By Dick Broom

So how does a doctor treat GI bleeding in someone who is at high risk for a heart attack?

The answer is “ very carefully.”

“You have to walk a fine line,” says Thomas Swantkowski, M.D., a gastroenterologist with Pinehurst Medical Clinic. “You want to take the patient off the blood thinner, but then you need to stop the bleeding quickly so the patient can get back on the blood thinner to avoid coronary problems.”

Fortunately, GI specialists have a number of ways to stop bleeding in the GI system. First, however, they have to find out exactly where the bleeding is occurring. They use a flexible scope called an endoscope to examine the upper GI system—the esophagus, stomach and duodenum. If bleeding is suspected in the colon, they use a colonoscope.

The most common source of upper GI bleeding is stomach ulcers, which are most often caused by a bacteria called Helicobacter pylori. Next are aspirin and anti-inflammatory drugs that are used to treat arthritis.

“These medications are the cause of many thousands of deaths each year from bleeding,” Dr. Swantkowski says.

Two-step treatment
Physicians typically use a two-step treatment for bleeding ulcers.

“First, we inject epinephrine (adrenaline) or saline around the ulcer,” says Wayne Lucas, M.D., who also is a gastroenterologist with Pinehurst Medical Clinic and medical director of Moore Regional Hospital’s Esophageal Center. “The epinephrine constricts the vessel, but the fluid also helps pinch it off. Then we compress the vessel and heat it with an electrical current, which cauterizes it.”

People with cirrhosis of the liver often develop thin-walled blood vessels in the esophagus (called varices) that rupture much more easily than normal vessels. When that happens, the bleeding can be
life-threatening. The most common treatment for this is called banding.

“Variceal hemorrhages are typically treated by ‘ligating’ the varices with small elastic bands,” Dr. Lucas says. “This is accomplished by using a special device called a band ligator, which is attached to the end of the endoscope. The bleeding varix is first suctioned into the device, and then a small elastic band is popped over the varix. This method is highly effective and controls up to 91 percent of variceal bleeds. If banding is not possible, we typically inject the varix with a medication, which causes it to shrink and clot off.”

Sometimes tiny metal clips are used to clamp bleeding vessels, which then clot shut. The clips fall off after about three weeks and pass through the system.

Patients with serious bleeds sometimes may need to be referred to a general surgeon for surgery.

The newest tool for repairing certain types of upper GI problems is a tiny sewing machine on the end of a scope.

“It is still pretty experimental,” Dr. Swantkowski says, “but we will probably have one in another few years.”

The major sources of bleeding in the lower GI system are small pouches called diverticula that can develop on the inside of the colon.

Diverticula, which are particularly common in older people, tend to form where there is a weakness in the wall of the colon. Small arteries in those areas are more likely to bleed.

“It is a frustrating type of bleed to fix, because it typically starts and stops,” Dr. Lucas says. “When you look inside the colon, you might see hundreds of these little pouches, and identifying the source of the bleeding is often very challenging.”

When the bleeding vessel is located, it can usually be treated with one of the same techniques that are used to stop upper GI bleeds. Otherwise, the patient may need to be sent to radiology for an angiography procedure, which addresses the problem from inside the arteries.

Older people also are more prone to bleeding from vessels—called arteriovenous malformations—that sometimes form between small arteries and veins in the colon. If these vessels develop too close to the surface, they can easily rupture and leak.

Bleeding anywhere in the GI system often requires immediate attention and hospitalization, and patients usually come in through the Emergency Department.

“A national measure of treatment for patients with GI bleeding is how soon they have an endoscopy or colonoscopy after they get to the hospital,” Dr. Swantkowski says. “That has been linked to the rate of mortality. And, certainly, patients who get scoped right away tend to do better.

“That is one of things we do very well here at Moore Regional. There is a GI physician at the hospital all the time, so we can start taking care of patients very quickly.”