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Gastrointestinal BleedingGastrointestinal Bleeding
HematemesisHematemesis-- Vomiting of bright redVomiting of bright redbloodblood
usually represents bleeding proximal tousually represents bleeding proximal tothe ligament of Treitzthe ligament of Treitz
HematocheziaHematochezia-- bright red blood perbright red blood per
rectumrectum indicates a lower GI source of bleedingindicates a lower GI source of bleeding
Blood has a laxative effect so with massiveBlood has a laxative effect so with massivebleeding the stool may be bright redbleeding the stool may be bright red
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Gastrointestinal BleedingGastrointestinal Bleeding
Blood streaks on the stool indicates anal outletBlood streaks on the stool indicates anal outletbleedingbleeding
Blood mixed with stool indicates bleeding sourceBlood mixed with stool indicates bleeding sourcehigher than the rectumhigher than the rectum
Blood with mucus indicates an infectious orBlood with mucus indicates an infectious orinflammatory diseaseinflammatory disease
Currant jellyCurrant jelly--like material indicates vascularlike material indicates vascularcongestion and hyperemia (intussusception orcongestion and hyperemia (intussusception ormidgut volvulus)midgut volvulus)
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Gastrointestinal BleedingGastrointestinal Bleeding
MaroonMaroon--colored stools indicate voluminouscolored stools indicate voluminousbleeding proximal to the rectosigmoid areableeding proximal to the rectosigmoid area
Melena, passage of black, sticky (tarry)Melena, passage of black, sticky (tarry)stools suggests upper GI tract bleeding,stools suggests upper GI tract bleeding,but can be as distal as the right colonbut can be as distal as the right colon
Hematemesis suggests a large bleed withHematemesis suggests a large bleed withpossible recurrence, melena alonepossible recurrence, melena aloneindicates less voluminous bleedingindicates less voluminous bleeding
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Causes of Upper GI BleedingCauses of Upper GI Bleeding
CommonCommon
NasopharyngealNasopharyngeal
bleedingbleeding
Erosive EsophagitisErosive Esophagitis
Peptic ulcerPeptic ulcer
Gastritis (H. pylori)Gastritis (H. pylori) MalloryMallory--Weiss tearWeiss tear
Prolapse gastropathyProlapse gastropathy
Less CommonLess Common
Bleeding disordersBleeding disorders
Duplication cystDuplication cyst
Foreign bodyForeign body
Tube traumaTube trauma
Vascular malformationVascular malformation Esophageal varicesEsophageal varices
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Causes of Lower GI BleedingCauses of Lower GI Bleeding
CommonCommon
Anal fissureAnal fissure
Infectious colitisInfectious colitisSalmonella, Shigella,Salmonella, Shigella,Campylobacter, C.diffCampylobacter, C.diff
Inflammatory bowelInflammatory boweldiseasedisease
IntussusceptionIntussusception
Upper GI sourceUpper GI source
Less CommonLess Common
Meckels diverticulumMeckels diverticulum
Duplication cystDuplication cyst
HirschsprungsHirschsprungsenterocolitisenterocolitis
Gangrenous intestineGangrenous intestine Vascular malformationVascular malformation
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Clinical Findings in PUDClinical Findings in PUD
Neonatal PeriodNeonatal Period Gastric ulcers are more common thanGastric ulcers are more common than
duodenal ulcers in neonatesduodenal ulcers in neonates
Spontaneous Perforation is a moreSpontaneous Perforation is a morecommon presentation than bleedingcommon presentation than bleeding
Frequently associated with:Frequently associated with:
Hypoxia, Sepsis, RDS, CNS disorderHypoxia, Sepsis, RDS, CNS disorder
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Clinical Findings in PUDClinical Findings in PUD
Infants and ToddlersInfants and Toddlers Presenting symptoms:Presenting symptoms:
VomitingVomiting
Poor feedingPoor feeding
Irritability during and after eatingIrritability during and after eating
Abdominal distentionAbdominal distention
Hematemesis, melenaHematemesis, melena
Commonly associated with underlyingCommonly associated with underlyingdisease in this age groupdisease in this age group
