الرحيم الرحمن اللله بسم

Gastrointestinal bleeding

Draz MY , Egypt 2008Mb. Bch, D. Sc (Alazhar) .,M. Sc (Cairo) ,M. Sc

(Ain shams).Surgeon ,Internist, Emergency Registrar.

mahmood_yasin37@yahoo.com

bleeding from gastrointestinal tract

Bleeding from GIT presents in 5 ways:

1 -Hematemesis 2 -Melena

3 -Hematochezia 4 -Occult blood in stools

5 -Chronic blood loss and anemia.

1 – Hematemesis: *IS vomiting of bright red blood (=

profuse bleeding) * Or coffee ground material (= altered

blood converted to acid hematin by gastric HCL).

*It is due to bleeding from above ligament of treitz.

*Hematemesis may be false due swallow of blood e.g. from nose, mouth or pharynx.

* Or true due to bleeding from any place from esophagus down to duodenojejunal junction.

2 - Melena: *the passage of black tarry

loose stools containing digested blood by the action of digestive enzymes and bacteria.

*It is due to bleeding from any place above and including caecum.

* If bleeding is sever, red blood clots may pass in stools.

3 – Hematochasia: is passage of red blood per rectum due to bleeding from the ascending colon downwards.

4 – Occult blood in stools detected by laboratory methods.

5 -Chronic interrupted minimal blood loss presents by signs and symptoms of anemia.

(Laine, 2001).

Bleeding from GIT may be

A- UPPER GIT BLEEDING: above the ligament of treitz i.e. the

duodenojejunal junction >------------hematemesis or melena.

A- LOWER GIT BLEEDING: below ligament of Treitz leading to

melena and hematochazia but no hematemesis.

True hematemesis(vomiting) and naso-gastric tube

aspiration is a sign of upper git bleeding.

BUT MELENA MAY OCCUR IN UPPER OR LOWER GIT

BLEEDING. )Marko and Pons ,2003.(

Causes of upper GIT bleeding

A – General causes: e.g. bleeding diathesis

B – GIT causes: 1 - Esophageal causes:

Esophageal varicies - Esophagitis – tumours - trauma .

Rupture aortic aneurysm into esophagus. 2 – Gastrodoudinal causes:

Peptic ulcer disease - Gastritis - gastric erosions. Hiatus hernia - Mallory-Weiss tear .Tumours - Angiodysplasia .

Hereditary hemorrhagic telangeactasia.Aorto-enteric fistula .

( Edmundowicz and Zuckerman, 1992)

CAUSES OF LOWER GIT BLEEDING:A – GENERAL CAUSES: B – LOCAL GIT CAUSES:

1 -SMALL INTESTINE : digested blood (melena)enteritis (T.B. ,TYPHOID) – meckel,s diverticulitis –

crhon,s – tumours – vascular malformations.

2 – COLON : blood mixed with stools

diverticulosis coli – cancer & polypi –intussusception vascular malformations –– ulcerative colitis.

3 – RECTUM : blood streaked on stools cancer – polypi –prolapse- proctitis.

4 – ANAL CANAL: fresh blood after defecation)with pain or not(

piles – fissure - cancer.

COMMON CAUSES OF UPPER GIT BLEEDING: PEPTIC ULCER.

GASTRITIS AND EROSIONSVARICES

COMMON CAUSES OF LOWER GIT BLEEDING: CHILDREN:

MECKEL,S DIVERTICULUMPOLYPSULCERATIVE COLITIS

ADULTS: HEMORRHOIDSVASCULAR ECTASIADIVERTICULOSISPOLYPSCARCINOMACONGENITAL ARTERIOVENOUS MALFORMATIONS

SOME VIDEO SCENES OF GIT

DISEASES

EVALUATION OF THE CASEEVALUATION OF THE CASE: :

11 – – IS THERE HEMODYNAMIC CMPROMISEIS THERE HEMODYNAMIC CMPROMISE? ?

22 – – IS THERE ACTIVE BLEEDINGIS THERE ACTIVE BLEEDING??

33 – – IS THIS A HIGH RISK PATIENTIS THIS A HIGH RISK PATIENT? ?

44 – – IS THIS UPPER OR LOWER GIT BLEEDINGIS THIS UPPER OR LOWER GIT BLEEDING??

