G'I' Bleeding

1
G.I. Bleeding

• Presented by
• Ahmed T. Al-Suwaidi
• Mohamed S. Al-Hoqani

2
G.I. Bleeding Case

• 50 yrs, Pakistani, male
• C/O Bleeding/rectum Abd. pain
• Painless bleeding, 1 yr excess bleeding, 1
  month
• Black, 4-5 times/day, little quant.
• Abd. pain
• Vomiting, 1 week

3
G.I. Bleeding Case

• M.H
• no peptic ulcer disease
• no medications (NSAIDs)
• no urinary symptoms
• not known DM, HPTN, IHD
• weight loss

4
G.I. Bleeding Case

• O/E
• Afebrile
• no pallor
• not dyspneaic
• no lymphoadenopathies
• no S.C.L.N

5
G.I. Bleeding Case

• Vital Signs
• Pulse 78 bts/min
• BP 130/80
• RR 18 br/min
• Heart NAD
• Lung NAD

6
G.I. Bleeding Case

• Abd.
• not distended
• no epigast. tenderness
• tender, firm, partly mobile mass at Rt
  lumbar region.
• spleen not palpable
• Lt lobe liver palpable, mildly tender
• bowel sounds present

7
G.I. Bleeding Case

• PR
• no enlarged piles
• no active bleeding
• no palpable mass
• no blood on finger
• ECG, CBC, Sr Amylase, Bleeding profile, Abd
  X-ray, fecal loading ascending colon

8
G.I. Bleeding Case

• Lab Results
• Hb 14.1 g/dl Plt 252 103
• Hypochromic, microcytic
• PT 17.3 sec aPTT 35.4 sec
• Sr Amy 129 U/l ? 106 U/l
• Na 140 mmol/l K 4.1 mmol/l
• BUN 17 mg/dl

9
G.I. Bleeding

• Acute Vs Chronic
• Acute Upper G.I.Bleeding
• Acute Lower G.I.Bleeding

10
Acute Upper G.I. Bleeding

• Haematemesis
• Melaena
• Site Time

11
Acute U.G.I. Bleeding

•  Aetiology
• 1. Drugs (Aspirin NSAIDs)
• 2. Alcohol
• 3.Chronic peptic ulceration (50 of GI
  hemorrhage)
• 4.Others reflux esophagitis, varices, gastric
  carcinoma, acute gastric ulcers erosions.

12
Acute U.G.I. Bleeding

•   Clinical approach
• 1. recent (24 hrs), then hospitalized.
• 2. if small amount, no immediate Tx, because CVS
  can compensate
• 3. 85 stop bleeding during 48 hrs
• 4. history helps in diagnosing the cause of the
  hemorrhage, eg long history of indigestion, or
  previous hem. from ulcers.

13
Acute U.G.I. Bleeding

•     Clinical approach
• 5. factors include
•  age (60 )
•  amount of bld lost
•  continuing visible bld loss.
•  signs of chronic liver disease
•  classical clinical features of shock

14
Acute U.G.I. Bleeding

•     Clinical approach
• 6. liver disease ? severe, recurrent bleeding
  (if from varices)
• 7. splenomegaly ? portal hypertension

15
Acute U.G.I. Bleeding

•   Immediate management
• Emergency management
•   History exam.
•   Monitor pulse BP /30 min
•  Bld sample haemoglobin, urea, electrolytes,
  grouping cross-matching
•       I.v. access

16
Acute U.G.I. Bleeding

• Emergency management (cntd)
• Bld transfusion in case of
• 1) shock 2) haemoglobin lt10 g/dl
•       Urgent endoscopy
•       Surgery when recommended

17
Acute U.G.I. Bleeding

•  Shock management
•   ABC
• Airway endotracheal tube, oropharyngeal
  airway.
• Give oxygen

18
Acute U.G.I. Bleeding

• Shock management (cntd)
•    Breathing support respiratory function
• Monitor resp. rate, bld gases, chest
  radiograph
• Circulation expand circulating volume blood,
  colloids, crystalloids support CVS function
  vasodilators
• Monitor skin color, peripheral temp., urine
  flow, BP, ECG

19
Acute U.G.I. Bleeding

•  General Investigations
• 1. Hb, PCV
• 2. CBC (WBC etc)
• 3. Bld glucose
• 4. Platelets, coagulation
• 5. Urea, creatinine, electrolytes
• 6. Liver biochem.
• 7. Acid-base state
• 8. Imaging chest abd. radiography, US, CT

20
Acute U.G.I. Bleeding

• General management
•  Blood volume
• 1. restore volume to normal
• 2. transfusion
•  Endoscopy
• 1. shock, suspected liver disease or
  continued bleeding
• 2. control varices or ulcers to reduce
  re-bleeding

21
Acute U.G.I. Bleeding

• General management
• Drug therapy
• 1. H2 receptor antagonists
• 2. proton pump inhibitors
• Factors in reassessment
• 1. age 60 ? greater mortality
• 2. recurrent hemorrhage mortality
• 3. re-bleeding mostly within the 1st 48 hrs
• 4. surgical procedures in case of severe
  bleeding.

22
Lower gastrointestinal haemorrhage
Causes

• Diverticular disease

• Angiodysplasia

• Inflammatory bowel disease

• Ischaemic colitis

• Infective colitis

• Colorectal carcinoma

23
Investigation

• Most patients are stable and can be investigated
  once bleeding has stopped

• In the actively bleeding patient consider

• Colonoscopy - can be difficult

• Selective mesenteric angiography

• Requires continued bleeding of gt1 ml/minute

• May show angiodysplastic lesions even once
  bleeding has ceased

24

• Radionuclide scanning
• Uses technetium-99m labeled red blood cells

25
Management

• Acute bleeding tends to be self limiting

• Consider selective mesenteric embolisation if
  life threatening haemorrhage

• If bleeding persists perform endoscopy to exclude
  upper GI cause

• Proceed to laparotomy and consider on-table
  lavage an panendoscopy

• If right-sided angiodysplasia perform a right
  hemicolectomy

• If bleeding diverticular disease perform a
  sigmoid colectomy

• If source of colonic bleeding unclear perform a
  subtotal colectomy and end-ileostomy