surgery 6th year, tutorial (dr. abdulwahid)

GI Hemorrhage

ABDWAHID M SALIS, M.D

Incidence

1-2% of all hospital admissions Most common diagnosis of new ICU admits

5-12% mortality 40% for recurrent bleeders

85% stop sponateously Those with massive bleeding need urgent intervention Only 5-10% need operative intervention after

endoscopic interventions

Site

UpperEsophagealStomachDoudenumHepaticPancreatic

LowerSmall bowelColonAnus

Gastric varices

Gastric varices

EsophagealVarices

Gastric varicesBleeding ulcers

EsophagealVarices

Gastritis

Gastritis Dieulafoy’s lesion

Mallory-weiss

Watermelon stomach

Upper GI hemorrhage

EtiologyPeptic ulcer disease - 50%Varices – 10-20%Gastritis – 10-25%Mallory-weiss – 8-10%Esophagitis – 3-5%Malignancy – 3%Dieulafoy’s lesion – 1-3%Watermelon stomach – 1-2%

Gastrointestinal BleedingGastrointestinal Bleeding

HematemesisHematemesis- Vomiting of blood from the oropharynx to the - Vomiting of blood from the oropharynx to the ligament of Treitz. ligament of Treitz.

Gross Blood And Blood Clots:Gross Blood And Blood Clots: rapid bleeding rapid bleeding Coffee-ground EmesisCoffee-ground Emesis: chronic bleeding. : chronic bleeding.

Melena-Melena- Passage of black and tarry stool caused by digested blood. Passage of black and tarry stool caused by digested blood.

Hematochezia-Hematochezia- Passage of maroon to red blood and Passage of maroon to red blood and blood clots.blood clots.

MelenaMelena

usually the result of usually the result of severe uppersevere upper GI bleeding. GI bleeding. without hematemesis :severe bleeding distal to the without hematemesis :severe bleeding distal to the

ligament of Treitz.ligament of Treitz. 50-60 mL50-60 mL of blood in the GI tract produces melena of blood in the GI tract produces melena after a after a 2 unit bleed2 unit bleed: Melena can persist from 5-: Melena can persist from 5-77

days and stools can remain occult positive up to days and stools can remain occult positive up to 33 weeks.weeks.

Nose bleeds-Nose bleeds-

Rarely the cause of major bleeding. Rarely the cause of major bleeding.

EsophagitisEsophagitis

Hiatus herniaHiatus hernia Significant bleeding in Significant bleeding in para- esophageal hernias.para- esophageal hernias.

Reflux esophagitisReflux esophagitis is more likely to resultis more likely to result in chronic occultin chronic occult

VaricesVarices

Esophageal And GastricEsophageal And Gastric: :

in the presence of in the presence of liverliver disease are life disease are life threatening situations precipitated by the threatening situations precipitated by the inability of the liver to synthesize inability of the liver to synthesize clotting clotting factors factors

Alcoholism Alcoholism hepatitis B and Chepatitis B and C

Mucosal tear (Mallory-Weiss)Mucosal tear (Mallory-Weiss)

Esophagogastric mucosal tear Initially Esophagogastric mucosal tear Initially the patient has the patient has vomiting withoutvomiting without blood. Continued emesis leads to pain blood. Continued emesis leads to pain from the from the teartear and eventually the and eventually the patient develops patient develops hematemesishematemesis. .

GastritisGastritis

– Diffuse gastritisDiffuse gastritis.. – Erosions Erosions are usually are usually multiple multiple and found and found

primarily in the fundus and body of the primarily in the fundus and body of the stomach. stomach.

– Chronic slowChronic slow bleeds are most commonly bleeds are most commonly associated with associated with H. pyloriH. pylori

– Brisk BleedingBrisk Bleeding: ingested substances as : ingested substances as NSAIDs, alcohol, steroids, or other drugs.NSAIDs, alcohol, steroids, or other drugs.

Peptic ulcerPeptic ulcer

– Most common cause of upper GI bleed 1/2- 2/3.Most common cause of upper GI bleed 1/2- 2/3.– Causes:H. pylori 40-50%,NSAID’s 40-50% andOther (Z-E syndrome)

– Duodenal bleed is Duodenal bleed is four timesfour times more common than more common than gastric ulcer bleed. gastric ulcer bleed.

– Duodenal ulcers are usually Duodenal ulcers are usually posteriorposterior and involve and involve branches of the gastroduodenal artery.branches of the gastroduodenal artery.

– Benign gastric ulcers bleed more than malignant ulcers.Benign gastric ulcers bleed more than malignant ulcers.

– There will be There will be significant bleeding in 10-15%significant bleeding in 10-15%– surgical intervention is needed in 20%surgical intervention is needed in 20%

Duodenal ulcersDuodenal ulcers

located on the located on the anterioranterior wall are prone to wall are prone to perforationperforation and present as peritonitis and free air. and present as peritonitis and free air.

Those on the Those on the posteriorposterior wall, which is the more wall, which is the more common location, lead to common location, lead to bleedingbleeding The The gastroduodenal arterygastroduodenal artery

Gastric antral vascular ectasia (GAVE) watermelon stomach

Dilated small blood vessels in the antrum, or the last part of the Streaky long red areas.

Stress ulcersStress ulcers– Acute gastroduodenal lesions that arise after Acute gastroduodenal lesions that arise after

episodes of episodes of shock, sepsis, surgery, trauma, shock, sepsis, surgery, trauma, burnsburns (curling’s ulcer),(curling’s ulcer),

– or intracrainial pathology or surgery or intracrainial pathology or surgery

(cushing’s ulcer). (cushing’s ulcer). – The result of The result of bile refluxbile reflux damage to the gastric damage to the gastric

protective barrier combined with decreased gastric protective barrier combined with decreased gastric blood flow secondary to blood flow secondary to splanchnic splanchnic vasoconstriction.vasoconstriction.

– Sepsis, Sepsis, coagulopathycoagulopathy, and activation of , and activation of cytokines may also play a role.cytokines may also play a role.

Dieulafoy’s vascular Dieulafoy’s vascular malformationsmalformations

– Dilated Arterial LesionsDilated Arterial Lesions

Other causesOther causes

– Gastric neoplasmsGastric neoplasms:: malignant and benign malignant and benign

usually mild and chronic. usually mild and chronic.

– Aorto-enteric fistulasAorto-enteric fistulas : : As a herald bleed followed by a massive bleedAs a herald bleed followed by a massive bleed

In patients with prior aortic reconstructions. In patients with prior aortic reconstructions.

– HematobiliaHematobilia : :

following hepatic injuries or manipulations.following hepatic injuries or manipulations.

لله الحمد