Gastrointestinal Hemorrhage

DEFINITION

Bleeding into the lumen of the gastro-intestinal tract usually from mucosal and sub-mucosal vessels.

Divided into Upper and Lower gastrointestinal hemorrhage by LIGAMENT OF TREITZ.

Ligament of Treitz is a peritoneal fold at the duodeno-jejunal junction.

Upper gastro-intestinal hemorrhage is from lesions above the ligament of Treitz [80%].

Lower gastro-intestinal hemorrhage is from lesions below the ligament of Treitz.

CEALIAC TRUNK

Supplies:

• Lower esophagus, stomach, upper duodenum
• Liver
• Pancreas
• Spleen

Divides into three branches:

• Left Gastric: Gastric/Esophageal branches
• Common Hepatic: Hepatic, Gastro-duodenal, Right gastric
• Splenic: Gastro-epiploic branches, Short gastric, Pancreatic, Terminal splenic

SUPERIOR MESENTERIC ARTERY

Supplies:

• Small intestine
• Caecum
• Ascending/Transverse colon

Branches:

• Inf pancreaticoduodenal
• Jejenal/Ileal branches
• Ileo-colic
• Right colic
• Middle colic

INFERIOR MESENTERIC ARTERY

Supplies:

• Descending colon
• Sigmoid colon
• Rectum

Branches:

• Left colic
• Sigmoid
• Superior rectal

VENOUS DRAINAGE: PORTAL VEIN

Drains GIT except lower anal canal.

Formed post neck of pancreas by the junction of splenic and superior mesenteric veins.

Has no valves.

Drains into the liver.

Obstruction causes increased portal venous pressure.

Porto-systemic anastomoses:

• Lower esophagus
• Anal canal
• Umbilicus
• Retroperitoneal colon area/Bare area of liver

Hemorrhage may be ACUTE or CHRONIC.

ACUTE: Sudden onset and may be torrential leading to:

• Sweating
• Pallor
• Tachycardia/Tachypnea
• Cold extremities
• Hypotension
• Cardiovascular collapse
• Loss of consciousness

CHRONIC: Small bleeds that may occur for prolonged periods often causing chronic iron deficiency anemia.

• Easy fatiguability
• Weakness
• Dizziness
• Palpitation

CAUSES OF UPPER GASTROINTESTINAL HEMORRHAGE

Can originate from:

The Esophagus

• Mallory Weiss syndrome
• Gastro-esophageal Varices
• Reflux esophagitis

The Stomach

• Peptic Ulcer
• Erosive gastritis
• Vascular ectasia
• Gastric carcinoma
• Dieulafoy’s lesion

Duodenum

• Peptic ulcer
• Aorto-enteric fistula
• Hemobilia / Iatrogenic
• Hemosuccuss pancreaticus

CAUSES OF LOWER GASTROINTESTINAL HEMORRHAGE

Small intestine

• Typhoid enteritis
• Mekel’s diverticulum with ectopic gastric tissue
• Benign/Malignant tumors

Colon/Rectum

• Diverticulosis
• Vascular ectasia and angiodysplasia
• Benign/Malignant tumors
• Ulcerative colitis
• Crohn’s disease

Anal canal

• Hemorrhoids
• Fissure in ano

PRESENTATION OF GASTRO-INTESTINAL HEMORRHAGE - ACUTE UPPER

• Hematemesis
• Fresh blood
• Blood clots
• Coffee grounds
• Melena
• Black foul-smelling tarry stool
• Hydrochloric acid
• Digestive enzymes
• Bacteria
• Hematochezia
• Fresh blood
• Clots
• Altered blood

PRESENTATION OF GASTRO-INTESTINAL HEMORRHAGE - LOWER

• Melena
• Small intestine
• Right side of colon
• Hematochezia
• Lower colon
• Brisk bleed from Small intestine

RESUSCITATION

• Quick history: Age/Number of bouts/Character/Relevant past medical history
• Quick physical examination: State of consciousness/Pallor/Pulse rate/BP

AIRWAY

• Positioning/oro-pharyngeal airway/endo-tracheal intubation

BREATHING

• Spontaneous Ventilation

CIRCULATION

• Crystalloids - Normal saline/Ringers lactate
• One or two wide bore cannula into big veins

Blood samples

• PCV/Grouping and cross-matching/Liver function test/Blood gas analysis/Clotting profile/Platelet count

MONITOR PERFUSION

• Pulse/Blood pressure/Hourly urine output/Central venous pressure

NASOGASTRIC intubation

• Diagnosis and monitor upper GI hemorrhage

Full History

• Previous episodes
• Weight loss
• Vomiting
• Epigastric pain
• Peptic ulcer diagnosis
• Non-steroidal anti-inflammatory drugs
• Other drugs
• Alcoholism/chronic liver disease
• Co-morbid conditions

Physical examination

• Pallor
• Palmer erythema
• Epigastric tenderness
• Dilated anterior abdominal wall vein
• Ascites
• Palpable abdominal masses
• Rectal examination

INVESTIGATION UPPER GI HEMORRHAGE

• Upper gastrointestinal endoscopy
• Diagnostic in 90% of cases
• Therapeutic
• Abdominal Ultrasound
• Abdominal CT
• Selective Angiography and embolization

INVESTIGATION LOWER GI HEMORRHAGE

• Colonoscopy
• Therapeutic
• Selective angiography and embolization
• Enteroscopy
• Capsule endoscopy

TREATMENT OF GI HEMORRHAGE

Multidisciplinary Team:

• Medical/Surgical Endoscopist
• Hematologist
• Radiologist
• Surgeon

Aim:

• Arrest Hemorrhage
• Prevent recurrence

ARREST

Most patients [80%] with Gastrointestinal Hemorrhage stop bleeding spontaneously.

Endoscopic Maneuver:

• Coagulation
• Injection of vaso-active substances
• Sclerotherapy

Other Interventions:

• Transjugular Intrahepatic Porto-systemic Shunt
• Drugs
• Surgery

• Age of patient
• Volume of hemorrhage
• Diagnosis
• Adequate resuscitation
• Co-morbid factors
• Overall >5%