Transcript Define GIT bleeding

GIT Bleeding
1) Define and classify GIT bleeding:
Maha AlTuwaijri.
Define GIT bleeding:
- Gastrointestinal bleeding refers to
any bleeding that starts in the
gastrointestinal tract that extends
from the mouth to the rectum.
Classification of GIT bleeding:
1) Upper GI bleeding (UGIB):
bleeding derived from a source
proximal to the ligament of Treitz.
2) Lower GI bleeding (LGIB):
bleeding derived from a source distal
to the ligament of Treitz.
2) Causes of upper GI bleeding
Afnan AlHazmi
2133788
1- Esophageal causes:
2- Gastric causes:


Esophageal varices.


Esophagitis.

Esophageal cancer.


Esophageal ulcers.


Mallory-Weiss tear.
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Gastric ulcer.
Gastric cancer.
Gastritis.
Gastric varices.
Gastric antral vascular ectasia.
Dieulafoy's lesions.
•
3- Duodenal causes:


Duodenal ulcer.
Vascular malformation, including aorto-enteric fistulae. Fistulae are
usually secondary to prior vascular surgery and usually occur at the
proximal anastomosis at the third or fourth portion of the duodenum
where it is retroperitoneal and near the aorta.

Hematobilia, or bleeding from the biliary tree.

Hemosuccus pancreaticus, or bleeding from the pancreatic duct.

Severe superior mesenteric artery syndrome.
Peptic ulcer disease:
Peptic ulcers are localized erosions of the mucosal lining of the
digestive tract. Ulcers usually occur in the stomach or duodenum.
Breakdown of the mucosal lining results in damage to blood
vessels, causing bleeding.
Gastritis:

General inflammation of the stomach lining, which can result in bleeding.
Gastritis also results from an inability of the gastric lining to protect itself
from the acid it produces. Causes of gastritis include:
o
NSAIDs or nonsteroidal anti-inflammatory drugs, for example: (ibuprofen)
o
Steroids
o
Alcohol
o
Burns
o
Trauma
Esophageal varices:

Swelling of the veins of the esophagus
or stomach usually resulting from liver
disease. Varices most commonly occur
in alcoholic liver cirrhosis. When
varices bleed, the bleeding can be
massive, catastrophic and occur
without warning.
Mallory-Weiss tear:

A tear in the esophageal or
stomach lining, often as a
result of vomiting or retching.
Mucosal tears also can occur
after seizures,
forceful coughing or laughing,
lifting, straining, or childbirth.
Physicians often find tears in
people who have recently
binged on alcohol.
Cancer:
• One of the earliest signs of esophageal or stomach cancers may be
blood in the vomit or stool.
Inflammation:

When the mucous membranes break down, they are unable to
counteract the harsh effects of stomach acid. NSAIDs, aspirin,
alcohol, and cigarette smoking promote gastric ulcer
formation. Helicobacter pylori is a type of bacteria that also
promotes formation of ulcers.
3-What are the causes of lower GIT bleeding …
Aeshah Abdullah
2147789
Etiology of lower gastrointestinal bleeding :
Classifications
Anatomic
Vascular
Neoplasms
Inflammation
others
anatomic etiology
1-Diverticulosis:
• pressure within the colon causes bulging pockets of tissue
(sacs) that push out from the colon walls.
A small bulging sac pushing outward from the colon wall
is called a diverticulum.
• most common near the end of the left colon called the
sigmoid colon.
• This condition is uncommon before the age of 40 years,
but its incidence increases after this age.
anatomic etiology
factors that can cause diverticular
disease as follows:
* A diet low in fibre content or high in
fat
* Increasing age
* Constipation
* Connective tissue disorders, which
can weaken the colon wall.
complication:
Rectal Bleeding
1st stage
2nd stage
Last stage
anatomic etiology
2- Meckel's diverticulum:
• a true congenital diverticulum, is abulge in the small intestine present at birth .
• caused by an incomplete obliteration of the vitelline duct (ie, omphalomesenteric duct)
located in the distal ileum.
• also contain heterotopic tissue of the stomach (and thus contain parietal cells that secrete
HCl), pancreas, or both.
•
It is the most common malformation of the gastrointestinal tract
• The most common presenting symptom is painless rectal bleeding such as melaena-like
black offensive stools
A memory aid is the rule of 2s:
•2% (of the population)
•2 feet (proximal to the
ileocecal valve)
•2 inches (in length)
•2 types of common ectopic
tissue (gastric and pancreatic)
•2 years is the most common
age at clinical presentation
•2:1 male:female ratio
Vascular etiology
1- Gastro enteric angiodysplasia (AD):
• defined as pathologically dilated communications
between veins and capillaries .
• frequently involve the cecum or ascending colon,
although they can occur at other places.
• Angiodysplasia of the GI tract happens most often in
older adults.
• cause of gastrointestinal bleeding and anemia.
Vascular etiology
2- Ischemic colitis:
• IC is also known as mesenteric artery ischemia,
mesenteric vascular disease, or colonic ischemia.
• Inflammation and injury of the large intestine that results
from an interruption of its blood supply .
• more common among people with:
 heart and blood vessel disease,
 people who have had surgery on their aorta,
 people who have problems with increased blood
clotting.
Ischemic colitis affects primarily people who are 60 or
older.
Neoplasm etiology
Colorectal cancer (CRC):
• also known as bowel cancer, is the development of cancer from the colon
or rectum (parts of the large intestine).
• Signs and symptoms may include blood in the stool , a change in bowel
movements, weight loss, and feeling tired all the time.
• Most colorectal cancers are due to old age and lifestyle factors with only a
small number of cases due to underlying genetic disorders .
Inflammations etiology
1-ulcerative colitis :
• long-term condition that results in inflammation and ulcers of the
colon and rectum.
• The cause of UC is unknown, Theories involve immune system
dysfunction, genetics, changes in the normal gut bacteria, and
environmental factors.
• The primary symptom of active disease is abdominal pain and
diarrhea mixed with blood.
Inflammations etiology
2- Crohn’s disease :
• Crohn’s Disease is a condition that causes chronic inflammation of the
digestive system or gut.
• Crohn’s most commonly affects the end of the small bowel (the ileum) and
the beginning of the colon, but it may affect any part of the gastrointestinal
(GI) tract, from the mouth to the anus.
• The primary symptoms is diarrhea with mucus and blood .
Others diseases
1- rectal hemorrhoid:
• swollen veins located around the
anus or in the lower rectum.
About 50 % of adults
experienced the symptoms of
hemorrhoids by the age of 50.
• Two types : internal &external
• From the symptoms :
 blood on tissue after having a
bowel movement.
Others diseases
2- Anorectal varices :
•
the dilation of collateral submucosal
vessels due to backflow in the veins of
the rectum.
• Typically this occurs due to portal
hypertension which shunts venous
blood from the portal system
through the portosystemic
anastomosis present at this site into
the systemic venous system.
Others diseases
3-Rectal prolapse
• is a condition in which the rectum (the
last part of the large intestine exits the
anus) loses its normal attachments
inside the body.
• Can occurs on all ages but common in
older adults with a long-term history of
constipation or a weakness in the pelvic
floor muscles.
A = Rectal Prolapse
B = Hemorrhoids
Others diseases
4- Anal fissures
•anal fissure is a tear in the lining of
the lower rectum (anal canal)
Anal fissures are caused :
• constipated
• repeated diarrhea.
• give birth
Infection etiology
Shigella
bacteria
Group A
Shigella
dysenteriae
Group B
Shigella
flexneri
Group C
Shigella
boydii
Group D
Shigella
sonnei
Shigellabacteriaare
