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APPROACH TO PATIENT WITH GI BLEED

Zaidatul Atiqah Mustafa M000810

Contents
Relevant history taking of GI bleeding Relevant abdominal examination findings Differential diagnoses Relevant investigations

Management options

Upper GI bleeding vs. Lower GI bleeding


Upper GI bleeding
Source in the upper GI tract (above the ligament of Treitz)

Lower GI bleeding
Source in the small intestine or colon (below the ligament of Treitz)

Bleeding from GI tract may present in 5 ways


Hematemesis: vomitus of red blood or "coffee grounds" material Melena: black, tarry, foul-smelling stool Hematochezia: passage of bright red or maroon blood from the rectum Occult GI bleeding: blood in the stool in the absence of overt bleeding

Symptoms of blood loss or anaemia (e.g. light-headedness or shortness of breath)

HISTORY

History Taking
Upper or lower abdominal pain, and pattern of relief or exacerbation Rectal or anal pain Diaphoresis, light-headedness or syncope Black or grossly bloody stools Brown or grossly bloody emesis

Bleeding from oral cavity/nasopharynx


Forceful retching (Mallory-Weiss tear) Painless hematochezia (angiodysplasia, tumor) Painful hematochezia with or without tenesmus (colitis) Anorexia, loss of appetite, rapid weight loss (carcinoma) Any skin telangiectasia Any pigmentation (perioral/diffuse)

Relevant History
Past Medical
History of liver disease Previous history of peptic ulcer disease Known colonic diverticula History of vascular disease (ischemic colitis or bowel infarction)

Past Surgical Family

History of surgical intervention Hematemesis Carcinoma History of drug intake NSAIDs, aspirin or anti coagulants

Drug

Social
Alcohol use (varices, mucosal bleeding) Smoking

PHYSICAL EXAMINATION

General Examination & Vital Signs


Built & nourishment Pallor Jaundice Cyanosis

Clubbing
Lymphadenopathy (Ca Stomach) Edema

Hemodynamic instability (Hypotension, tachycardia, postural changes in BP & HR)


Temperature

Assessment of Blood Loss


Clinical Features No systemic signs except in elderly & anemic patient Tachycardia, orthostatic hypotension, syncope, light-headedness, nausea, sweating, thirst Profound shock & possibly death Blood Loss 500ml 1000ml (20% reduction in blood volume)

2000ml (40% reduction in blood volume)

Look for
Any source of bleeding from oral cavity Telangiectasis in skin, conjunctiva, oral cavity Perioral/ diffuse pigmentation Stigmata of CLD

Abdominal Examination
Abdominal tenderness
Unusual in uncomplicated GI bleeding, except occasionally with peptic ulcer disease Severe tenderness suggests GI bleeding associated with bowel ischaemia, obstruction or perforation

Ascites Any mass lesion Hepatosplenomegaly Bowel sounds


Hyperactive bowel sounds usual - blood in proximal gut stimulates peristalsis Normal bowel sounds suggest lower GI bleeding Hypoactive bowel sounds - suggest bowel ischaemia, ileus or obstruction

Examination of Lymph nodes Rectal examination


blood? melaena? haemorrhoids or fissures?

Nasogastric aspiration
frankly bloody aspirate - on-going upper GI bleeding

coffee grounds - recent upper GI bleeding


absence of blood or coffee grounds does not exclude upper GI bleed - duodenal bleeding with a closed pylorus will not result in blood or coffee grounds in the stomach. bile - suggests that reflux from the duodenum into the stomach is occurring. In this case the absence of blood or coffee grounds in the aspirate suggests that the bleeding is not from the upper GI tract or stopped many hours earlier

Investigations
complete blood count - useful for comparison of serial values. Initial haemoglobin concentration may be normal if taken early, before haemodilution has taken place

liver function tests


renal function tests - urea may be raised out of proportion to creatinine clotting

serial ECGs and cardiac enzymes to exclude myocardial infarction (complicates ~10% of severe GI bleeds)
Endoscopy Colonoscopy Angiography Radionuclide scanning

TREATMENT

Fluid resuscitation
give blood, FFP and platelets in a 1:1:1 ratio for patients with massive bleeding to prevent dilutional thrombocytopaenia and coagulopathy beware over-transfusion, particularly in patients with variceal bleeding in whom over-transfusion may result in a significant rise in portal pressure

Pharmacotherapy
Proton pump inhibitor (IV)
start even before endoscopy reduces risk of re-bleeding, need for surgery and need for transfusion but not mortality benefit greatest for those at high risk of recurrent bleeding

Octreotide
somatostatin analogue inhibits glucagon-induced mesenteric vasodilatation

Endoscopy
investigation and intervention of choice variety of endoscopic interventions can be used to stop bleeding complications include:
GI perforation precipitation of bleeding missed pathology aspiration

features of peptic ulcer associated with recurrent bleeding:


spurting or oozing 85-90% risk of rebleeding protuberant vessel 35-55% adherent clot 30-40% flat pigmented spot on ulcer base 5-10%

Embolization
angiographic embolization is now treatment of choice for those patients in whom endoscopic treatment is unsuccessful angiography can usually successfully locate the site of bleeding when:
haemorrhage is severe enough to cause shock transfusion requirement 3 units per 24h active haemorrhage seen endoscopically

complications include:
adverse effects of contrast puncture-related complications
haematoma arterial thrombosis or dissection

bowel ischaemia (5% of patients)

Surgery Generally the last resort

The indications for surgery include the following


Persistent hemodynamic instability with active bleeding Persistent, recurrent bleeding Transfusion of more than 4 units packed red bloods cells in a 24-hour period, with active or recurrent bleeding

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