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Clinical Findings in PUDClinical Findings in PUD
PrePre--SchoolersSchoolers Periumbilical or generalized abdominalPeriumbilical or generalized abdominal
painpain
Vomiting after eatingVomiting after eating
Nocturnal or early morning painNocturnal or early morning pain
Gastric ulcers are as common as duodenalGastric ulcers are as common as duodenalulcersulcers
Primary ulcers are as common asPrimary ulcers are as common assecondary ulcerssecondary ulcers
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Clinical Findings in PUDClinical Findings in PUD
School AgeSchool Age Male: Female ratio is 3:1Male: Female ratio is 3:1
Burning epigastric painBurning epigastric pain
Nocturnal painNocturnal pain
Melena, hematemesis, fecal occult bloodMelena, hematemesis, fecal occult blood
Primary ulcers are more common thanPrimary ulcers are more common thansecondary ulcerssecondary ulcers
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Pathophysiology of GI BleedingPathophysiology of GI Bleeding
Mucosal lesionsMucosal lesions
AcidAcid--peptic disease, drugpeptic disease, drug--induced (NSAIDs),induced (NSAIDs),Infectious (H. pylori), inflammatory bowel dzInfectious (H. pylori), inflammatory bowel dz
Portal hypertensionPortal hypertension
Esophageal varices, hypertensive gastropathyEsophageal varices, hypertensive gastropathy
CoagulopathyCoagulopathy -- Hemophilia, hepaticHemophilia, hepaticcoagulopathy, CHF w/hepatic congestioncoagulopathy, CHF w/hepatic congestion
Vascular lesionsVascular lesions -- hemangiomashemangiomas
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Causes and Effects of HCauses and Effects of H++ IonIon
BackdiffusionBackdiffusionLowflow states Drugs, EtOH Stress H. pylori Bile Reflux
Mucosal Barrier Break
Parietal Cells
Release of histamine + Vasodilatation
Increased HCl and Pepsin Secretion
H+
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Peptic Ulcer DiseasePeptic Ulcer Disease
Diagnostic EvaluationDiagnostic Evaluation History (medications, family history)History (medications, family history)
Physical exam (include Hemoccult)Physical exam (include Hemoccult)
CBC, type & screen for GI bleedingCBC, type & screen for GI bleeding
PT, PTTPT, PTT
H. pyloriH. pylori antibody, fasting gastrin levelantibody, fasting gastrin level Upper GI SeriesUpper GI Series
EGDEGD
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Indications for EGDIndications for EGD
Hematemesis, Melena, Heme (+) stoolHematemesis, Melena, Heme (+) stool
Severe pain, weight lossSevere pain, weight loss
Unexplained anemiaUnexplained anemia
Symptoms persist despite trial ofSymptoms persist despite trial ofantisecretory therapyantisecretory therapy
Evaluation of abnormal UGI seriesEvaluation of abnormal UGI series
Evaluation of status ofEvaluation of status of H. pyloriH. pylori
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Case #1Case #1 UGI BleedingUGI Bleeding
12 YOWF with S/P splenectomy 2 yr ago for12 YOWF with S/P splenectomy 2 yr ago forEvans syndromeEvans syndrome
Weakness, pallor, melana x 2 daysWeakness, pallor, melana x 2 days ExamExam HRHR-- 128, BP128, BP--86/54, tachycardic, pale,86/54, tachycardic, pale,
abdomen nontender, nondistended, noabdomen nontender, nondistended, nohepatomegalyhepatomegaly
LabLab H/H=6.8/19.1, WBC, 5.7; platelets,H/H=6.8/19.1, WBC, 5.7; platelets,115,000, PT=13.2 sec; AST, 38; ALT, 45; T.bili,115,000, PT=13.2 sec; AST, 38; ALT, 45; T.bili,0.5; alk phos, 2270.5; alk phos, 227
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Esophageal varicesEsophageal varices
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Case #2Case #2 UGI BleedingUGI Bleeding
11 YOWM previously healthy with 1 day h/o11 YOWM previously healthy with 1 day h/ofever, vomiting and diarrheafever, vomiting and diarrhea
Emesis x 6 over past 24 hr, w/blood last 2 timesEmesis x 6 over past 24 hr, w/blood last 2 times ExamExam HRHR-- 84, BP84, BP--116/74, abdomen116/74, abdomen
nontender, nondistended, no hepatomegalynontender, nondistended, no hepatomegaly
LabLab H/H=13.8/39.1, WBC, 8.7; platelets,H/H=13.8/39.1, WBC, 8.7; platelets,235,000, PT=12.2 sec235,000, PT=12.2 sec
