/Duodenal Erosions: Similar to PUD, inflammation or erosion in the duodenum can cause bleeding.
7. Upper GI Cancers: Tumors in the stomach or esophagus can bleed, sometimes massively.
8. Mallory-Weiss Tear: A tear in the mucosa at the junction of the stomach and esophagus, usually due to severe vomiting or retching.
9. Drugs:
   
   • NSAIDs: Nonsteroidal anti-inflammatory drugs can cause mucosal damage and bleeding.
   • Steroids and Anticoagulants: Increase the risk of bleeding, particularly in combination with other risk factors.
10. Gastrointestinal Stromal Tumors (GIST): Rare tumors in the GI tract that can cause bleeding.

Question 5

GI bleeding is a potentially life-threatening condition, but with prompt and appropriate intervention, many cases can be managed effectively. Initial steps include resuscitation and stabilization of the patient, followed by diagnostic procedures to identify the source of bleeding. Endoscopy is the primary diagnostic tool, particularly for upper GI bleeding, offering both diagnostic and therapeutic options.

Question 6

What are the causes of #### Upper Gastrointestinal (GI) Bleeding:

Answer 6

Upper GI bleeding occurs due to a variety of anatomic and pathophysiologic factors, including:

1. Ulcerative Causes:
   
   • Peptic Ulcer Disease (PUD): The most common cause of acute upper GI bleeding. This includes bleeding from ulcers in the stomach and duodenum, often exacerbated by the use of aspirin and NSAIDs. The acidic environment of the stomach and duodenum can erode blood vessels, leading to significant hemorrhage.
2. Vascular Causes:
   
   • Variceal Hemorrhage: Enlarged veins (varices) in the esophagus or stomach, typically resulting from portal hypertension due to liver cirrhosis, can rupture and cause massive bleeding.
   • Vascular Ectasias and Dieulafoy’s Lesions: These are abnormal, dilated blood vessels in the GI tract that can bleed spontaneously.
3. Traumatic Causes:
   
   • Mallory-Weiss Tear: A tear at the gastroesophageal junction caused by severe vomiting or retching.
4. Iatrogenic Causes:
   
   • Post-procedural Bleeding: Bleeding that occurs as a complication of medical procedures such as endoscopy, surgery, or biopsy.
5. Neoplastic Causes:
   
   • Gastric and Esophageal Cancers: Tumors in the upper GI tract can ulcerate and bleed.
6. Portal Hypertension: This leads to the formation of varices, which are prone to rupture and bleeding.

Question 7

What are the causes of #### Lower Gastrointestinal (GI) Bleeding:

Answer 7

Lower GI bleeding originates from the small bowel, colon, or rectum and can also be classified based on its pathophysiology:

1. Vascular Causes:
   
   • Angiodysplasia/Angiectasia: Abnormal, fragile blood vessels in the colon that can cause bleeding.
   • Diverticular Disease: Outpouchings in the colon wall (diverticula) that can erode into blood vessels and cause bleeding.
2. Inflammatory Causes:
   
   • Colitis: Inflammation of the colon, which can be due to infections, inflammatory bowel disease (such as Crohn’s disease or ulcerative colitis), or ischemia.
   • Rectal Ulcers: Often related to underlying inflammatory processes.
3. Neoplastic Causes:
   
   • Colorectal Cancer: Tumors in the colon or rectum that can bleed, leading to chronic or acute blood loss.
4. Traumatic Causes:
   
   • Anal Fissures and Hemorrhoids: These benign anorectal lesions can bleed, particularly after bowel movements.
5. Iatrogenic Causes:
   
   • Post-procedural Bleeding: Similar to the upper GI tract, this can occur following medical interventions.

