Gastro intestinal hemorrhage
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Erosive gastritis, esophagitis, duodenitis Esophageal and gastric varices causes by portal hypertension Mallory-Weiss syndrome – longitudinal mucosal tear in the cardioesophageal region caused by repeated retching
8
stress ulcers arteriovenous malformation malignancy aortoenteric fistula
9
Causes of Lower GI Bleeding
Hemorrhoids - most common cause Diverticulosis – common, painless, and can be massive Caused from an erosion into a penetrating artery from the diverticulum. Arteriovenous malformations – common and seen in people with hypertension and aortic stenosis
13
Investigations
• • • • CBC Electrolytes Glucose BUN/Creatine –BUN will be elevated in upper GI bleeds • Coagulation studies • Liver function studies • Type and cross-match
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• • • • • •
Proton-pump inhibitor Endoscopy Somatostatin, octretide for varices Balloon tamponade Surgery Must get early consultation with gastroenterologist and general surgeon for significant GI bleeds.
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Probable Source of GI Bleeding Within the Gut Clinical Indicator Hematemesis Melena Hematochezia Bloodstreaked stool Occult blood in stool Probability of Upper GI Source Almost certain Probable Possible Rare Possible Probability of Lower GI Source Rare Possible Probable Almost certain Possible
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RESUSCITATION
Initial steps in the management of upper gastrointestinal bleeding
Airway protection Airway monitoring Endotracheal intubation (if indicated) Hemodynamic stabilization Large bore intravenous access Intravenous fluids Red cell transfusion (for symptomatic anemia) Fresh-frozen plasma, platelets (if indicated) Consider erythropoeitin Nasogastric oral administration Large bore orogastric tube/lavage Clinical and laboratory monitoring Serial vital signs Serial hemograms, coagulation profiles, and chemistries (as clinically indicated) Electrocardiographic monitoring Hemodynamic monitoring (if indicated in high-risk patients) Endoscopic examination and therapy
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Haematemesis may be red with clots when bleeding is profuse, or black ('coffee grounds') when less severe. Syncope may occur and is due to hypotension from intravascular volume depletion. Symptoms of anaemia suggest chronic bleeding. Melaena - characteristic appearance is the result of the action of digestive enzymes and of bacteria upon haemoglobin. Severe acute UGI bleeding can sometimes cause bright red stool.
15
Management
1. Resuscitation and stabilization 2. Assessment of onset and severity of bleeding Severity- clinically, endoscopically 3. Diagnostic endoscopy For causees and severity 4. Therapeutic endoscopy
5. Pharmacological treatment 6. Surgical treatment
16
Correlation betweend prognosis
Ulcer Characteristics and Correlations Ulcer Characteristics Clean base Flat spot Adherent clot Visible vessel Active bleeding Prevalence Rate, % 42 20 17 17 18 Rebleeding Rate, % 5 10 22 43 55 Surgery Rate, % 0.5 6 10 34 35 Mortality Rate, % 2 3 7 11 11
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• ECG • Angiography - can be diagnostic and therapeutic but requires a brisk bleed at .52ml/min • Bleeding scans - can only be diagnostic but are more sensitive then angiography and require a bleeding rate of only .1ml/min • Colonoscopy - is diagnostic and therapeutic and more accurate than bleeding scans and angiography
4
Causes of UGI Bleeding
Peptic ulcer disease - most common cause A) duodenal ulcers 29% will rebleed in 10% of cases within 24-48h B) gastric ulcers 16% more likely to rebleed C) stomal ulcers <5%
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Poor prognostic factors
• Increasing age, > 60 yrs • Increasing number of comorbid conditions (especially renal failure, liver failure, heart failure, cardiovascular disease, disseminated malignancy) • Variceal bleeding (as compared with nonvariceal bleeding) • Shock or hypotension on presentation • Red blood in the emesis or stool • Increasing number of units of blood transfused • Active bleeding at the time of endoscopy • Bleeding from a large (>2.0 cm) ulcer • Bleeding from a visible or spurting vessel • Onset of bleeding in the hospital • Need for emergency surgery
10
CA/polyps inflammatory bowel disease infectious gastroenteritis Meckel diverticulum
11
Diagnosis
• Questions to ask in history • Any hematemesis, coffee-ground emesis, melena, or hematochezia. • Any weight loss or changes in bowel habits. • Any vomiting and retching. • Any history of ASA, NSAID’s, steroids • Any history of iron or bismuth which can simulate melena and beets which can simulate hematochezia.
GASTROINTESTINAL HEMORRHAGE
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• Most common gastrointestinal emergency • May be acute or chronic • Symptoms depend upon onset and amount of bleeding • Upper GI bleed 100/100,000 Above the ligament of Treitz • Lower GI Bleed 20/100,000 Below the ligament of Treitz • Both are more common in males and elderly.
12
Physical exam
• Vital signs may show hypotension and tachycardia. • Cool, clammy skin then in shock. • Spider angiomata, palmer erythema, jaundice, and gynecomastia seen in liver disease. • Petechiae and purpura seen in coagulopathy. • Careful ENT exam to rule out causes that can mimic upper GI bleeds. • Proper abdominal exam and rectal exam.
Injection of adrenaline (epinephrine) into the bleeding point application of thermal energy or electrocoagulation Banding and sclerotherapy for Varices.