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Prolapse GastropathyProlapse Gastropathy
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Meckels ScanMeckels Scan
99m99mTcTc--Pertechnetate ScanPertechnetate Scan -- injected IV andinjected IV andaccumulates in gastric tissueaccumulates in gastric tissue -- RLQ uptakeRLQ uptake
is diagnostic of Meckels diverticulumis diagnostic of Meckels diverticulum False (+)False (+) -- bleeding lesions such asbleeding lesions such as
Crohns disease, intussusception,Crohns disease, intussusception,hemangioma, PUDhemangioma, PUD
False (False (--)) -- Barium, bladder overdistention,Barium, bladder overdistention,no gastric mucosa in diverticulumno gastric mucosa in diverticulum
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99m99mTcTc-- Labeled Red Cell ScanLabeled Red Cell Scan
99m99mTcTc--sulfur colloid is added to a sample ofsulfur colloid is added to a sample ofthe patients blood cells and rethe patients blood cells and re--infused IVinfused IV--
patient is scanned with gamma camerapatient is scanned with gamma camera
HalfHalf--life is short (2.5 min) so that after 10life is short (2.5 min) so that after 10minutes only 10% is left in the circulationminutes only 10% is left in the circulation
99m99mTc accumulates at the bleeding site andTc accumulates at the bleeding site andlights up on scanlights up on scan -- can detect 0.1 ml/mincan detect 0.1 ml/min
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GI BleedingGI Bleeding -- TreatmentTreatment
ABCsABCs -- protect airway with hematemesis inprotect airway with hematemesis inan obtunded patientan obtunded patient
IV accessIV access -- two lines (0.9% NS in one line,two lines (0.9% NS in one line,PRBCs not compatible with dextrose)PRBCs not compatible with dextrose)
Transfuse for Hgb < 8 w/active bleedingTransfuse for Hgb < 8 w/active bleeding
NG lavageNG lavage Antacids (1 ml/kg up to 30 ml q 2 hr)Antacids (1 ml/kg up to 30 ml q 2 hr)
PPI 2 mg/kg loading dose, then 1PPI 2 mg/kg loading dose, then 1mg/kg/day IVmg/kg/day IV
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Drug Efficacy in Healing UlcersDrug Efficacy in Healing Ulcers
DrugDrug RegimenRegimen Ulcers HealedUlcers Healed
H2RAH2RA 4 weeks4 weeks 8 weeks8 weeks
CimetidineCimetidine 40 mg/k/d40 mg/k/d 80%80% 90%90% RanitidineRanitidine 44--8 mg/k/d8 mg/k/d
FamotidineFamotidine 11--2 mg/k/d2 mg/k/d
PPIsPPIs
OmeprazoleOmeprazole 0.70.7--3 mg/k/d3 mg/k/d85%85% 95%95% LansoprazoleLansoprazole 0.70.7--4 mg/k/d4 mg/k/d
SucralfateSucralfate 4040--80 mg/k/d80 mg/k/d 75%75% 86%86%
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ATLS Classification of ShockATLS Classification of Shock
ClassClass BloodBlood
LossLoss
BPBP HR HR CapCap
refillrefill
NeuroNeuro
11 150 > 3 sec> 3 sec AlertAlert
33 3030 35%35% DecreasedDecreased >150>150 > 3 sec> 3 sec LethargicLethargic
44 4040 45%45% NotNot
palpablepalpable
>150>150 > 3 sec> 3 sec ObtundedObtunded
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ManagementManagement
Class 1, no anemia, no active bleeding onClass 1, no anemia, no active bleeding onlavage, may be followed up as outpatientlavage, may be followed up as outpatient
Class 2, mild anemia, active bleeding mayClass 2, mild anemia, active bleeding maybe monitored on wardsbe monitored on wards
Class 3 or 4 admit to PICU, central line,Class 3 or 4 admit to PICU, central line,
arterial linearterial line
IVF boluses, transfusion as neededIVF boluses, transfusion as needed
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ManagementManagement
Iced saline?Iced saline? -- with cooling, bleeding timewith cooling, bleeding timeincreases to 3 x control, clotting timeincreases to 3 x control, clotting time
increases up to 60%, and PT can increaseincreases up to 60%, and PT can increaseto 2 x control, and can cause hypothermiato 2 x control, and can cause hypothermia
NG tube is useful to monitor bleeding, butNG tube is useful to monitor bleeding, but
not in treatmentnot in treatment Therapeutic endoscopy (sclerotherapy)Therapeutic endoscopy (sclerotherapy)
useful in variceal hemorrhageuseful in variceal hemorrhage
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ManagementManagement -- OctreotideOctreotide