•Shigella organisms are a group of gram-negative They attack the intestinal wall
and may cause ulcers that bleed.
• Children between the ages of 2 and 4 are most likely to get shigella infection.
• Can trans from person to persons
• can be passed in contaminated food or by drinking or swimming in
contaminated water.
• The main sign of shigella infection is diarrhea, which often Blood, mucus, or pus
in the stool.
References :
signs and symptoms of upper GIT bleeding?
bayan Al-Abbad
Upper Gastrointestinal Bleed
1-Melena or Melenic stools
(black, tarry and foul smelling
stools or dark-colored stools)
Red Hematemesis – *
2-Hematemesis
vomiting
of fresh blood
Coffee Ground Hematemesis – *
vomiting of blood altered
by stomach acids and enzymes.
3-Dyspepsia
4-Heartburn or epigastric pain
5-Abdominal pain
Dysphagia – difficulty in swallowing6-
7-Jaundice if bleeding is
related to liver diseases
8-Weight loss
Syncope and/or Presyncope910-Pallor
sign and symptoms of lower
gastrointestinal bleeding
Amna al-ahmed
lower gastrointestinal bleeding
young patient may present with fever, dehydration, •
abdominal cramps, and hematochezia
elderly patients presenting with abdominal pain, rectal •
bleeding, and diarrhea may have ischemic colitis
The presentation of LGIB can also vary depending on the etiology.
Diverticulosis •
Diverticulosis presents as painless bright red hematochezia in patients over
50 years of age. Bleeding stops spontaneously
patients may be hypotensive and display signs of shock.
hematochezia - passage of stools containing blood
Angiodysplasia •
Patients present with painless bleeding most commonly above the age of
70 years.
patients may present with Hemoccult-positive stools, iron-deficiency
anemia, and syncop
Hemoccult-positive stools
Diverticulosis
Colon carcinoma•
right-sided bleeding: iron-deficiency anemia , syncope ,
melena.
left-sided colonic cancers: bright red blood per rectum
Inflammatory bowel disease•
Most commonly ulcerative colitis presents with diarrhea
with occult blood or recurrent hematochezia Abdominal
pain, tenesmus and urgency are often present
Anorectal disease Hemorrhoids•
present as painless bleeding mixed with stool or
dripping into the toilet bowl. There is painful small
bleeding in case of anal fissure.
Ischemic colitis is seen in elderly especially those who
have atherosclerosis presenting as bloody diarrhea with
mild abdominal cramps
Enumerate the complications
of GIT bleeding
Amal Alharthi
1) Anemia
• Prolonged bleeding detectable in a microscopic study can
lead to the loss of iron in the individual. Red blood cells
contain a protein called hemoglobin. It is required to carry
oxygen to the tissues of the body. A lack of hemoglobin and a
lack of red blood cells can occur during constant GI bleeding,
causing anemia.
• Symptoms of anemia include chest pain,
dizziness, fatigue, weakness, headaches,
shortness of breath and lack of mental clarity.
2) Hypovolemia
• Due to a severe loss of blood and fluid in acute GI bleeding,
the heart finds it difficult to pump enough blood to the body,
which is referred to as hypovelemia. It is a life-threatening
condition since it can cause the body's organs to stop
working.
• Symptoms of this condition include cool, clammy
skin; confusion; agitation; decreased urine output;
weakness; pale skin; quick breathing; and loss of
consciousness.
3) Shock
• Acute and massive bleeding from the gastrointestinal tract
can lead to a lack of blood flow to the body. This can damage
the different organs of the body, causing organ failure. shock
is an emergency condition and if it is not treated
immediately, it can worsen quickly, causing irreversible
damage to the organs or even death.
• Symptoms of shock include an extremely low blood
pressure, bluish lips and fingernails, chest pain,
confusion, dizziness, anxiety, pale skin, decreased or
no urine output, racing but weak pulse rate, shallow
breathing, and unconsciousness.
4) Dehydration and Chest Pain
• dehydration is another complication of gastrointestinal
bleeding. The individual may also develop pain in the chest,
especially if there is a heart condition present . Dyspnea and
chest pain in the setting of GI bleeding are ominous signs of
decreased oxygen-carrying capacity, and myocardial ischemia
must be ruled out.
• 5) Hypotension
6) puncture site hematoma
• The bleeding is typically from arterial puncture above the
inguinal ligament or inadequate hemostasis after the
procedure but may also occur spontaneously from the
anticoagulation used for PCI. Whatever its cause, the
diagnosis of retroperitoneal hematoma is initially made on
clinical grounds. Symptoms, signs, and laboratory
abnormalities that should raise suspicion of retroperitoneal
bleed include hypotension, back or flank pain.
• References
• http://www.medscape.org/viewarticle/565528_2
• Gastrointestinal Bleeding: A Practical Approach to Diagnosis and Management
• http://www.livestrong.com/article/190741-complications-of-gi-bleeding/
Give an account in diagnostic tools of GIT Bleeding.
By: basmah Al afari
2141556
Upper endoscopy. .
An upper endoscopy is a procedure used to visually examine your
upper digestive system with a tiny camera on the end of a long,
flexible tube.
Colonoscopy.
