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G.I. Bleeding. Presented by: Ahmed T. Al-Suwaidi Mohamed S. Al-Hoqani. 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. G.I. Bleeding Case.

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g i bleeding
G.I. Bleeding

Presented by:

Ahmed T. Al-Suwaidi

Mohamed S. Al-Hoqani

g i bleeding case
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
g i bleeding case1
G.I. Bleeding Case
  • M.H:

* no peptic ulcer disease

* no medications (NSAIDs)

* no urinary symptoms

* not known DM, HPTN, IHD

** weight loss

g i bleeding case2
G.I. Bleeding Case
  • O/E:

* Afebrile

* no pallor

* not dyspneaic

* no lymphoadenopathies

* no S.C.L.N

g i bleeding case3
G.I. Bleeding Case
  • Vital Signs:

* Pulse: 78 bts/min

* BP: 130/80

* RR: 18 br/min

  • Heart: NAD
  • Lung: NAD
g i bleeding case4
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

g i bleeding case5
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
g i bleeding case6
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

g i bleeding1
G.I. Bleeding
  • Acute Vs Chronic
  • Acute Upper G.I.Bleeding:
  • Acute Lower G.I.Bleeding:
acute upper g i bleeding
Acute Upper G.I. Bleeding
  • Haematemesis
  • Melaena
  • Site & Time
acute u g i bleeding
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.
acute u g i bleeding1
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.
acute u g i bleeding2
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
acute u g i bleeding3
Acute U.G.I. Bleeding

·Clinical approach:

6. liver disease  severe, recurrent bleeding (if from varices)

7. splenomegaly  portal hypertension

acute u g i bleeding4
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
acute u g i bleeding5
Acute U.G.I. Bleeding

** Emergency management (cntd):

  • · Bld transfusion in case of
    • 1) shock 2) haemoglobin <10 g/dl
  • ·Urgent endoscopy
  • ·Surgery when recommended
acute u g i bleeding6
Acute U.G.I. Bleeding

 **Shock management:

  • ·ABC
  • · Airway: endotracheal tube, oropharyngeal airway.

*Give oxygen

acute u g i bleeding7
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

acute u g i bleeding8
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

acute u g i bleeding9
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

acute u g i bleeding10
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.

slide22

Lower gastrointestinal haemorrhage

Causes

  • Diverticular disease
  • Angiodysplasia
  • Inflammatory bowel disease
  • Ischaemic colitis
  • Infective colitis
  • Colorectal carcinoma
slide23

Investigation

  • Mostpatients 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 >1 ml/minute
  • May show angiodysplastic lesions even once bleeding has ceased
slide24

Radionuclide scanning

    • Uses technetium-99m labeled red blood cells
slide25

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