CALCULATION OF AMOUNT OF BLOOD LOSS AND

RESUSCETAION FLUIDS MARINO ( 1998):

STEP 1

1 – CALCULATION OF BLOOD VOLUME AND BODY FLIUDS:

STEP 22 – CALCULATION

OF VOLUME DEFICIT

USE OF OXYGEN EXTRACTION % TO EVALUATE HYPOVOLAEMIA:

*MEASURE ) SaO2( BY PULSE OXIMETRY.

*Measure O2 SATURATION IN VENOUS BLOOD GASES

Clinical picture of hypovolaemic shockRapid weak pulse : - 1

*catecholamine release , *mary,s law =tachycardia with hypotension ,*stimulated cardiac accelerating center directly by hypoxia and reflexly by carotid and aortic body chemoreceptor.

2 -Hypotension and low pulse pressure: Decrease in blood volume= decrease in venous

return = decrease in cardiac output = decrease in ABP.

3- Subnormal temperature : vasoconstriction and decreased tissue metabolism.

4 - Increased rate and depth of respiration : Due to tissue hypoxia and hypotension.

Continue,hypovol.shock:5- Pale(vasoconstriction of capillaries), cold

(vasoconstriction of arterioles) , clammy skin(sweat secretion ) = sympathetic over

activity. 6- Collapsed viens and decreased CVP.

7- Oliguria : decreased renal blood flow and ADH release.

8- Thirst sensation: 9 - Restlessness early with mild to moderate

hypovoleamia and lethargy with moderate to sever hypovoleamia.

10 – CLINICAL PICTURE OF THE CAUSE:

LABORATORY INVESTIGATIONS: 1 -BLOOD GROUP AND CROSS MATCHING:

FOR 4 – 8 UNITS ACCOIRDING TO SUSPECTING REBLEEDING STORE PLASMA FOR ONGOING CROSS MATCHING

TAKE SAMPLE BEFORE COLLOID USE

2-CBC: HB%, PCV :

CHANGED ONLY IN MASSIVE GIT BLEEDING , GIVES IDEA ABOUT PREVIOUS FITTNESS OF PATIENS .

WBCS: IF MORE THAN 15000 CONFIRM ABOUT ANY SEPSIS .PLATELATS COUNT: if less than 50000 consider platelet support.

3-Urea and electrolytes: may be elevated inspite of normal creatinine due to increased protein absorption AND RETURNS AFTER

VOLUME RESTORATION..

4-Blood glucose: may decrease in liver disease .

5-PT, PTT AND LFTS: CHANGED IN LIVER DISEASE AND IN PATIENTS TAKING WARFARIN .

6-Monitor Arterial Blood. gases in morbid conditions. OCCULT BLOOD IN STOOL in minimal bleeding

DeterminATION OF SITE OF BLEEDING:

1 – History:DETERMINE DEGREE OF BLOOD LOSS BUT

NOT SO ACCURATE ,LEVEL OF BLEEDING ,ETIOLOGY OF BLEEDING,PRECIPITATING FACTOR,PREVIOUS BLEEDING.

2 – Ryle tube and PR:

3 – Upper endoscopy, anorectosegmoidoscopy and colonoscopy:

4 – RADIOISOTOPIC Scanning by technetium labelled Rbcs:

FOR SCREENING BEFORE ARTERIOGRAPHY ,IT CAN DETECT BLEEDING LESS THAN 0.5ML /MIN,A POSITIVE SCAN POINT

TO CANDIDATE OF ARTERIOGRAPHY,NEGATIVE SCAN INDICATES SHORT TERM GOOD PROGNOSIS.

5 – Selective arteriography: DETERMINES THE SITE OF BLEEDING NOT THE CAUSE .

USED FOR THERAPEUTIC INTRA-ARTERIAL INJECTION OF VASOPRESSIN OR ARTERIAL EMBOLISATION BY GELFOAM

PRIMARY EVALUATION AND RESSUSCITATION: IF IMPENDING HYPOVOLEMIC SHOCK:

A airway protection and consider endotracheal tube if aspiration is suspected.

B BREATHING SUPPORT

C circulatory support:

1 -wide pore venous access. 2 – appropriate fluid transfusion according to

patient condition and facilities. 3 – contact with surgeons and emergency

endoscopic team early. insert retained urinary cath.and calculate urine hourly.

