Gastrointestinal bleeding Upper Gastrointestinal bleeding Definition Bleeding from
Gastro-intestinal bleeding
Upper Gastro-intestinal bleeding Definition: Bleeding from GI-tract where the source is proximal to the duodenum jejunal (DJ) flexure. n Aetiology n – Peptic Ulcers 50% – Acute mucosal lesions 25% – Oesophageal varices 12. 5% – Miscellaneous 12. 5% (anatomical)
Lower Gastro-intestinal Bleeding Definition: Bleeding distal to the DJ-flexure n Aetiology (Common) n – Diverticular disease – Angiodysplasia – Local anorectal pathology
Lower Gastro-intestinal Bleeding n Aetilogy (less common) – Congenital – Traumatic – Inflammatory – Neoplasia – Vascular – Solitary rectal ulcer – Clotting abnormalities
Clinical Picture n Upper GI Bleed – Hematemesis – Vomiting of bright red blood – Coffee ground vomiting – Dark granular blood – Melena – Pitch-black, tarry, foul-smelling stools
Clinical Picture n Lower GIT Bleed – Fresh bright red blood per rectum – Changed blood per rectum – Occult blood n NB: Occult blood and bright red blood per rectum can occour in upper GIT as well as lower GIT bleeding
Results of GI bleeding Hemodynamic: Hypovolemia, shock, renal failure, death n Encephalopathy: If liver function is reduced n
Management n Three phases 1) Resuscitation n 2) History and Examination n 3) Anatomic localisation n
Management n Initial management (UGIB and LGIB) – Intravenous lines, fluid resuscitation – Monitor blood pressure, pulse rate, haematocrit keep NPM – Full blood count, U+E, liver function test, clotting profile and cross-match – Nasogastric tube – Massive Upper GI Bleed - emergency surgery
Further Evaluation and Management n History and Examination – Symptoms of PUD – Risk factors – Examine the patient for stigmata of chronic liver disease – Examination patient for signs of portal hypertension – Evaluate patient for signs of stomach carcinoma
Further Evaluation and Management n Anatomical localization – Upper GIT endoscopy n Peptic Ulcer (endoscopic therapy) – – n Thermal Injection Mechanical Topical Oesophageal Varices – Intraoesophageal Balloon – Injection sclerotherapy via endoscope – Banding via endoscope n Other conditions – Treat on merit
Surgical Management n Indications for surgery – Massive bleeding – Continuous bleeding – Rebleeding to shock – Older patients (> 60 yrs) where higher risk has been identified clinically or on scope
Specific Management LGIB n n n Localization of the source of the bleeding is often problematic Rule out an UGIB Exclude local anorectal pathology Massive Bleeding - the surgeon is forced to do an emergency operation without any further localization examinations No bleeding point localised and surgery is necessary - intra-operative pan-endoscopy Slow, but continuous bleeding – – Colonoscopy Arteriography Tc 99 m Red blood cell scan Video capsule
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