• A procedure whereby a physician inserts a viewing tube
(colonoscope) into the rectum for the purpose of inspecting the
colon.
Capsule endoscopy
• Capsule endoscopy is a procedure that uses a tiny wireless camera to
take pictures of your digestive tract. A capsule endoscopy camera sits
inside a vitamin-size capsule you swallow. As the capsule travels
through your digestive tract.
•
Balloon-assisted enteroscopy
•
Balloon assisted or "deep" enteroscopy is a procedure which allows
advancement of a long endoscope into the small intestine for both
diagnostic and therapeutic purposes.
Reference….
• www.mayoclinic.com
continue to
diagnostic tools of GIT Bleeding.
Fatimah Al Nassir
ID:2145435
Endoscopic ultrasound.
An ultrasound probe attached to an endoscope allows
doctors to see all the layers of tissue in the digestive
tract.
Endoscopic retrograde cholangiopancreatography
(ERCP)
A scope combined with an X-ray procedure allows
doctors to see the ducts of the gallbladder, liver and
pancreas. However, this test is rarely needed in the
evaluation of GI bleeding.
.Angiography
A contrast dye is injected into an artery, and a series of Xrays are taken to look for and treat bleeding vessels or other
.abnormalities
MR Enterography Procedure
Or Multiphase CT enterography.
preparation for an MRI exam, prior to MR enterography the patient is given two
minutes before the exam and 20 bottles of a special liquid to drink (one bottle
minutes before the exam). The liquid serves to distend the bowel 10 one bottle
and marks the bowel for clear identification during the imaging study. Towards
the end of the exam the patient is given a small dose of glucagon followed by an
injection of gadolinium (an MRI contrast agent). Glucagon prevents the bowel
.from moving for a short time, which improves the quality of the images
MR Enterography:
Uses a powerful magnetic field,
radio waves and a computer to
produce detailed pictures of the
small intestine which may help your
doctor diagnosis inflammatory
bowel disease,obstruction and
other abnormalities.
Reference:
http://www.mayoclinic.org/diseases-conditions/gastrointestinal20035736bleeding/care-at-mayo-clinic/tests-diagnosis/con-
Treatment of lower and upper
GIT
JEHAN ALMUTAIRI
2134424
The goal of medical
therapy in (UGIB) is to
correct shock &
coagulation abnormalities
& to stabilize the patient.
Bed rest. •
IV access ( if patient need blood transfusion- normal •
saline…etc.)
Sedation ; Inj. Diazepam to control restlessness & •
anxiety.
Oxygen therapy. •
Stop aspirin & other NSAIDs. •
Therapeutic endoscopy.
Under direct vision •
cauterization in peptic
ulcer.
Sclerotherapy; •
sclerosing & banding for
varicose.
Medications
1-Proton pump inhibitor ; omeprazole 40mg\BD for
5days.reduced rebleeding of patient with peptic ulcer.
2-Octreotide (sandostatin) ; IV 100maicrogram. Reduce
bleeding by decrease splanchnic blood flow & portal
pressure in bleeding varicose.*not very effective for
bleeding peptic ulcer
3-Vasopressor=vasoconstrictions. IV dec. splanchnic blood
flow & dec. portal pressure.(reserved for patient with
esophageal varical bleeding).
Surgery
Sever bleeding or •
rebleeding that can’t be
controlled by treatments.
Slow continuous bleeding •
for more than 48 hours.
Lower GI
Therapeutic endoscopy.
Endoscopic •
electrocoagulation of
angiodysplasia ; if
bleeding
continuous.(coagulation
of bleeding ).
colonoscopy is •
performed also.
Intervention
Intra-arterial vasopressor or embolization in the bleeding site •
localized by angiography.
Intra-arterial vasopressor may stop bleeding in 90% cases with active •
bleeding. Esp. in angiodysplasia or diverticulum.
Embolization = angiography- site of bleeding-artificial agent= BLOCK •
blood vessels that fragile , bleed & malformation.
Surgery
Continuous bleeding •
unresponsive to the above
measure require surgical
resection.
Prognosis of GIT bleeding
RAGHAD MALLISHO
ID : 2136192
Death in those with a GI •
bleed is more commonly due
to other illnesses, than the
bleeding itself.
such as cancer or cirrhosis
Re-Bleeding because of upper •
GI is more common than
lower GI
Risk of bleeding is more •
common in males, and
increases with age.
Age older than 60 years is an independent marker for a poor outcome
in upper gastrointestinal bleeding .
The mortality rate ranging from 12-25 % in this group of patients.
3.3% for those aged 21-31 years
10% for those aged 41-50 years •
In those with esophageal varices, bleeding occurs in about 5–15% a
year and if they have bled once, there is a higher risk of further
bleeding within six weeks
The benefits versus risks
restarting blood thinners such as aspirin or warfarin and antiinflammatories such as NSAIDs need to be carefully considered.
If aspirin is needed for cardiovascular disease prevention, it is
reasonable to restart it within seven days in combination with a PPI for
those with nonvariceal upper GI bleeding
The following up risk factors are associated with •
an increase mortality, recurrent bleeding, the need for endoscopic
hemostasis, or surgery:
Age older than 60 years
Severe comorbidity
Hypotension
Sever coagulopathy
Red blood cell transfusion greater than 6 units
Inpatient at time of bleeding
Reference
WWW.Medscape.com
WWW.Wikipedia.org