GASTRO INTESTINAL BLEED Dr. PRAVEEN PEDDI
:: DEFINITION :: UPPER Ligament of TREITZ LOWER
Esophageal and Gastric Varices MOST COMMON CAUSES UPPER GI BLEED LOWER GI BLEED Peptic Ulcer Disease Erosive Gastritis Esophagitis Esophageal and Gastric Varices Mallory-Weiss Tear others Diverticulosis Vascular Ectasia Mesenteic Ischemia Ischemia Colitis Meckel Divrticulum
CAUSES OF UGI BLEED
CAUSES OF LOWER GI BLEED
PEPTIC ULCERS
ESOPHAGEAL AND GASTRIC VARICES
Erosive gastritis and esophagitis
MALLORY-WEISS TEAR
AORTO ENTERIC FISTULA
DIEULAFOYS LESIONS
DIVERTICULOSIS
MESENTERIC ISCHEMIA and ischemic colitis
RISK FACTOR. vasculitis Hyper coagulable state Aneurysmal rupture vasculitis Hyper coagulable state Prolonged strenous exercises IBS Diagnosis requires a high index suspicion age>60 Atrial Fibrillation CHF, MI post pondial and pain Diagnostic study of choice. ANGIOGRAPHY Prognosis
MECKEL DIVERTICULUM
OTHER CAUSES Coliti Rectal ulcers Trauma IBD Polyp Carcinoma hemorrhoids
Clinical presentation UGI BLEED Hematemesis Coffee ground emesis Melena ENT examination LOWER GI BLEED Hematochezia Frank blood Genito urinary tract
On examination Hypotension Tachycardia Decreased pulse pressure Tachypnea Shock- cool clamy skin, increased capillary refilling Liver disease—spider navi., palmar erythema, gynecomastia, jaundice Coagulopthy
INVESTIGATIONS Grouping and cross matching CBP BUN Creatinine Electrolytes Coagulation test ECG
Diagnostic studies UPPER GI BLEED. LOWER GI BLEED UGI endoscopy. Lower GI endoscopy Naso Gastric Tube Angiography Scintigraphy multiditector CT
Forrest classification 1a—spurting hemorrhage 1b—oozing hemorrhage 2a—visible vessels 2b—adherent clot 2c—flat pigmented hematin on ULCER base 3—without signs of hemorrhage
treatment PRIMARY : Immediate resuscitation O2 inhalation Crystalloids Blood transfusion
SECONDARY treatment Early therapeutic endoscopy Injection therapy Coagulative therapy Endoscopic clips Band ligations
Peptic ulcers Crystalloids Colloids PPI– Lansoprazole- 60mg bolus f/b 6ml/hr Pantoprazole – 80mg bolus f/b 8ml/hr Esomeprazole-- “”. “”. “”
Variceal bleed Colloids, Albumin Octreotide--- 50microgram Bolus f/b 50microgram /hr Vassopressin Beta blockers and Nitratesh
Endoscopic BANDING AND SCLEROTHERAPY
Balloon tamponade
Tips Trans jugular Intra hepatic Porto systemic shunts
DISPOSITION AND FOLLOW UP Adverse outcome Initial hematocrit <30% Initial SBP <100 Red blood in NG lavage H/O Cirrhosis
Glasgow-blathford bleeding score BLOOD UREA HAEMOGLOBIN SYSTOLIC BLOOD PRESSURE PULSE RATE MELENA SYNCOPE HEPATIC DISEASE CARDIAC FAILURE
ROCKALL RISK scoring SYSTEM