Transcript GASTROINTESTINAL BLEEDING

INTRODUCTION
• Gastrointestinal bleeding
describe every form of
haemorrhage in the GIT,
from the pharynx to the
rectum.
LIGAMENT OF TREITZ
• Can be divided into 2
clinical syndromes:- upper GI bleed
(pharynx to ligament of
Treitz)
- lower GI bleed
(ligament of Treitz to
rectum)
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CLINICAL FEATURES
• Haematemesis : vomiting of blood whether
fresh and red or digested and black.
• Melaena : passage of loose, black tarry
stools with a characteristic foul smell.
• Coffee ground vomiting : blood clot in the
vomitus.
• Hematochezia : passage of bright red blood
per rectum (if the haemorrhage is severe).
CLINICAL FEATURES
• Haematemesis without malaena is
generally due to lesions proximal to the
ligament of Treitz, since blood entering
the GIT below the duodenum rarely enters
the stomach.
• Malaena without haematemesis is usually
due to lesions distal to the pylorus
• Approximately 60mL of blood is required
to produced a single black stool.
ETIOLOGY
LOCAL
Oesophagus
-Oesophageal varices
-Oesophageal CA
-Mallory-Weiss syndrome
Stomach
-Gastric ulcer
-Erosive gastritis
-Gastric CA
Duodenum
-Duodenal ulcer
-Duodenitis
GENERAL
-Haemophilia
-Leukemia
-Thrombocytopenia
-Anti-coagulant therapy
OESOPHAGEAL VARICES
• Abnormal dilatation of subepithelial and
submucosal veins due to increased venous
pressure from portal hypertension (collateral
exist between portal system and azygous
vein via lower oesophageal venous plexus).
• Most commonly : lower esophagus.
Esophageal varices: a
view of the everted
esophagus and
gastroesophageal
junction, showing
dilated submucosal
veins (varices).
SENGSTAKEN TUBE
(Deflate
every 4
hours for
15
minutes )
• Mallory-Weiss syndrome refers to bleeding from tears (a Mallory-Weiss
tear) in the mucosa at the junction of the stomach and esophagus,
usually caused by severe retching, coughing, or vomiting.
• Mallory-Weiss tears account for 5% to 10% of cases of upper GI
bleeding.
MALLORY-WEISS TEAR:
MANAGEMENT
-
Bleeding from MWTs stops
spontaneously in 80-90% of patients
Endoscopic band ligation (use of elastic bands )
Endoscopic hemoclipping (a metallic mechanical
device used in endoscopy in order to close two
mucosal surfaces without the need for surgery )
Endoscopic band ligation
Endoscopic hemoclipping
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ESOPHAGEAL CANCER
• 8th most common cancer seen throughout
the world.
• 40% occur in the middle 3rd of the
oesophagus and are squamous
carcinomas.
• adenoCA (45%) occur in the lower 3rd of
the oesophagus and at the cardia.
CLINICAL FEATURES
1) Dysphagia
2) Odynophagia : retrosternal pain on
swallowing.
3) Regurgitation
4) Weight loss
5) Anorexia
6) Anemia
PEPTIC ULCER
• gastric ulcer & duodenal ulcer
• Caused by imbalance between
secretion of acid and pepsin,
and mucosal defence
mechanism.
AETIOLOGY
-Helicobacter pylori
infection
-NSAIDs
-others: stress,
smoking,alcohol, steroid
SIGNS & SYMPTOMS
-
epigastric pain
haematemesis
Melaena
heartburn
PEPTIC ULCER
Feature
Gastric ulcer
Duodenal ulcer
Onset
Soon after eating 2-3 hours after
eating
Relieving factor
vomiting
Eating
Precipitating
factor
eating
Missing a meal,
anxiety, stress
Duration of
attack
A few weeks
A month or two
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LOWER GI BLEED: ETIOLOGY
SMALL INTESTINE
Crohn’s disease
RECTUM
Rectal carcinoma
COLON
Carcinoma of colon
ANUS
Haemorrhoids
Anal carcinoma
Crohn's disease
• Crohn's disease (also spelled Crohn
disease) is a chronic inflammatory disease
of the intestines. It primarily causes
ulcerations (breaks in the lining) of the
small and large intestines
• The cause of Crohn's disease is unknown.
Some scientists suspect that infection by
certain bacteria, such as strains of
mycobacterium
Sign and symptom
• abdominal pain, diarrhea, and weight
loss. Less common symptoms include poor
appetite, fever, night sweats, rectal pain,
and occasionally rectal bleeding.
