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

EPIDEMIOLOGY COMMON AND POTENTIALLY FATAL DIAGNOSIS ACCOUNTING FOR ~30,000 ADMISSIONS/YEAR UPPER GIB ACCOUNTS FOR 20,000 DEATHS/YEAR

DEFINITIONS

PATHOPHYSIOLOGY OF GI BLEEDING

SOURCES OF GI BLEEDING

UPPER VS LOWER UPPER GI BLEED LOWER GI BLEED

UPPER VS LOWER UPPER GI BLEED LOWER GI BLEED

INCIDENCE UPPER GI BLEED 100/100,000 ABOVE THE LIGAMENT OF TREITZ LOWER GI BLEED 20/100,000 BELOW THE LIGAMENT OF TREITZ BOTH ARE MORE COMMON IN MALES AND ELDERLY.

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)

HISTORY HPI HEMATEMESIS (COFFEE GROUNDS VS. BRIGHT RED) HEMATOCHEZIA MELENA - DARK, TARRY STOOL PAIN SYMPTOMS PMHX ULCER DISEASE, JOINTS, SKIN SOCIAL HX ETOH MEDICATIONS NSAIDS, STEROIDS, ASA, PLAVIX, COUMADIN, LOVENOX, HEPARIN, IRON

PHYSICAL EXAM

LAB WORK UP CBC CBC SERIAL HGB SERIAL HGB PLATELETS PLATELETS BASIC PANEL BASIC PANEL LFT, RFT LFT, RFT BLOOD TYPE AND CROSSMATCH BLOOD TYPE AND CROSSMATCH COAGULATION STUDIES COAGULATION STUDIES STOOL WBCS TO EVALUATE INFECTIOUS STOOL WBCS TO EVALUATE INFECTIOUS IMAGING STUDIES? IMAGING STUDIES?

HOW TO LOCATE OF BLEEDING

EVIDENCE OF UPPER GI BLEED HEMATEMESIS (50%) HEMATEMESIS (50%) NGT WITH POSITIVE BLOOD ON ASPIRATE NGT WITH POSITIVE BLOOD ON ASPIRATE HEMATOCHEZIA (11%) HEMATOCHEZIA (11%) MELENA (BLACK TARRY STOOLS) MELENA (BLACK TARRY STOOLS) THIS DEVELOPS WITH APPROXIMATELY CC OF BLOOD IN THE UPPER GI TRACT. THIS DEVELOPS WITH APPROXIMATELY CC OF BLOOD IN THE UPPER GI TRACT. STOOL TURNS BLACK AFTER 8 HOURS OF SITTING WITHIN THE GUT. STOOL TURNS BLACK AFTER 8 HOURS OF SITTING WITHIN THE GUT. HEMATEMESIS (50%) HEMATEMESIS (50%) NGT WITH POSITIVE BLOOD ON ASPIRATE NGT WITH POSITIVE BLOOD ON ASPIRATE HEMATOCHEZIA (11%) HEMATOCHEZIA (11%) MELENA (BLACK TARRY STOOLS) MELENA (BLACK TARRY STOOLS) THIS DEVELOPS WITH APPROXIMATELY CC OF BLOOD IN THE UPPER GI TRACT. THIS DEVELOPS WITH APPROXIMATELY CC OF BLOOD IN THE UPPER GI TRACT. STOOL TURNS BLACK AFTER 8 HOURS OF SITTING WITHIN THE GUT. 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/SEVERAL DAYS) ACUTE ( 3 DAYS/SEVERAL DAYS) HEMATOCHEZIA VS MELENA HEMATOCHEZIA VS MELENA BLOOD IN TOILET, CLEAR NGT ASPIRATE BLOOD IN TOILET, CLEAR NGT ASPIRATE NORMAL RENAL FUNCTION NORMAL RENAL FUNCTION USUALLY HEMODYNAMICALLY STABLE USUALLY HEMODYNAMICALLY STABLE <200ML : NO EFFECT ON HR** <200ML : NO EFFECT ON HR** >800ML: SBP DROPS BY 10MMHG, HR INCREASES BY 10 >800ML: SBP DROPS BY 10MMHG, HR INCREASES BY 10 >1500ML: POSSIBLE SHOCK >1500ML: POSSIBLE SHOCKOR 10% HCT: TACHYCARDIA* 10% HCT: TACHYCARDIA* 20% HCT: ORTHOSTATIC HYPOTENSION 20% HCT: ORTHOSTATIC HYPOTENSION 30% HCT: SHOCK 30% HCT: SHOCK STOPS SPONTANEOUSLY ( % OF THE TIME) STOPS SPONTANEOUSLY ( % OF THE TIME)

MELENA VS HEMATOCHEZIA

ETIOLOGY OF HEMATOCHEZIA Barnet J and H Messmann H. Nat Rev Gastroenterol Hepatol 6, (2009).

COMMON CAUSE OF LOWER GI BLEED DIVERTICULOSISCOLONIC POLYPS

COMMON CAUSE OF LOWER GI BLEED HEMMORHOIDECOLON CARCINOMA

MANAGEMENT OF GI BLEED (1)

MANAGEMENT OF GI BLEED (2)