My HPE-CPG's
Health Processed Evidenced-based Clinical Practice Guideline
Health-Process-Evidence-based Clinical Practice Guidelines
Upper GI Bleeding and
Lower GI Bleeding
Clinical Questions
What is an operational concept of GI bleeding?
Ans:
GI gastrointestinal tract, but referred practically from the mouth to the anus hence the alimentary tract
Bleeding on going / active blood loss
Clinical Questions
2a. What are the two general categories of GI Bleeding?
Ans:
Upper GI mouth to duodenum vs
- stomach to duodenum
Lower GI jejunum to anus
Based on vascular supply and embryologic development
Clinical Questions
2b. What are the two general categories of GI Bleeding?
Ans:
Occult manifested by recurrent iron-deficiency anemia and/or recurrent positive fecal occult blood test results
Overt/Massive passage of visible blood.
What are common causes of Upper GI bleeding?
Duodenal Ulcer
Esophageal varices
Gastritis
What are common causes of Lower GI bleeding?
Colon (66-75%)
Small intestine (25-33%)
Common causes of Lower GI bleeding?
Clinical Questions
3a. What are reliable symptoms and signs (more than 90% certainty) that will indicate that patients with GI bleeding will need surgical treatment?
Ans: overt recurrent GI bleeding, Unresponsive to medical therapy
3b. What are different modalities of treatment?
endoscopic therapy
angiographic therapy
pharmacotherapy
surgery
Treatment Options
Clinical Questions
4. What are reliable symptoms and signs (more than 90% certainty) that a patient has GI bleeding that needs urgent celiotomy?
Ans:
massive GI bleeding (hematemesis, hematochizia), hemodynamic instability, failure of medical treatment and blood transfusionClinical Questions
6. What
are reliable symptoms and signs (more than 90% certainty) that a patient has massive upper gastrointestinal bleeding that needs urgent celiotomy?Ans:
- hemodynamic instability
- Massive Hematemesis/melena
Clinical Questions
7. What are reliable symptoms and signs (more than 90% certainty) that a patient has massive lower gastrointestinal bleeding that needs urgent celiotomy?
Ans:
- hemodynamic instability
- massive hematochezia
Clinical Questions
13. If a paraclinical diagnostic procedure is needed in a patient with suspected GI bleeding, what is the most cost-effective procedure?
Ans:
NGT bilous (lower GI), clear (r/o duodenal bleeding), coffee ground (upper GI)
Clinical Questions
15. If a paraclinical diagnostic procedure is needed in a patient with massive upper gastrointestinal bleeding, what is the most cost-effective procedure?
Ans:
Endoscopy with attempt to control bleeding, if not feasible
Arteriography to localize the bleeding, followed by urgent celiotomy
Clinical Questions
If a paraclinical diagnostic procedure is needed in a patient with massive lower gastrointestinal bleeding, what is the most cost-effective procedure?
Ans: colonoscopy
Paraclinical Diagnostic Options
Spell out the goal of treatment before the principles and the choice.
Massive upper gastrointestinal bleeding
2. Massive lower gastrointestinal bleeding
TREATMENT GOALS
Massive upper gastrointestinal bleeding
Localization
Control the bleeding
TREATMENT GOALS
Massive lower gastrointestinal bleeding
Localization
Control the bleeding
References - Upper GI Bleeding
Sakra L, Havlicek K, Vyhnalek P. Surgical therapy options for bleeding gastroduodenal peptic lesions. Rozhl Chir. 2004 Jul;83(7):314-9.
Lopez M, Garcia A, Gonzalez A. Failure of endoscopic therapy in upper gastrointestinal hemorrhage due to duodenal ulcers. Rev Esp Enferm Dig. 2003 Oct;95(10):700-6, 692-9.
Avgerinos A, Nevens F, Raptis S, et al: Early administration of somatostatin and efficacy of sclerotherapy in acute oesophageal variceal bleeds: the European Acute Bleeding Oesophageal Variceal Episodes (ABOVE) randomised trial. Lancet 350:1495, 1997
Garcia-Pagan JC, Feu F, Bosch J, et al: Propranolol compared with propranolol plus isosorbide-5-mono nitrate for portal hypertension in cirrhosis: a randomized controlled study. Ann Intern Med 114:869, 1991
Cook DJ, Guyatt GH, Salena BJ, et al: Endoscopic therapy for acute nonvariceal upper gastrointestinal hemorrhage: a meta-analysis. Gastroenterology 102:139, 1992
Poynard T, Cales P, Pasta L, et al: Beta-adrenergic-antagonist drugs in the prevention of gastrointestinal bleeding in patients with cirrhosis and esophageal varices. N Engl J Med 324:1532, 1991
References - Lower GI Bleeding
Richter JM, Christensen MR, Kaplan LM, et al: Effectiveness of current technology in the diagnosis and management of lower gastrointestinal hemorrhage. Gastrointest Endosc 41:93, 1995
Rossini FP, Ferrari A, Spandre M, et al: Emergency colonoscopy. World J Surg 13:190, 1989
Ohyama T, Sakurai Y, Ito M, et al: Analysis of urgent colonoscopy for lower gastrointestinal tract bleeding. Digestion 61:189, 2000
Ng D, Opelka F, Beck D, et al: Predictive value of technetium Tc 99m labeled red blood cell scintigraphy for positive angiogram in massive lower gastrointestinal hemorrhage. Dis Colon Rectum 40:471, 1997
Bloomfeld RS, Smith TP, Schneider AM, et al: Provocative angiography in patients with gastrointestinal hemorrhage of obscure origin. Am J Gastroenterol 95:2807, 2000
Bloomfeld RS, Rockey DC, Shetzline MA: Endoscopic therapy of acute diverticular hemorrhage. Am J Gastroenterol 96:2367, 2001
Wright HK, Pelliccia O, Higgins EF, et al: Controlled, semielective, segmental resection for massive colonic hemorrhage. Am J Surg 139:535, 1980
Jensen DM, Machicado GA: Colonoscopy for diagnosis and treatment of severe lower gastrointestinal bleeding: routine outcomes and cost analysis. Gastrointest Endosc Clin N Am 7:477, 1997