Gastrintestinal Bleeding

8/14/2019 Gastrintestinal Bleeding

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Upper and Lower Gastrointestinal

Bleeding

Dr. Shatdal Chaudhary MDAssistant Professor

Department of Internal Medicine, BPKIHS, Dharan



G I Bleeding

• Acute Vs Chronic

• Upper Vs Lower • Bleeding above/below the ligament of Treitz



Acute U G I Bleeding

Introduction• Most common gastrointestinal emergency

• Accounting for 50-120 admissions to hospitalper 100 000 of the population each year inthe U K.

• Higher among males, elderly



Causes of Upper GI Bleed (UGIB)

• Peptic Ulcer Disease (60% cases of UGIB)• Erosive Gastritis(10-20%)• Esophagitis (10%)•

Esophageal and Gastric Varices (2-9%)• Mallory-Weiss Syndrome(5%)• Malignancy(2%)

• Others – Stress ulcer, arteriovenous malformation, Aorto-

duodenal Fistula, corrosive poisoning















Clinical Features:

• History: Often misleading – Usually presents with obvious complaints (melaena,

hematemesis, etc.) or may present with more subtle signs(hypotension, tachycardia, etc)

•Hematemesis• Melaena

• Hematochezia• H/o NSAIDs, Alcohol abuse, corrosive intake• Weight loss/change in bowel habit (malignancy)• Vomiting/retching followed by hematemesis (Mallory-

Weiss)

• Hx aortic graft (possible aortocentric fistula)











• Angiography: sometimes can localize, but requiresbrisk bleeding rate (0.5 to 2.0 ml/min)

• Technetium-labeled red cell scan: more sensitive thanangiography



Treatment

• Primary – ABCs – Oxygen This should be given by facemask to all

patients in shock.

– Close monitoring

– Immediate resuscitation, 2 wide bore IV cannula

– NG tube in all patients with significant bleeding

– Consider blood transfusion if no improvementafter 2L of crystalloid or Hb < 10 gm/dL







Surgery – – if all other interventions are ineffective

– endoscopic haemostasis fails to stop activebleeding – rebleeding occurs on one occasion in an elderly

or frail patient, or twice in younger, fit patients







Lower GI Bleeding• Bleeding below the ligament of Treitz• This may be due to haemorrhage from the

– small bowel – colon or – anal canal

• Incidence: 20 per 100,000 population

CAUSES OF LOWER GI BLEEDING



CAUSES OF LOWER GI BLEEDING• Severe acute

– Diverticular disease

– Angiodysplasia – Ischaemia – Meckel's diverticulum

• Moderate, chronic/subacute

– Anal disease, e.g. fissure, haemorrhoids – Inflammatory bowel disease – Carcinoma – Large polyps

– Angiodysplasia – Radiation enteritis – Solitary rectal ulcer



ETIOLOGYDifferential Diagnosis of Lower Gastrointestinal Hemorrhage

COLONIC BLEEDING (95%) % SMALL BOWEL BLEEDING (5%)Diverticular disease 30-40 Angiodysplasias

Ischemia 5-10 Erosions or ulcers (potassium, NSAIDs)

Anorectal disease 5-15 Crohn's disease

Neoplasia 5-10 RadiationInfectious colitis 3-8 Meckel's diverticulum

Postpolypectomy 3-7 Neoplasia

Inflammatory bowel disease 3-4 Aortoenteric fistula

Angiodysplasia 3

Radiation colitis/proctitis 1-3

Other 1-5

Unknown 10-25





Options to diagnose and control the bleeding

• Colonoscopy• technetium-99m labeled RBC scan: requires 0.5-1

ml/min bleeding• Mesenteric angiography: requires 1-1.5 ml/min bleeding• Meckels scan• Capsule Endoscopy• Surgery

• faecal occult blood (FOB)



• Colonscopy: diagnostic and therapeutic• colonoscopy is necessary to exclude coexisting colorectal

cancer.

– subjects who also have altered bowel habit – and in all patients presenting at over 40 years of age,















The End



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Gastrintestinal Bleeding