GI bleeding

Question 1

Upper, middle, lower GI bleeds

Answer 1

• Upper: esophagus, stomach, duodenum
• Separation of upper from middle: ligament of trietz
• Middle: jejunum, ileum
• Lower: colon

Question 2

Examples of GI bleeds for each segment

Answer 2

• Upper: PUD bleeding, varices
• Middle: tumor, AVM, vascular ectasias, NSAIDs
• Lower: diverticular, tumor

Question 3

Manifestations of GI bleeds

Answer 3

• Hematemesis: either frank blood (blood in stomach for short time) or coffee-ground emesis (blood in stomach for long time)
• Melena: black stool from slow upper GI bleed, less commonly from SI or right colon
• Hematochezia: bright red blood in stool, usually due to colonic bleed or very rapid upper/middle bleed

Question 4

Approach to PUD bleeding

Answer 4

• Peptic ulcers: due to increased acid content of stomach and inflammation, from NSAIDs and/or H pylori
• NSAIDs reduce protective GI PG synthesis, resulting in reduced mucosal blood flow, increased WBC adherence, reduced bicarb production
• H pylori survives in antrum of stomach and breaks down urea in the unstirred layer to ammonia and CO2, exposing mucosa to acid
• Management of PUD bleeding: resus (airway/blood transfusion), medical Rx, endoscopic/surgical eval/Rx
• Pts w/ active bleeding or visible vessels need endoscopic Rx, w/ F/U PPI Rx

Question 5

Approach to variceal bleeding 1

Answer 5

• Portal HTN (from cirrhosis) leads to splanchnic vasodilation and thus back-up of blood thru porto-systemic collaterals
• These include esophageal varices, caput madusae (peri-umbilical), retroperitoneal, and hemorrhoidal varices
• Hepatic portal pressures >12mmHg associated w/ bleeding
• Pharmacologic Rx of portal HTN bleeding: BBs and octreotide both constrict splanchnic arteries and reduce blood in GI tract
• Octreotide generally better b/c it does not lower BP as much as BBs

Question 6

Approach to variceal bleeding 2

Answer 6

• Ablative Rx: ligation of varices in the esophagus via endoscopy reduces esophageal bleeding
• TIPS (transjugular intrahepatic portal-systemic shunt): redirects portal blood to IVC by re-routing it around liver
• Also can give antibios in setting of active variceal bleeding: prevent infection, re-bleed, lowers mortality
• Portal HTN also causes gastropathy: slow oozing of blood, no risk of brisk bleed (more difficult to Rx than esophageal varices)
• Rx w/ BBs/TIPS

Question 7

Methods to evaluate and causes of middle GI (SI) bleed

Answer 7

• SI bleeds were majority of obscure bleeds previously
• Capsule endoscopy
• Double balloon enteroscopy
• Vascular ectasias major cause of SI bleeding: friable thin walled vessel often w/ A-V connections
• Vascular ecstasias associated w/ renal disease and age
• Vascular ecstasies can be ablated by endoscopic coagulation

Question 8

Lower GI bleeding

Answer 8

• Diverticular bleeding and vascular ecstasies are most common
• Should also consider brisk upper GI bleed
• Ischemia, radiation, infection and inflammatory processes generally low bleeds and associated w/ other Sx
• Therapeutic colonoscopy is a consideration but controversial
• Non-emergent colonoscopy should be done (after bleeding stops) to confirm Dx