Approach to Hematemesis and Melena

6th Year Medicine Dr Yasir M Khayyat

Assistant Professor/Gastroenterologist

Management Outline Airway Breathing Circulation Decide on Admission

Causes of UGIB ( Hematemesis/Melena)

Melena: passage of blackTarry offensive stool due to Bleeding form the upper GIT proximal to ligmant ofTretiz ( > 100 ml).Basic Mechanisms:1.Hyperacidity2.H pylori3.Vascular anomalies4.Autoimmune5.Malignancy

Ligament of Treitz

Endoscopic Diagnosis

Take home message

• Always think of hemodynamic stability ABC• Then think to do H & P• Common things are common• Careful not to kill the patient and know when

to call for somebody help• Common diseases are peptic ulcers, liver

disease, drug induced and malignancy.• Decide if you admit ( ward/ICU) or discharge.

Approach to Diarrhea

Diarrhea : • Increased frequency or stoolWeight ( > 200g) or frequency( ≥ 3 BM/d)

Onset:Acute: < 4 weeksChronic : > 4 weeks

Basic Pathologic Mechanisms

Now think of the causes of diarrhea and mention 4 causes under each category ( Acute vs. chronic)

1-2-3-4-

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General approach to Diarrhea

History:• Normal bowel habits• Onset: sudden/chronic• Frequency, Food relation• Stool appearance, Smell• Drugs• Tenesmus• Travel. Contact• Stress • Associated features• Nocturnal diarrhea• Thyrotoxicosis

Physical Examination:• Vital signs:• Volume status/Dehydration:• Eyes : anemia,thyrotoxicosi• Skin: flushing, rashes• L.N: • Abdomen:

mass,distension,tenderness,• Hands: clubbing

Investigations:

• CBC:WBC (…….),Hb (……..),Plt (……….),INR ?why• Serum Electrolytes, (BUN , Creatinine ),Album• Stool : analysis, O & P, Culture, ?Fat ,Occult

blood. Clostridium difficle,24 hr fat>10g( malabsorption),Osmolality and gap ?

• Specialized Tests: Endoscopy ( U & L)• DM : FBS,RBS• Thyroid : TSH,Ft3,Ft4• Malabsorption: Folate, Vit B12,Iron, serum

gastric,VIP,Calcitonin,Cortisol,5 HIAA (for what?)

Outline of Diarrhea management

• Assure ABC as always, assess volume status and replace lost fluids and electrolyte ( Na,K,Cl,HCO3)

• Antimotility : Loperamide,Atropine ( careful)• Antibiotics : not for everybody, Gram

negative,parasites,anaerobes• Prevention of spread, identification of the source• Treat the underlying cause of inflammatory,

Secretory chronic diarrhea.

Take home message

• Think of the patient ( immunocompetent/Immunocompromised)

• Back to the basics ( city, Incubation period, types of culture and Investigations)

• DO NOT GIVE ANTIBIOTICS TO ALL DIARRHEA .• Antimicrobials are not the only thing that the

patient need ( hydration,shock,renal/liver.F)• GO home and Read ???