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Upper vs Lower
100%
0%
Melena Haemetemesis-melena
slow and intermittent, symptoms
Chronic GI
from blood loss or anemia
bleeding
esophagus lig.Treitz of duodenum
UPPER GI
BLEEDING Variceal & non variceal
LOWER GI
BLEEDING 85% spontaneous recover, 15% hemodynamic
disturbance (proximal terminal ileum)
6
Peptic Ulcer disease Aortoenteric fistel
Mallory Weiss Tears
Hemobilia
Dielufoy Lesion Hemosuccus pancreatikus
Vaskular malformation, and
Cameron lesion
Watermelon stomatch (gastric antral
Upper Gastrointestinal Tumors
vascular ectasia)
Saltzman JR. In Current diagnosis & treatment Gastroenterology, Hepatology & Endoscopy. 2009,pp324-342.
250
LOWER GI TRACT. 190 200
200
Hemorrhoid
Colorectal carsinoma 150 121
Inflammatory Bowel
disease (Ulcerative 100
colitis/Crohns disease) 42
50
Colorectal polyp 8
Diverticular disease 0
Iskemia colitis Hemorroid IBD Colorectal Polip Diverticulosis
Angiodysplasia cancer
Intestinal hemorrhage
8
Syncope : tachycardia, headache,
drowsy
Shock: hypotension (systolic
blood pressure <100 mm
Hg), rapid pulse (100 beats
/minute), pallor (conjungtiva,
PHYSICAL
HISTORY mucosa membran,nail bed), LABORATORY STUDY
EXAMINATION
coolless of extremities
Vomiting or Precise cause of Initial blood study :
passage of blood bleeding (blood CBC, electrolytes,
from rectum loss & peripheral blood urea nitrogen
Age of patient vasoconstriction, (BUN), creatinine,
Ingestion of gastric sign of CLD) glucose, clotting
mucosal irritants Rectal examination status (platelet
(aspirin, NSAIDs, Postural sign (age, count, PT/APTT)
alcohol) CV status, rate of
Associated medical blood loss)
condition (no=1% &
4=70%)
5/30/2012 9
UGI LGI
Melena
10
CLINICAL MANIFESTATION
11
POSTURAL SIGNS
Estimate :
5/30/2012 12
Blood loss < 750 750-1500 1500- > 2000
(ml) 2000
Blood loss (%) < 15 15-30 30-40 > 40
Pulse rate < 100 > 100 > 120 > 140
14
blood drawn
>1 iv cath
1. for laboratory
A large-bore iv catheter inserted
promptly into a peripheral vein
Immediate venous access
(jugular,subclavia
infusion or femoral)
Shock, continue bleeding,
normal saline angina pectoris, hematocrite
hypotonic sodium < 20%
2.
solution
Infusion of
transfusion (PRC)
fluids & blood
electrolyte solution
clotting factor
High risk patients : older age, coexisting
cardiac illnesses, hepatic cirrhosis
packed red cells (PRC)until Ht > 30%
Young healthy patients
4. : whole blood until
3.
Ht > 20%
Monitoring of urine
Central venous pressure
output
catheter
Adverse
Benefits
effects
Document the be passed in all patients
Should Patient discomfort
presence of blood
Predisposition to GE
Monitor the rate of reflux & pulmonary
bleeding aspiration
Aspirate is
1. DIAGNOSTIC
clear Irritation of
NG tube esophageal & gastric
Removed Identify recurrence of
mucosa, creating
bleeding after initial
mucosal artifact &
control
2. THERAPEUTIC Clears with Fresh blood
Large mount of existing
aggravating old blood
lavage lesion
Retained material
Barium contrast
Selective angography
radiography
Identifies the source of the bleeding after restoring stability patient hemodynamic
Acid inhibiting drugs
Fasting Histamin-2 antagonist < Proton pump inhibitory
Non-fasting : (omeprazole, pantoprazole, esomeprazole)
Offending
few-often Emergency
80mg surgery
iv followed : Persistent
80mg/hour or recurrent
continous infusion
agent/ulcerog
severe bleeding
up to 72hours or iv/12hours
Less stimulating enic drugs
acid/pepsin Oral 1-2 weeks
Hypotension or shock
Continued bleed w/ transfusion 6 units
blood & no diagnosis in initial endoscopy
Severe active bleeding cant controlled by
Others :
endoscopy or angiography
Cytoprotective agent (sucralfate, rebamipide,
teprenone)
Endoscopic treatment
Hemostatic (tranexamic acid,
carbamazochrome) Surgery
Vasoactive drugs (vasopressin, somatostatin)
Antibiotics
High risk/poor prognosis