Approach to Hematemesis and Melena

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Approach to Hematemesis and Melena

• 6th Year Medicine
• Dr Yasir M Khayyat
• Assistant Professor/Gastroenterologist

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Management Outline
Airway ? Breathing ? Circulation ? Decide on
Admission
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Causes of UGIB ( Hematemesis/Melena)
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• Melena passage of black
• Tarry offensive stool due to
• Bleeding form the upper
• GIT proximal to ligmant of
• Tretiz ( gt 100 ml).
• Basic Mechanisms
• Hyperacidity
• H pylori
• Vascular anomalies
• Autoimmune
• Malignancy

Ligament of Treitz
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Endoscopic Diagnosis
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Take home message

• Always think of hemodynamic stability ABC
• Then think to do H P
• Common things are common
• Careful not to kill the patient and know when to
  call for somebody help
• Common diseases are peptic ulcers, liver disease,
  drug induced and malignancy.
• Decide if you admit ( ward/ICU) or discharge.

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Approach to Diarrhea
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• Diarrhea
• Increased frequency or stool
• Weight ( gt 200g) or frequency
• ( 3 BM/d)
• Onset
• Acute lt 4 weeks
• Chronic gt 4 weeks

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Basic Pathologic Mechanisms
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Now think of the causes of diarrhea and mention 4
causes under each category ( Acute vs. chronic)
1- 2- 3- 4-
1- 2- 3- 4-
1- 2- 3- 4-
1- 2- 3- 4-
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General approach to Diarrhea

• History
• Normal bowel habits
• Onset sudden/chronic
• Frequency, Food relation
• Stool appearance, Smell
• Drugs
• Tenesmus
• Travel. Contact
• Stress
• Associated features
• Nocturnal diarrhea
• Thyrotoxicosis

• Physical Examination
• Vital signs
• Volume status/Dehydration
• Eyes anemia,thyrotoxicosi
• Skin flushing, rashes
• L.N
• Abdomen mass,distension,tenderness,
• Hands clubbing

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Investigations

• CBCWBC (.),Hb (..),Plt (.),INR ?why
• Serum Electrolytes, (BUN , Creatinine ),Album
• Stool analysis, O P, Culture, ?Fat ,Occult
  blood. Clostridium difficle,24 hr fatgt10g(
  malabsorption),Osmolality and gap ?
• Specialized Tests Endoscopy ( U L)
• DM FBS,RBS
• Thyroid TSH,Ft3,Ft4
• Malabsorption Folate, Vit B12,Iron, serum
  gastric,VIP,Calcitonin,Cortisol,5 HIAA (for
  what?)

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Outline of Diarrhea management

• Assure ABC as always, assess volume status and
  replace lost fluids and electrolyte (
  Na,K,Cl,HCO3)
• Antimotility Loperamide,Atropine ( careful)
• Antibiotics not for everybody, Gram
  negative,parasites,anaerobes
• Prevention of spread, identification of the
  source
• Treat the underlying cause of inflammatory,
  Secretory chronic diarrhea.

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Take home message

• Think of the patient
  ( immunocompetent/Immunocompromis
  ed)
• Back to the basics ( city, Incubation period,
  types of culture and Investigations)
• DO NOT GIVE ANTIBIOTICS TO ALL DIARRHEA .
• Antimicrobials are not the only thing that the
  patient need ( hydration,shock,renal/liver.F)
• GO home and Read ???