GASTRO INTESTINAL BLEEDING AN APPROACH TO DIAGNOSIS GASTRO INTESTINAL BLEEDING Gatot Sugiharto, dr. SpPD Internal Medicine Dept. Faculty of Medicine Wijaya Kusuma University 2014

DEFINITIONS

PATHOPHYSIOLOGY OF GI BLEEDING

SOURCES OF GI BLEEDING

UPPER VS LOWER LOWER GI BLEED UPPER GI BLEED A directed history and physical is pertinent to directing treatment and diagnostic testing. 9

UPPER VS LOWER UPPER GI BLEED LOWER GI BLEED A directed history and physical is pertinent to directing treatment and diagnostic testing. 10

UPPER GI BLEED RISK FACTORS NSAID USE H. PYLORI INFECTION INCREASED AGE UPPER GI BLEEDING ACCOUNTS FOR APPROXIMATELY 350,000 HOSPITALIZATIONS PER YEAR.

ETIOLOGY OF UPPER BLEEDS

CAUSES OF UPPER GI BLEED(1)

CAUSES OF UPPER GI BLEED (2)

CAUSES OF UPPER GI BLEED (3)

CAUSES OF LOWER GI BLEEDING (1)

CAUSES OF LOWER GI BLEEDING (2)

PHYSICAL EXAM NGT Positive: UGIB NGT Negative: bleeding stopped. Bleeding is beyong pylorus 20

LAB WORK UP CBC BASIC PANEL BLOOD TYPE AND CROSSMATCH SERIAL HGB PLATELETS BASIC PANEL LFT, RFT BLOOD TYPE AND CROSSMATCH COAGULATION STUDIES STOOL WBCS TO EVALUATE INFECTIOUS IMAGING STUDIES? BUN/Cr > 30 indicates GI bleed, prob UGIB. 21

HOW TO LOCATE OF BLEEDING

EVIDENCE OF UPPER GI BLEED HEMATEMESIS (50%) NGT WITH POSITIVE BLOOD ON ASPIRATE HEMATOCHEZIA (11%) MELENA (BLACK TARRY STOOLS) THIS DEVELOPS WITH APPROXIMATELY 150-200CC OF BLOOD IN THE UPPER GI TRACT. STOOL TURNS BLACK AFTER 8 HOURS OF SITTING WITHIN THE GUT.

COMMON CAUSE OF UPPER GI BLEEDING DUODENAL ULCER VARICOSE

COMMON CAUSE OF UPPER GI BLEEDING ANGIODYSPLASIA ESOPHAGITIS

GI MALIGNANCY GASTRIC CARCINOMA ESOPHAGEAL TUMOR

SIGN & SYMPTOM OF LOWER GI BLEED ACUTE (<3 DAYS) VS CHRONIC (>3 DAYS/SEVERAL DAYS) HEMATOCHEZIA VS MELENA BLOOD IN TOILET, CLEAR NGT ASPIRATE NORMAL RENAL FUNCTION USUALLY HEMODYNAMICALLY STABLE <200ML : NO EFFECT ON HR** >800ML: SBP DROPS BY 10MMHG, HR INCREASES BY 10 >1500ML: POSSIBLE SHOCK OR 10% HCT: TACHYCARDIA* 20% HCT: ORTHOSTATIC HYPOTENSION 30% HCT: SHOCK STOPS SPONTANEOUSLY (80 - 85% OF THE TIME) *Pocket Medicine, 3rd edition **Barnet J and H Messmann H. Nat Rev Gastroenterol Hepatol 6, 637-646 (2009). 27

MELENA VS HEMATOCHEZIA

ETIOLOGY OF HEMATOCHEZIA Mnemonic for: painful --> I = infectious, inflam, ischemic Ischemic colitis - usually elderly, transient hypoperfusion of mesenteric arteries, resulting in pain from episodic low BP or vasospasm. Water shed area: splenic flexure AND rectosigmoid. Barnet J and H Messmann H. Nat Rev Gastroenterol Hepatol 6, 637-646 (2009). 29

COMMON CAUSE OF LOWER GI BLEED COLONIC POLYPS DIVERTICULOSIS

COMMON CAUSE OF LOWER GI BLEED COLON CARCINOMA HEMMORHOIDE

MANAGEMENT OF GI BLEED (1)

MANAGEMENT OF GI BLEED (2)