Question 8

What are the ### Clinical Presentation of Upper GI Bleeding

Answer 8

Upper GI bleeding can present in several ways, often depending on the bleeding site:

1. Hematemesis (40-50% of UGIB):
   
   • Vomiting of fresh blood, usually indicating active bleeding from the upper GI tract.
2. Coffee-Ground Vomitus:
   
   • Vomited blood that has been in contact with stomach acid long enough to turn dark brown, resembling coffee grounds, which indicates older or slower bleeding.
3. Melena (70-80% of UGIB):
   
   • Black, tarry stools caused by digestion of blood, typically from bleeding proximal to the cecum.
4. Hematochezia:
   
   • Passage of fresh blood per rectum, usually associated with lower GI bleeding but can occur with massive upper GI bleeding.
5. Occult Blood:
   
   • Blood not visible to the naked eye but detectable with tests like fecal occult blood tests, often indicating slower, chronic bleeding.
6. Iron Deficiency Anemia:
   
   • Chronic blood loss leading to a decrease in hemoglobin, often detected when a patient presents with fatigue, pallor, and other signs of anemia.

Question 9

Check SLIDES

Answer 9

Differentiating between variceal and non-variceal bleeding is crucial due to differences in management and prognosis:

1. Variceal Bleeding:
   
   • History: Often associated with chronic liver disease, portal hypertension, or cirrhosis.
   • Presentation: Massive hematemesis, with or without melena. Patients may present with signs of liver disease, such as jaundice, ascites, or hepatic encephalopathy.
   • Endoscopic Findings: Prominent, dilated veins in the esophagus or stomach (varices), which can be confirmed via endoscopy.
     - painful bleeding
     - usually hematemesis
     - sign of CLD
     > 90% Hemodynamic change or Hct<30%
2. Non-Variceal Bleeding:
   
   • History: Often linked to NSAID use, Helicobacter pylori infection, or other causes like peptic ulcer disease.
   • Presentation: Hematemesis, melena, or coffee-ground vomitus, without signs of liver disease.
   • Endoscopic Findings: Peptic ulcers, erosive gastritis, Mallory-Weiss tears, or malignancies.
     - pain or painless
     - Hematemesis, coffee ground, Melena
     Non specific dxs indication

The differentiation is vital because variceal bleeding often requires specific interventions like band ligation, sclerotherapy, or the use of vasoactive drugs, whereas non-variceal bleeding might be managed with proton pump inhibitors, endoscopic hemostasis, or surgery depending on the cause.

Question 10

What are the complications of GI bleed

Answer 10

1. Anemia:
   
   • Chronic or acute blood loss from the gastrointestinal tract can lead to anemia, characterized by a decrease in hemoglobin levels. This can cause symptoms like fatigue, pallor, and weakness due to the reduced oxygen-carrying capacity of the blood.
2. Need for Blood Transfusion:
   
   • Significant blood loss may necessitate blood transfusions to replace lost blood volume, restore hemoglobin levels, and improve oxygen delivery to tissues.
3. Hypovolemic Shock:
   
   • Severe blood loss can lead to hypovolemic shock, a life-threatening condition where the heart is unable to pump sufficient blood to the body due to reduced blood volume. This results in decreased tissue perfusion and can lead to organ failure if not promptly treated.
4. Acute Kidney Injury (AKI):
   
   • Hypotension and reduced blood flow during severe bleeding can lead to AKI, where the kidneys fail to filter waste products from the blood effectively.
5. Cancer Spread:
   
   • In cases where the gastrointestinal bleeding is caused by a malignancy, there is a risk of the cancer spreading (metastasis) if not properly managed.
6. Spread of Infection:
   
   • If the source of bleeding is associated with an ulcer or lesion, there is a risk of infection spreading from the gastrointestinal tract to other parts of the body, especially if the mucosal barrier is breached.

Question 11

What are the ### Investigations to be done in Gastrointestinal Bleeding

Answer 11

1. Group and Crossmatch (GXM):
   
   • Prepare 4-6 units of fresh whole blood in case a transfusion is needed. This is crucial in managing significant blood loss and stabilizing the patient.
2. Urea, Electrolytes, Creatinine (Cr-):
   
   • These tests assess kidney function and electrolyte balance, which may be disrupted by severe blood loss or dehydration.
3. Full Blood Count (FBC):
   
   • Evaluates hemoglobin levels, white blood cell count, and platelet count to assess the severity of anemia, infection, or clotting issues.
4. Platelet Count (Plt) and Prothrombin Time (PT):
   
   • Platelet count and PT are important for evaluating the patient’s clotting ability, which may be impaired in cases of massive bleeding or underlying liver disease.
5. Endoscopy (Gastroscopy, Enteroscopy):
   