6
7
Erosive gastritis, esophagitis, duodenitis Esophageal and gastric varices causes by portal hypertension Mallory-Weiss syndrome – longitudinal mucosal tear in the cardioesophageal region caused by repeated retching
8
stress ulcers arteriovenous malformation malignancy aortoenteric fistula
9
Causes of Lower GI Bleeding
Hemorrhoids - most common cause Diverticulosis – common, painless, and can be massive Caused from an erosion into a penetrating artery from the diverticulum. Arteriovenous malformations – common and seen in people with hypertension and aortic stenosis
13
Investigations
• • • • CBC Electrolytes Glucose BUN/Creatine –BUN will be elevated in upper GI bleeds • Coagulation studies • Liver function studies • Type and cross-match
18
• • • • • •
Proton-pump inhibitor Endoscopy Somatostatin, octretide for varices Balloon tamponade Surgery Must get early consultation with gastroenterologist and general surgeon for significant GI bleeds.
2
Probable Source of GI Bleeding Within the Gut Clinical Indicator Hematemesis Melena Hematochezia Bloodstreaked stool Occult blood in stool Probability of Upper GI Source Almost certain Probable Possible Rare Possible Probability of Lower GI Source Rare Possible Probable Almost certain Possible
17
RESUSCITATION
Initial steps in the management of upper gastrointestinal bleeding
Airway protection Airway monitoring Endotracheal intubation (if indicated) Hemodynamic stabilization Large bore intravenous access Intravenous fluids Red cell transfusion (for symptomatic anemia) Fresh-frozen plasma, platelets (if indicated) Consider erythropoeitin Nasogastric oral administration Large bore orogastric tube/lavage Clinical and laboratory monitoring Serial vital signs Serial hemograms, coagulation profiles, and chemistries (as clinically indicated) Electrocardiographic monitoring Hemodynamic monitoring (if indicated in high-risk patients) Endoscopic examination and therapy
3
Haematemesis may be red with clots when bleeding is profuse, or black ('coffee grounds') when less severe. Syncope may occur and is due to hypotension from intravascular volume depletion. Symptoms of anaemia suggest chronic bleeding. Melaena - characteristic appearance is the result of the action of digestive enzymes and of bacteria upon haemoglobin. Severe acute UGI bleeding can sometimes cause bright red stool.
15
Management
1. Resuscitation and stabilization 2. Assessment of onset and severity of bleeding Severity- clinically, endoscopically 3. Diagnostic endoscopy For causees and severity 4. Therapeutic endoscopy
5. Pharmacological treatment 6. Surgical treatment
16
Correlation betweend prognosis
Ulcer Characteristics and Correlations Ulcer Characteristics Clean base Flat spot Adherent clot Visible vessel Active bleeding Prevalence Rate, % 42 20 17 17 18 Rebleeding Rate, % 5 10 22 43 55 Surgery Rate, % 0.5 6 10 34 35 Mortality Rate, % 2 3 7 11 11
14
• ECG • Angiography - can be diagnostic and therapeutic but requires a brisk bleed at .52ml/min • Bleeding scans - can only be diagnostic but are more sensitive then angiography and require a bleeding rate of only .1ml/min • Colonoscopy - is diagnostic and therapeutic and more accurate than bleeding scans and angiography
4
Causes of UGI Bleeding
Peptic ulcer disease - most common cause A) duodenal ulcers 29% will rebleed in 10% of cases within 24-48h B) gastric ulcers 16% more likely to rebleed C) stomal ulcers <5%
19
20
Poor prognostic factors
• Increasing age, > 60 yrs • Increasing number of comorbid conditions (especially renal failure, liver failure, heart failure, cardiovascular disease, disseminated malignancy) • Variceal bleeding (as compared with nonvariceal bleeding) • Shock or hypotension on presentation • Red blood in the emesis or stool • Increasing number of units of blood transfused • Active bleeding at the time of endoscopy • Bleeding from a large (>2.0 cm) ulcer • Bleeding from a visible or spurting vessel • Onset of bleeding in the hospital • Need for emergency surgery
10
CA/polyps inflammatory bowel disease infectious gastroenteritis Meckel diverticulum
11
Diagnosis
• Questions to ask in history • Any hematemesis, coffee-ground emesis, melena, or hematochezia. • Any weight loss or changes in bowel habits. • Any vomiting and retching. • Any history of ASA, NSAID’s, steroids • Any history of iron or bismuth which can simulate melena and beets which can simulate hematochezia.
GASTROINTESTINAL HEMORRHAGE
1
• Most common gastrointestinal emergency • May be acute or chronic • Symptoms depend upon onset and amount of bleeding • Upper GI bleed 100/100,000 Above the ligament of Treitz • Lower GI Bleed 20/100,000 Below the ligament of Treitz • Both are more common in males and elderly.
12
Physical exam
• Vital signs may show hypotension and tachycardia. • Cool, clammy skin then in shock. • Spider angiomata, palmer erythema, jaundice, and gynecomastia seen in liver disease. • Petechiae and purpura seen in coagulopathy. • Careful ENT exam to rule out causes that can mimic upper GI bleeds. • Proper abdominal exam and rectal exam.
Injection of adrenaline (epinephrine) into the bleeding point application of thermal energy or electrocoagulation Banding and sclerotherapy for Varices.