MANAGEMENT

GASTROINTESTINAL
BLEEDING
THE ROLE OF NATURAL
HEMOSTATIC

DEFINITIONS
UPPER GASTROINTESTINAL
BLEEDING:

originating proximal to the

ligament of Treitz
Hematemesis & melena
LOWER GASTROINTESTINAL
BLEEDING:

originating from the small

bowel and colon.
hematoschezia/ melena

CAUSE OF SMALL BOWEL BLEEDING

(Based on 76 cases)
1.
2.
3.
4.

Tumor (37/76)
Meckels diverticulum (21/76)
Angiopathy (15/76)
Ectopic pancreas (3/76).

World J Gastroenterol 2006 December 7; 12(45): 7371-7374

INITIAL EVALUATION
Hemodynamics
Unstable Resuscitate
Admit to ICU

Stable

Resuscitate
2 large bore IVs 16 gauge or larger
Transfuse PRBCs
High risk cardiac, liver disease ,
elderly Hb >10
Young low risk Hb >7
INR >1.5 give FFP
Platelet < 50.000 give platelets

Elective intubation
Airway compromise
Altered Mental Status
hemetemesis

GI Medicine
consultation
Obtain history:
NSAIDs, ASA, Plavix,
Coumadin, Goodys,
BC
Alcohol abuse
Liver disease
Variceal bleeding
Abdominal Aortic
Aneurism (AAA)
Post surgical repair
of AAA

Full Rockall
Rockall score
score

INITIAL
INITIAL ROCKALL
ROCKALL SCORE
SCORE >0
>0 EMERGENCY
EMERGENCY
ENDOSCOPY
ENDOSCOPY UNDERTAKEN
UNDERTAKEN WITHIN
WITHIN 24
24 HOURS
HOURS

DETECTION SOURCE OF BLEED

NGT: Aspirate
Blood

NGT: Aspirate
BiliousNo Blood

90%
90%

%
% recurrent
recurrent
bleeding
bleeding

50%
50%

FORREST GRADING OF
PEPTIC ULCER
Clin Endosc 2012;45:220-223
5%
5%

INJECTION TO STOP
BLEEDING
The commonest injection fluid is 1:10,000
adrenaline (epinephrine)
Endoscopic injection of fluid around and into the
bleeding point reduces the rate of rebleeding in
patients with non-bleeding visible vessels from
approximately 50% to 15-20%.
Rebleeding following injection into ulcers with
adherent blood clot is also significantly reduced from
approximately 35 to 10%.

STOP PEPTIC ULCER BLEEDING BY

ENDOCLIP
CLIPPING better than ADRENALIN INJECTION
Definitive haemostasis: clipping (86.5%) injection
(75.4%; relative risk, RR 1.14, 95% CI 1.00 to 1.30).
Reduced rebleeding: clipping (9.5%), injection (19.6%;
RR 0.49, 95% CI 0.30 to 0.79) (Significant)
Need for surgery: (2.3% v 7.4%; RR 0.37, 95% CI 0.15
to 0.90).
CLIPPING comparable with THERMOCOAGULATION
comparable efficacy (81.5% and 81.3%; RR 1.00)

COMBINATION ENDOSCOPIC
INTERVENTION: BETTER RESULT
One meta-analysis of 16 RCTs adding a second endoscopic
intervention (thermal, mechanical or injection) following an
endoscopic adrenaline injection reduced:
further bleeding rate from 18.4% to 10.6% (OR 0.53, 95% CI, 0.40
to 0.69),
emergency surgery from 11.3% to 7.6% (OR 0.64, 95% CI, 0.46 to
0.90),
mortality fell from 5.1% to 2.6% (OR 0.51, 95% CI 0.31 to 0.84).58

RECOMMENDATION
RECOMMENDATION
Combinations
Combinations of endoscopic therapy comprising an injection of at least
least 13 ml
of
of 1:10,000
1:10,000 adrenaline
adrenaline coupled with either a thermal or
or mechanical
mechanical treatment
are
are recommended
recommended in preference
preference to
to single
single modalities.
modalities.

SECOND LOOK ENDOCSOPY

Meta-analysis of 10 studies, including 1,202 patients,
showed reduction of rebleeding in patients undergoing
second look endoscopy (11.4% v 15.7%; OR 0.69;
95% CI 0.49 to 0.96)
Recommendation:
Endoscopy and endo-therapy should be repeated
within 24 hours when initial endoscopic treatment was
considered sub-optimal (because of difficult access,
poor visualisation, technical difficulties) or in
patients in whom rebleeding is likely to be life
threatening

MEDICAL THERAPY AFTER ENDOSCOPY

IV bolus followed by infusion of high-dose PPI
reduces recurrent bleeding, need for repeated
endoscopy, surgery, blood transfusion and
mortality (cochrane meta-analysis) and also
cost effective.
Patients with lower risk stigmata (clean base,
flat pigmented spot), standard PPI therapy
(e.G., Oral PPI once-daily) is enough to heal the
ulcer.

Clin Endosc 2012;45:220-223

EFFICACY OF COMBINATION OF
OMEPRAZOLE AND YUNNAN BAIYAO IN
GASTRO INTESTINAL BLEEDING
RCT, 82 gastro intestinal bleeding cases were randomly
divided into two groups.
Intervention: Infusion of 40 mg omeprazole solved in 5%
saline 250 mL and oral 1 g of Yunnan Baiyao (STOBLED) tid.
Control: Infusion of 40 mg omeprazole diluted in 5% saline
250 mL .
Therapeutic period is 10 days
Efficacy and adverse effect were compared between two
groups.