4 -insert ryle tube to detect hematemesis and or do gastric wash according to cause.

5 – in compromised patients cvp and intensive care measurements is considered according to every case.

Vasopressin : constrict splanchnic arterioles 0.4 u/min. for one day then 0.2 u /min . for another day.

Better given with nitroglycerin.Glypressin:long duration ,less side effects

2mg iv every hour till bleeding stops then 1 mg every 6 hours octreotide : selective splanchnic arteriolar vasoconstriction

50 microgr iv bolus then 50 microgram every 6 hours for 48 hours

CERTAIN PRECAUTIONS *HB% OF 7-8 gm.WILL GIVE ADEQUATE OXYGENATION

FOR NORMOVOLEMIC BUT IN HYPOVOLEMIC OR COMPROMISED PATIENT 9-10 gm. IS BETTER ACHIEVED.

* GIVE PACKED RBS IN CARDIAC RISKY PATIENTSPLATELETS FOR MASSIVE BLOOD TRANSFUSION

* FFP FOR COAGULATION DISORDERS

* PLATELET CONCENTRATE FOR THROMBOCYTOPENIA less than 50,000.

* BLOOD GROUP O NEGATIVE EVEN WITHOUT CROSS MATCHING FOTR LIFE THREATENING CONDITIONS.

* CALCIUM ONE AMPULE FOR EVERY FOUR UNITS.

* CHECK FOR BLOOD HAEMOLYSIS IN UNCONSCIOUS PATIENTS.

Hypovolaemia and shock: * 500 ml. of blood loss leads to minimal clinical

finding. * 1000 ml. of blood loss causes positive tilt test.

* 2000 ml. of blood loss presents with features of shock.

* Rapid loss of 50% of blood volume is usually fatal.

* Elders cannot accommodate for hypovolaemia properly.

* Mild hypovolaemia = compensatory vasoconstriction to maintain blood pressure.

* More hypovolaemia = hypotension, increase in peripheral vascular resistance, capillary and venous bed collapse, and all of these leads to more tissue hypoxia.

Low risk criteria : Low risk criteria : Henneman,2003Henneman,2003..

11 – – No co morbid diseasesNo co morbid diseases . .22 – – Normal vital signsNormal vital signs..

33 – – Normal or trace positive stool Normal or trace positive stool guaiacguaiac . .

44 - - Negative gastric aspirateNegative gastric aspirate . .55 – – Normal or near normal HBNormal or near normal HB

%&hematocrit%&hematocrit..66 – – No problem to ask for medical No problem to ask for medical

help on needhelp on need . .77 – – Proper understanding of S. &S. Proper understanding of S. &S.

of bleedingof bleeding..88 – – No high risk factors and easy No high risk factors and easy

medical follow upmedical follow up..

HIGH RISK PATIENTS : HIGH RISK PATIENTS : VELAYO,2003VELAYO,2003..

11 – – AGE > 60 YEARSAGE > 60 YEARS. . 22 – – COMORBID CONDITIONS : COMORBID CONDITIONS : D.M. , D.M. ,

RENAL, CARDIAC, HEPATIC FAILURE, RENAL, CARDIAC, HEPATIC FAILURE, IHD,CANCERIHD,CANCER..

33 – – PERSISTENT HYPOTENSIONPERSISTENT HYPOTENSION . . MORE THAN 4 UNITS OF TRANSFUSION.MORE THAN 4 UNITS OF TRANSFUSION.- -

44 55 – – BLEEDING OR REBLEEDING BLEEDING OR REBLEEDING DURING DURING

HOSPITALISATIONHOSPITALISATION . .66 – – BLOODY NASOGASTRIC ASPIRATEBLOODY NASOGASTRIC ASPIRATE. . 77 – – NEED FOR EMERGENCY SURGERYNEED FOR EMERGENCY SURGERY. . 88 – – HIGH RISK LESIONS : HIGH RISK LESIONS : ESPGHAGIAL ESPGHAGIAL

VARECES ,VARECES ,A-E FISTULAA-E FISTULA,BIGACTIVELY ,BIGACTIVELY BLEEDING ULCERS IN POSTERIOR PULP BLEEDING ULCERS IN POSTERIOR PULP

OF DUODINUMOF DUODINUM..

Band ligationBand ligation

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