Treatment
• There is no medication that can cure Crohn's
disease. Patients with Crohn's disease
typically will experience periods of relapse
(worsening of inflammation) followed by
periods of remission (lessening of
inflammation) lasting months to years.
• Medications for treating Crohn's disease
include anti-inflammatory agents
and corticosteroids, topical antibiotics, and
immuno-modulators.
ADENOCARCINOMA OF COLON &
RECTUM
• Rare < 50 years old,
Common > 60 years old
• Common site- sigmoid colon,
rectum
• Clinical features:
-altered bowel habit & large
bowel obstruction
-rectal bleeding
-iron deficiency anaemia
-tenesmus
-perforation
-anorexia & weight loss
HAEMORRHOIDS
• M>F
• Female- late pregnancy, puerperium
• Supine lithotomy position- 3 ,7, 11
o’clock positions
• Classification:
1st degree : never prolapse
2nd degree: prolapse during
defaecation but
return spontaneously
3rd degree : remain prolapse but
can be reduced digitally
4th degree : long-standing
prolapse cannot be
reduced
HAEMORRHOIDS: SIGNS &
SYMPTOMS
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Rectal bleeding
Perianal irritation & itching
Mucus leakage
Mild incontinence of flatus
Prolapse
Acute pain
Skin tags at anal margin
MANAGEMENT OF ACUTE
GASTROINTESTINAL BLEEDING
• Rapid history and examination.
• Monitor the pulse and blood pressure halfhourly.
MANAGEMENT OF ACUTE GASTROINTESTINAL
BLEEDING :
HISTORY TAKING
MODE OF
ONSET
CHARACTER
EXTENT AND
RATE
-
when?
have u vomited blood/passed black tarry stools?
had both haematemesis & malaena?
have u had, bleeding from the nose? Bloody
expectoration? A dental extraction?
-
what is the color, the appearance of the vomited
blood?
red? Dark red? Brown? Black?
‘coffee ground appearance?
bright red & frothy?
what is the color of the stool? Bright red? Black
tarry?
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have u vomited blood only once/several times?
has the bleeding been abrupt/massive?
have u had >1 black, tarry stool within a 24-h
period?
for how long have the tarry stools persisted?
MANAGEMENT OF ACUTE GASTROINTESTINAL
BLEEDING :
HISTORY TAKING
OTHER
SYMPTOMS
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retching & severe nonbloody vomiting?
lightheadedness? Nausea? Thirst? Sweating?
faintness when lying down/when standing/syncope?
following the haemorrhage did you have diarrhea?
IATROGENIC
FACTORS
-
aspirin? anticoagulant therapy? iron preparation?
age of the patient?
what is your smoke/alcohol intake?
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have there been similar episode in the past? When?
Diagnosis?
were u hospitalized on this occasion? Did u receive a
transfusion?
are there any other members of your family who
have intestinal disease/bleeding tendency/peptic
ulcer/liver disease, History of Malignancy?
PREVIOUS
EPISODES
FAMILY
HISTORY
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MANAGEMENT OF ACUTE GASTROINTESTINAL
BLEEDING : PHYSICAL EXAMINATION
GENERAL INSPECTION
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Anaemic
Bruishing/ Purpura
Cachexic
Dehydrated
Jaundice
RECTAL
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CNS
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ABDOMEN
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Inspection - distension, scar,
prominent vein.
Palpation - tenderness, mass/
organomegaly
Percussion - shifting dullness,
fluid thrill.
Auscultation - hyperactive
bowel sound.
Perianal Skin Lesion
Masses
Melaena

Confusion ( Shock, liver
failure….)
Neurological Deficit
MANAGEMENT OF ACUTE GASTROINTESTINAL
BLEEDING : PHYSICAL SIGN
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Clinical shock
Systolic BP < 100mmHg
Pulse rate > 100 bpm
Postural sign: patient place in a upright
position
– pulse rate rises 25% or more
- systolic BP alls 20mmHg or more
Sign of liver disease & portal hypertension
Sign of GI disease
Sign of bleeding abnormalities
Bloody / black stools on per rectal
examination.
MANAGEMENT OF ACUTE
GASTROINTESTINAL BLEEDING
• Take blood for haemoglobin, urea,
electrolytes, ,liver functions ,blood
grouping and crossmatching .
• Establish intravenous access - central line
if brisk bleed.
• Stop drugs, e.g. NSAIDs, warfarin
MANAGEMENT OF ACUTE GASTROINTESTINAL
BLEEDING : INVESTIGATIONS
BASELINE INVESTIGATION
-Full Blood Count- Hb, Platelet
- PCV*
-Coagulation Profile
-Liver Function tests
-Serum urea and electrolytes
-Blood urea nitrogen
-Cross matching of blood.