   • After resuscitation, endoscopy is used to directly visualize the source of bleeding in the upper or lower gastrointestinal tract. It also allows for therapeutic interventions like cauterization, clipping, or banding.
6. Ultrasound:
   
   • Ultrasound can help identify structural abnormalities in the abdomen, such as liver cirrhosis, which might contribute to variceal bleeding.
7. CT Scan:
   
   • A CT scan can provide detailed images of the abdomen, helping to identify masses, vascular anomalies, or sources of bleeding not accessible by endoscopy.
8. Angiography:
   
   • Used to visualize blood vessels and identify active bleeding, particularly in cases where endoscopy is inconclusive. It also allows for therapeutic embolization to stop the bleeding.
9. Radiolabelled RBC Scan:
   
   • This scan helps detect the location of active bleeding by using radiolabelled red blood cells. It’s particularly useful when the bleeding site is difficult to locate through other methods.

Question 12

How do you treat/ manage GI Bleed

Answer 12

1. Resuscitation and Quick Evaluation:
   
   • The initial priority is to stabilize the patient with intravenous fluids, plasma expanders, and, if necessary, blood transfusions. Rapid assessment of the patient’s hemodynamic status is crucial to determine the urgency of intervention.
2. Plasma Expanders and Blood Transfusion:
   
   • Plasma expanders are used to increase blood volume, and transfusions may be needed to restore hemoglobin levels and improve oxygen delivery.
3. Medical Treatment:
   
   • Depending on the cause, medications such as proton pump inhibitors (PPIs) for peptic ulcer disease, antibiotics for H. pylori eradication, or vasoactive drugs for variceal bleeding may be administered.
4. Endoscopic Diagnosis and Treatment:
   
   • Endoscopy is not only diagnostic but also therapeutic. It allows for the treatment of bleeding lesions through techniques such as cauterization, clipping, or band ligation of varices. Early referral to a specialist for endoscopic intervention is crucial.
5. Surgical Intervention:
   
   • Indications for surgery include failure of endoscopic therapy, ongoing massive bleeding, or when the source of bleeding cannot be identified or controlled by other means. Surgical options may include resection of the bleeding area or other operative procedures to control the hemorrhage.
6. Second-Look Endoscopy:
   
   • A repeat endoscopy may be performed to ensure that the initial treatment was successful and to check for any recurrent or residual bleeding.
7. Secondary Prevention (Re-bleeding):
   
   • Secondary prevention strategies include addressing the underlying cause of bleeding, such as eradicating H. pylori, discontinuing NSAIDs, and managing underlying liver disease to prevent variceal re-bleeding. Regular follow-up and possibly long-term medical therapy are essential for preventing recurrence.

Question 13

1. Hemodynamically Stable Patients:
   
   • Patients who are stable, have no signs of active bleeding, no significant comorbidities, and normal endoscopic findings may be managed on an outpatient basis.
2. Unstable Patients:
   
   • Patients with signs of ongoing bleeding, hemodynamic instability, or significant comorbidities require admission for intensive monitoring, resuscitation, and further evaluation. Depending on the severity, they may need to be admitted to a High Dependency Unit (HDU), Intensive Care Unit (ICU), or require surgical care.

This comprehensive approach ensures that gastrointestinal bleeding is managed effectively, reducing the risk of complications and improving patient outcomes.

Question 14

How do you manage an unstable patient with upper GI bleed

Answer 14

1. Resuscitation:
- Secure Airway and Ventilation:
- Airway (A), Breathing (B), and Circulation (C): These are the immediate priorities. Ensure the patient has a clear airway, adequate breathing, and sufficient circulation.
- Oxygen Therapy: Administer oxygen as needed through a mask, nasal prongs, or endotracheal tube to ensure adequate oxygenation.