Practical Clinical Medicine 2010, Vol 11

RESULT
GROUP

NO

MARKED
EFFECTIVE

EFFECTIVE

NOT EFFECTIVE

CASE

CASE

CASE

TOTAL
EFFECT
IVITY
(%)

TRIAL

41

34

82,9

17,1

100*

CONTR
OL

41

19

46,3

12

29,3

10

24,4

75,6

Compared
Compared with
with control
control group
group ** P<0.05
P<0.05

Side effect:
trial group: one pts had headache, dizziness, and nausea;
control group: two patients headache, and dizziness, 1 patient
abdomen distention and diarrhea.
all symptoms were vanished once the therapy is stopped.

REBLEEDING FOLLOWING ENDOSCOPIC

THERAPY ULCER BLEEDING
Randomized into operative surgery vs repeat
endoscopic. Thirty day mortality and transfusion
requirements were low and similar more complications
occurred in surgical patients
Failure: Angiography and simultaneous superselective
coil transcatheter embolisation using coils and polyvinyl
alcohol, and gelatine sponge showed high rates of
technical success (98%)
A retrospective study: embolisation vs surgery showed
no difference in rebleeding or mortality

ESOPHAGUS & GASTRIC VARICES

11% of patients
undergoing
endoscopy for upper
GI bleeding have
variceal bleeding,
majority have
bleeding
oesophageal varices
(90%)

ESOPHAGEAL VARICES BLEEDING

injection sclerotherapy for bleeding oesophageal varices
mortality was reported at 32% for Childs A, 46% for Childs B
and 79% for Childs C
A meta-analysis: variceal band ligation therapy was superior
tosclerotherapy in terms of rebleeding (OR 0.52, 95% CI 0.37
to 0.74), all-cause mortality (OR 0.67 CI 0.46 to 0.98), and
death due to bleeding (OR 0.49, CI 0.24 to 0.996)

Recommendation
Patients with confirmed oesophageal variceal haemorrhage
should undergo variceal band ligation.

GASTRIC VARICES
Endoscopic obturation using cyanoacrylate was more
effective and safer than band ligation. Initial haemostatic
rate (defined as no bleeding for 72 hours after treatment)
was 87% VS 45% (p=0.03), rebleeding rates were 31%
vs 54 % p=0.0005).

Recommendation
Patients with confirmed gastric variceal haemorrhage should
have endoscopic therapy, preferably with cyanoacrylate
injection.

MANAGEMENT OF BLEEDING VARICES

NOT CONTROLLED BY ENDOSCOPY
A retrospective study: overall improvement in survival with TIPSS
compared with oesophageal transection for the management of
variceal haemorrhage (mortality 42% v 79%).
One RCT: H-graft porto-caval shunt more effective than TIPSS for
uncontrolled variceal haemorrhage, but the proportion of patients
treated by surgical shunting on an emergency or urgent basis was
much lower than those treated with TIPSS (20% v 37%).

RECOMMENDATION
RECOMMENDATION

Transjugular intrahepatic portosystemic stent shunting is recommended

as the treatment of choice for uncontrolled variceal haemorrhage.

MODIFIED SUGIURA PROCEDURE FOR THE

MANAGEMENT OF VARICEAL BLEEDING:
Voros. World J surg. 2012 mar;36(3):659-66.

When acute sclerotherapy/ banding fails, and in cases where

no further treatment is accessible, emergency surgery
may be life saving.
Retrospectively analyzed the results of the modified Sugiura
procedure (46 pts. Acute bleeding was controlled in all
patients.
Postoperative mortality was 23.9%. The mortality rate was
34.6% in Child class C patients , and 12.5% in Child class B
patients.
Twenty-four patients had long-term follow-up extending from
14 months to 22 years (mean 83.1 months). Ten of 24 patients
(41.6%) did not develop rebleeding for 5-22 years (mean 10.3
years).
Overall 5-year survival in these 24 patients was 62.5%.

MANAGEMENT OF LOWER GASTROINTESTINAL

BLEEDING

80-85% bleeding will stop spontaneously

Rectal examination (digital & proctoscopy) is
essential to detect ongoing bleeding and enable
diagnosis of local anorectal conditions ( 14% of
acute LGIB).
Anal source of bleeding:
Balloon compression (Foley catheter)
Suturing/ Stapling

LOCALISING & MANAGING THE LGIB

COLONOSCOPY:
Urgent colonoscopy (within eight hours) vs standard colonoscopy
(within 48 hours): improved diagnosis with urgent colonoscopy .
Source of bleeding can be stopped using adrenaline infiltration, thermo
coagulation or clipping.

ANGIOGRAPHY
Failure detection of source of bleeding using colonoscopy or
failure in colonoscopy hemostasis angiography & embolization
(succes rate 89-100%)

SURGERY
If no angiography facility or failure: surgery. If preoperative
localization was not possible, a subtotal colectomy was a safe
procedure with acceptable functional results

MEDICAL TREATMENT
OF GI BLEED
Mild try medical treatment only
Moderate Severe :
Endoscopic intervention, embolization or
surgery
+ Medical treatment:
- PPI
- Antifribrinolytic
- Yunnan Baiyao (activated thrombocyte)

TERIMAKASIH

TERIMAKASIH