Gastrointestinal Bleeding G Muthukumarasamy Specialist Registrar in General Surgery

Anatomy and Physiology

Oesophagus

Stomach

Duodenum

History taking Complaints Haematemesis Malena Haemotochezia Pain Light-headedness, syncope, dyspnoea, altered mental status (blood loss symptoms) occult blood loss (anaemia)

Malena and Coffee ground vomiting

Clinical Indicator Probability of Upper GI Source Probability of Lower GI Source HematemesisAlmost certainRare MelenaProbablePossible HematocheziaPossibleProbable Blood-streaked stoolRareAlmost certain Occult blood in stoolPossible

Contd., H/o Drug intake – Aspirin, Anticoagulants (warfarin), NSAIDS, Clopidogrel, steroids H/o Alcohol intake, smoking H/o Weight loss Past History : Chronic liver disease, peptic ulcer, bleeding Disorders

Examination General Examination Mental status Eyes – Pallor, Jaundice Liver disease – caput medusae, spider angiomas, ascites, palmar erythema, flap Bleeding disorders – Petechia, echymosis Vital Signs – BP, HR, SaO2, RR, T⁰, CRF Urine output

Jaundice and Anaemia

Liver disease

Petechiae/Echymosis

Examination – contd., Abdominal Inspection – Shape, symmetry, Dilated Veins, signs of liver failure Palpation – tenderness, Splenomegaly, hepatomegaly Percussion – Shifting dullness, Fluid thrill Auscultation – BS, Bruit Rectal Examination – Fresh blood, Malena CVS, RS, Neurological Examination

Investigation FBC, Coagulation profile, U&ES, LFT, CRP, Calcium Type and Crossmatch Blood ECG CXR OGD Angiogram CT or Catheter Nasogastric lavage USS/CT (to assess liver disease) Tc-99m-labeled erythrocyte scans (rarely)

Management RESUSCITATION – ABCDE Fluid and BLOOD Replacement Medical Management - PPIs, Vasoactive agents, B-blocker, ISMN (to prevent re-bleeding) Endoscopic management – Adrenaline, coagulation, banding, clipping Interventional Angiography – coiling, TIPS Surgical Management

Haemorrhagic Shock

UpperGI Bleeding Non variceal Upper GI bleeding 90%Variceal bleeding 10%

Causes

Esophageal VaricesBleeding esophageal varices Oesophageal varices

Oesophagitis

Angiodysplasia

Gastric varices Mallory Weiss Tear Esophagitis Other causes

Glasgow-Blatchford Score Scores of 6 or more were associated with a greater than 50% risk of needing an intervention

Variceal bleeding

Sengstaken-Blakemore tube

Child Pugh classification

Further reading/References Clinical Anatomy: Applied Anatomy for Students and Junior Doctors by Prof H Ellis Review Of Medical Physiology by W F Ganong Guidelines

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