Chapter 042. Gastrointestinal Bleeding (Part 3)

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Hemorrhagic and Erosive Gastropathy ("Gastritis") Hemorrhagic and erosive gastropathy, often labeled gastritis, refers to endoscopically visualized subepithelial hemorrhages and erosions. These are mucosal lesions and thus do not cause major bleeding. They develop in various clinical settings, the most important of which are NSAID use, alcohol intake, and stress. Half of patients who chronically ingest NSAIDs have erosions (15–30% have ulcers), while up to 20% of actively drinking alcoholic patients with symptoms of UGIB have evidence of subepithelial hemorrhages or erosions. Stress-related gastric mucosal injury occurs only in extremely sick patients: those who have experienced serious trauma, major surgery, burns...

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Chapter 042. Gastrointestinal Bleeding (Part 3) Hemorrhagic and Erosive Gastropathy ("Gastritis") Hemorrhagic and erosive gastropathy, often labeled gastritis, refers to endoscopically visualized subepithelial hemorrhages and erosions. These are mucosal lesions and thus do not cause major bleeding. They develop in various clinical settings, the most important of which are NSAID use, alcohol intake, and stress. Half of patients who chronically ingest NSAIDs have erosions (15–30% have ulcers), while up to 20% of actively drinking alcoholic patients with symptoms of UGIB have evidence of subepithelial hemorrhages or erosions. Stress-related gastric mucosal injury occurs only in extremely sick patients: those who have experienced serious trauma, major surgery, burns covering more
than one-third of the body surface area, major intracranial disease, and severe medical illness (i.e., ventilator dependence, coagulopathy). Significant bleeding probably does not develop unless ulceration occurs. The mortality rate in these patients is quite high because of their serious underlying illnesses. The incidence of bleeding from stress-related gastric mucosal injury or ulceration has decreased dramatically in recent years, most likely due to better care of critically ill patients. Pharmacologic prophylaxis for bleeding may be considered in the high-risk patients mentioned above. Multiple trials document the efficacy of intravenous H2-receptor antagonist therapy, which is more effective than sucralfate but not superior to a PPI immediate-release suspension given via nasogastric tube. Prophylactic therapy decreases bleeding but does not lower the mortality rate. Other Causes Other, less frequent causes of UGIB include erosive duodenitis, neoplasms, aortoenteric fistulas, vascular lesions [including hereditary hemorrhagic telangiectasias (Osler-Weber-Rendu) and gastric antral vascular ectasia ("watermelon stomach")], Dieulafoy's lesion (in which an aberrant vessel in the mucosa bleeds from a pinpoint mucosal defect), prolapse gastropathy (prolapse of proximal stomach into esophagus with retching, especially in alcoholics), and
hemobilia and hemosuccus pancreaticus (bleeding from the bile duct or pancreatic duct). SMALL-INTESTINAL SOURCES OF BLEEDING Small-intestinal sources of bleeding (bleeding from sites beyond the reach of the standard upper endoscope) are difficult to diagnose and are responsible for the majority of cases of obscure GIB. Fortunately, small-intestinal bleeding is uncommon. The most common causes are vascular ectasias and tumors (e.g., adenocarcinoma, leiomyoma, lymphoma, benign polyps, carcinoid, metastases, and lipoma). Other less common causes include Crohn's disease, infection, ischemia, vasculitis, small-bowel varices, diverticula, Meckel's diverticulum, duplication cysts, and intussusception. NSAIDs induce small-intestinal erosions and ulcers and may be a relatively common cause of chronic, obscure GIB; coxibs induce less small-intestinal injury than traditional NSAIDs. Meckel's diverticulum is the most common cause of significant lower GIB (LGIB) in children, decreasing in frequency as a cause of bleeding with age. In adults 50–60 years, vascular ectasias are usually responsible. Vascular ectasias should be treated with endoscopic therapy if possible. Surgical therapy can be used for vascular ectasias isolated to a segment of the small intestine when endoscopic therapy is unsuccessful. Although
estrogen/progesterone compounds have been used for vascular ectasias, a double- blind trial found no benefit in prevention of recurrent bleeding. Isolated lesions, such as tumors, diverticula, or duplications, are generally treated with surgical resection. COLONIC SOURCES OF BLEEDING The incidence of hospitalizations for LGIB is about one-fifth that for UGIB. Hemorrhoids are probably the most common cause of LGIB; anal fissures also cause minor bleeding and pain. If these local anal processes, which rarely require hospitalization, are excluded, the most common causes of LGIB in adults are diverticula, vascular ectasias (especially in the proximal colon of patients >70 years), neoplasms (primarily adenocarcinoma), and colitis—most commonly infectious or idiopathic inflammatory bowel disease, but occasionally ischemic or radiation-induced. Uncommon causes include post-polypectomy bleeding, solitary rectal ulcer syndrome, NSAID-induced ulcers or colitis, trauma, varices (most commonly rectal), lymphoid nodular hyperplasia, vasculitis, and aortocolic fistulas. In children and adolescents, the most common colonic causes of significant GIB are inflammatory bowel disease and juvenile polyps. Diverticular bleeding is abrupt in onset, usually painless, sometimes massive, and often from the right colon; minor and occult bleeding is not characteristic. Clinical reports suggest that bleeding colonic diverticula stop
bleeding spontaneously in ~80% of patients and rebleed in about 20–25% of patients. Intraarterial vasopressin or embolization by superselective technique should stop bleeding in a majority of patients. If bleeding persists or recurs, segmental surgical resection is indicated. Bleeding from right colonic vascular ectasias in the elderly may be overt or occult; it tends to be chronic and only occasionally is hemodynamically significant. Endoscopic hemostatic therapy may be useful in the treatment of vascular ectasias, as well as discrete bleeding ulcers and post-polypectomy bleeding, while endoscopic polypectomy, if possible, is used for bleeding colonic polyps. Surgical therapy is generally required for major, persistent, or recurrent bleeding from the wide variety of colonic sources of GIB that cannot be treated medically, angiographically, or endoscopically.