Acute Gastrointestinal Bleeding

15c – Acute gastrointestinal bleeding
Acute GI bleeding presents with :
 * 1) hematemesis (vomitting of blood) and/or
 * 2) 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 (NSIADs, 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:
 * 1) Administration high flow of oxygen
 * 2) Intravenous access + blood sample taken for cross match + iv fluid
 * 3) Nasogastric tube – to monitor the bleeding + prevent aspiration
 * 4) Urinary catheter
 * 5) Central or arterial line
 * 6) 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:
 * 1) Aim: identify the bleeding point, arrest the bleeding and prevent recurrence
 * 2) Once resuscitation established, endoscopy is used to detect the site of bleeding
 * 3) Endoscopy may be used to stop or prevent further bleeding
 * 4) Risk of further bleeding : active bleeding from ulcer base, presence of visible vessel, and adherent of clot overlying the ulcer
 * 5) Sclerotherapy injection (adrenaline, sclerosant) commonly used
 * 6) Heat probs and clips
 * 7) Therapeutic endoscopy used in management of oesophageal and gastric varices and vascular malformation
 * 8) Angiography – only detect active bleeding greater 1ml/min -> selective embolization (may lead to mesenteric ischemia)


 * Surgical management:
 * Emergency surgery may be indicated if:
 * 1) endoscopy reveals bleeding from major artery
 * 2) 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 :
 * 1) Simply be under-run with sutures, through a duodenectomy
 * 2) Once tolerating oral fluids, patient should be started on H.pylori eradication therapy empirically


 * Gastric ulcer :
 * 1) The possibility of malignancy must be considered
 * 2) Ulcer must be biopsied to determine the nature
 * 3) Young, fit patient – ulcer should be excised completely by taking small wedge resection.
 * 4) Elderly – under-running of the ulcer may be preferable
 * 5) If confirmed malignancy – accurate staging and further treatment
 * 6) If benign – H.pylori eradication indicated
 * 7) NSAIDs should be avoided

References :
 * Principles & Practise of Surgery – Chapter 17, Gastroduodenal disorders, page 232
 * OHCM – Gastroenterology, page 244