Somatostatin analogSomatostatin analog -- octreotide has a longeroctreotide has a longerhalfhalf--life than somatostatinlife than somatostatin
Decreases splanchnic blood flow andDecreases splanchnic blood flow andgastrointestinal secretiongastrointestinal secretion
Make a 1Make a 1 QQg/ml dripg/ml drip -- begin drip at a rate of 0.1begin drip at a rate of 0.1QQg/kg/ming/kg/min -- increase to 0.5increase to 0.5 QQg/kg/min untilg/kg/min until
bleeding stops, then wean ratebleeding stops, then wean rate Side effectsSide effects -- nausea, gas, hyperglycemia,nausea, gas, hyperglycemia,
gallstones, elevated liver enzymesgallstones, elevated liver enzymes
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GI BleedingGI Bleeding SummarySummary
Remember your abCsRemember your abCs
IV access if bleeding is significantIV access if bleeding is significant
Plan diagnostic workPlan diagnostic work--up based onup based onpresentationpresentation
Consider nonConsider non--GI causes of blood in the GIGI causes of blood in the GI
tract (e.g., swallowed blood)tract (e.g., swallowed blood)
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Question #1Question #1 An 18An 18--monthmonth--old boy passed a dark red stool four hours ago andold boy passed a dark red stool four hours ago and
another bloody stool during physical examination. He has no fever,another bloody stool during physical examination. He has no fever,vomiting, diarrhea, or constipation. His growth and developmentvomiting, diarrhea, or constipation. His growth and developmenthave been normal. On physical examination, his pulse is 140/min,have been normal. On physical examination, his pulse is 140/min,respiratory rate 24/min, and blood pressure is 86/54 mmHg. Therespiratory rate 24/min, and blood pressure is 86/54 mmHg. Theabdomen is soft and nontender. Rectal examination reveals maroonabdomen is soft and nontender. Rectal examination reveals maroon--
colored stool that is guaiac positive. The remainder of the physicalcolored stool that is guaiac positive. The remainder of the physicalexamination is normal. Gastric aspirate is negative for blood.examination is normal. Gastric aspirate is negative for blood.Laboratory evaluation reveals hemoglobin 8 g/dL, hematocrit 26%.Laboratory evaluation reveals hemoglobin 8 g/dL, hematocrit 26%.Prothrombin time, partial thromboplastin time, and INR wereProthrombin time, partial thromboplastin time, and INR werenormal. After intravenous fluid administration and erythrocytenormal. After intravenous fluid administration and erythrocytetransfusion, which of the following is most likely to be diagnostic?transfusion, which of the following is most likely to be diagnostic?
A. Barium enemaA. Barium enemaB. Meckel radionuclide scanB. Meckel radionuclide scanC. Computerized tomography (CT scan) of the abdomenC. Computerized tomography (CT scan) of the abdomenD. Upper gastrointestinal series with small bowel follow throughD. Upper gastrointestinal series with small bowel follow throughE. Abdominal angiographyE. Abdominal angiography
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Question #2Question #2
A 6A 6--weekweek--old infant has done well since birth until blood and mucusold infant has done well since birth until blood and mucusappeared in the stool for the past 3 days. He is taking his usual fourappeared in the stool for the past 3 days. He is taking his usual fourounces of cowounces of cow--milk formula per feeding without vomiting. He ismilk formula per feeding without vomiting. He ismore irritable during defecation. Physical examination reveals thatmore irritable during defecation. Physical examination reveals that
the abdomen is soft and not distended. The hemoglobin is 10 g/dL.the abdomen is soft and not distended. The hemoglobin is 10 g/dL.
Which of the following is the most likely explanation for the findingsWhich of the following is the most likely explanation for the findingsin this infant?in this infant?
A. Hirschsprung diseaseA. Hirschsprung disease
B. Meckel diverticulumB. Meckel diverticulumC. Anal fissureC. Anal fissureD. CowD. Cow--milk protein colitismilk protein colitisE. Midgut volvulusE. Midgut volvulus
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