• IV Access and Fluid Resuscitation:
  
  • IV Line: Place a large bore IV line (14-18 gauge) for rapid fluid administration.
  • Blood Draw: Obtain blood samples for essential tests, including Full Blood Count (FBC), Urea/Electrolytes/Creatinine (U/E/Cr), Liver Function Tests (LFT), Prothrombin Time (PT), Partial Thromboplastin Time with Kaolin (PTTK), and urgent blood grouping and cross-matching.
  • Fluid Infusion: Administer Normal Saline or Ringer’s Lactate rapidly to maintain tissue perfusion. Be cautious with fluid and blood transfusions, particularly in patients with variceal bleeding, aiming for a Hematocrit (PCV) of about 21% based on evidence-based medicine (EBM).
• Monitoring and Supportive Care:
  
  • Nasogastric (NG) Tube: Insert an NG tube to assess ongoing bleeding and prevent aspiration pneumonitis, especially in drowsy or unconscious patients. However, be cautious as it may provoke bleeding in cases of varices.
  • Urethral Catheter: Insert a urethral catheter to monitor urine output, aiming for at least 30 ml/hr as a measure of adequate renal perfusion.
  • Vital Signs Monitoring: Continuously monitor vital signs every 15 minutes until the patient is stable, then reduce to hourly monitoring.

Question 15

Whats the 2. Role of Nasogastric (NG) Tube in UGIB:

Answer 15

• Bloody Aspirate: If the aspirate from the NG tube is bloody, it indicates a need for urgent oesophago-gastroduodenoscopy (OGD).
  
  • Clear and Bile-Stained Aspirate: If the aspirate is clear and bile-stained, the source of bleeding is unlikely to be in the stomach, duodenum, or hepatopancreaticobiliary tree.
  • Persistent Bleeding Assessment: The NG tube helps in assessing the ongoing rate of bleeding.
  • Aspiration Pneumonitis Prevention: In drowsy or unconscious patients, the NG tube helps prevent the aspiration of gastric contents, which could lead to pneumonitis.

Question 16

What are the ** Indications for Blood Transfusion in UGIB:**

Answer 16

• Hemodynamic Instability:
  
  • Shock, with a rapid pulse rate >100 beats/min, systolic blood pressure (BP) <100 mmHg, and urine output <30 ml/hr, indicate a need for blood transfusion.
  • Postural Hypotension: Sudden drop in blood pressure upon standing.
  • Falling Hematocrit (PCV): Progressive decrease in PCV.
  • Overt Continuous Bleeding: Visible ongoing bleeding.

Question 17

What are the ** Medical Treatment of UGIB:**

Answer 17

• Gastric Acid Control:
  
  • Mechanism: Gastric acid and pepsin can inhibit clot formation and promote clot lysis, which impairs ulcer healing. Coagulation is optimal at a pH of 7.4, while platelet aggregation is impaired at a pH <5.9. Therefore, maintaining a gastric pH >6 is crucial.
  • Proton Pump Inhibitors (PPI):
    
    • IV Rabeprazole: 40-80 mg bolus, followed by an infusion of 4-8 mg/hr for 48-72 hours.
    • IV Omeprazole: 80 mg bolus, followed by an infusion of 8 mg/hr for 48-72 hours.
    • Lansoprazole: High-dose IV or oral Lansoprazole is also effective in controlling gastric acid secretion.
  • Vasoactive Agents for Suspected Variceal Bleeding:
    
    • Vasopressin: Administer IV Vasopressin at 0.4 units/min until bleeding stops or for 24 hours, then maintain at 0.2 units/min for another 24 hours.
    • Terlipressin: An alternative to Vasopressin, Terlipressin is given as a 2 mg bolus every 6 hours.
    • Octreotide: A synthetic form of somatostatin, Octreotide reduces portal pressure and can halt variceal bleeding. It is given as a 50 mcg IV bolus followed by an infusion of 50 mcg/hour.
    • Lanreotide and Vapreotide: These agents also reduce portal hypertension and can be used in variceal bleeding.
  • Antibiotic Prophylaxis:
    
    • Prophylactic antibiotics, such as Quinolones or Ceftriaxone, are recommended to prevent infections, especially in cirrhotic patients with variceal bleeding.
  • Beta-Blockers:
    
    • Role: Beta-blockers are used for both primary and secondary prevention of variceal bleeding by reducing portal hypertension.

Managing an unstable patient with upper gastrointestinal bleeding requires prompt and coordinated care, focusing on resuscitation, stabilization, and controlling the source of bleeding. Early endoscopic intervention, along with appropriate medical and possibly surgical management, is essential to improve outcomes and reduce the risk of complications.