-Serial ECG
IMAGING
- Barium meal / Double- contrast barium meal
-Ultrasound
-CT scan
MANAGEMENT OF ACUTE
GASTROINTESTINAL BLEEDING
• Oxygen therapy for shocked patients.
• Urgent endoscopy in shocked
patients/liver disease.
• Continue to monitor pulse and BP.
• Re-endoscope for continued
bleeding/hypovolaemia.
• Surgery if bleeding persists.
MANAGEMENT OF ACUTE
GASTROINTESTINAL BLEEDING
• Urgent resuscitation is required in patients with large
bleeds and the clinical signs of shock.
• Oxygen should be given by face mask and the patient
should be kept by mouth until endoscopy has been
performed.
• The major principle is to rapidly restore the blood volume
to normal. This can be best achieved by transfusion of
whole blood via one or more large-bore intravenous
cannulae; physiological saline is given until the blood
becomes available .
• The rate of blood transfusion must be monitored carefully
to avoid overtransfusion and consequent heart failure.
• The pulse rate and venous pressure are the best guides to
transfusion rates.
RESUSCITATION
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airway and oxygen
Insert 2 large-bore (14-16G) IV cannulate take blood
IV colloid - crossmatched.
haemodynamically stable.
Correct clotting abnormalities
Monitor
Insert urinary catheter and monitor hourly urine
output if shocked.
Consider a CVP line to monitor CVP and guide fluid
replacement.
Organize a ECG, and check arterial blood gases in
high-risk patient.
Arrange an urgent endoscopy.
Notify surgeon of all severe bleeds on admision.
MANAGEMENT OF ACUTE
GASTROINTESTINAL BLEEDING
Endoscopy
• should be performed within 24 hours in most patients.
Early endoscopy helps to make a diagnosis and to make
decisions regarding discharge from hospital, particularly
in patients with minor bleeds and under 60 years of age.
• Urgent endoscopy (i.e. after resuscitation) should be
performed in patients with shock, suspected liver disease
or with continued bleeding.
• Endoscopy can detect the cause of the haemorrhage in
80% or more of cases. In patients with a peptic ulcer, if
the stigmata of a recent bleed are seen (i.e. a spurting
artery, active oozing, fresh or organized blood clot or
black spots) the patient is more likely to re-bleed.
• Most important component of investigation
• 90% accuracy In diagnosis if done with in
24 hours
MANAGEMENT OF ACUTE GASTROINTESTINAL
BLEEDING : ENDOSCOPY
MANAGEMENT OF ACUTE
GASTROINTESTINAL BLEEDING
• all bleeding ulcers should be either injected with
epinephrine (adrenaline), the vessel coagulated either
with a heater probe or with laser therapy or metallic
clips applied. Epinephrine injection -reduces or stops
bleeding via a mechanism of vasoconstriction and
tamponade
• These methods reduce the incidence of re-bleeding,
although they do not significantly improve mortality as
re-bleeding still occurs in 20% within 72 hours.
• Intravenous omeprazole 80 mg followed by infusion 8
mg/h for 72 hours should be given to all patients in this
group, as it reduces re-bleeding rates and the need for
surgery.
MANAGEMENT OF ACUTE GASTROINTESTINAL
BLEEDING : DRUG THERAPY
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Antacid – aluminium/Mg hydroxide, Mg Trisiclate
Mucosal protective agents – sucralfate
H2 receptor antagonist – cimetidine & ranitidine
Proton pump inhibitor – omeprazole &
lansoprazole
• Somatostatin (which reduces the splanchnic blood
flow as well as acid secretion) can be given as an
infusion if the bleeding is difficult to stop
There is little evidence that H2-receptor
antagonists or proton-pump inhibitors (PPIs) affect
the mortality rate of GI haemorrhage, but PPIs are
usually given to all patients with ulcers because of
their longer-term benefits.
MANAGEMENT OF ACUTE GASTROINTESTINAL
BLEEDING BLOOD TRANFUSION
BLOOD TEST
– Haemoglobin - May be normal during
the acute stages until haemodilution
occurs
– Urea and electrolytes - Elevated blood
urea suggests severe bleeding
– Cross match for transfusion - Two
units of blood are sufficient unless
bleeding is extreme.
– If the transfusion is not needed
urgently, group the blood and save
the serum
– LFT and coagulation profile
INDICATION OF BLOOD
TRANSFUSION
1.Systolic BP < 110
mmHg
2.Postural
hypotension
3.Pulse > 110/min
4.Haemoglobin
<8g/dl
5.Angina or
cardiovascular
disease with a
Haemoglobin
<10g/dl