Hemetamesis and Hemetochezia (Acute GI Hemorrhage) Dr. Wu ShuMing GI Dept. RenJi Hospital

Five Ways of GI Bleeding 4 Hematemesis ： vomitting of blood of altered blood （ coffee grounds ） indicates bleeding proximal to ligament of Treitz 4 Melena ： Tarry stool. Altered （ black ） blood per rectum （ >60ml ） 4 Hematochezia ： Bright red or maroon rectal,bleeding implies bleeding beyond Lig.T.* 4 FOB + and Iron deficiency anemia

Factors affect the way to manifest 4 Site of bleeding 4 Speed of bleeding 4 Amount of blood loss 4 Flora of enterocolon.

Differentiating Upper from Low GI Bleeding 4 Hematochezia usually represents a lower GI source bleeding 4 Upper GI lesion may bleed so briskly that blood doesn`t remain in bowl long enough to become melena 4 Bleeding lesion distal to T Lig.may be either M.or hematochezia, but never manifests hematemesis

Common cause of up GI bleeding Peptic ulcer ； Gastropathy （ alcohol ， aspirin ， NSAIDs ， stress ）； GE varices ； Gastric cancer

Less common cause of up GI bleeding Esophageal or intestinal neoplam Esophagitis ； Malloy-weiss tear ， Hemoptysis: Swallowed blood Anticoagulant fibrinoloytic therapy: Telangiectases ； aneurysm ； vasculitis ； Dieulafoy ulcer ； AV malformation Connective tissue disease ； Hemabilia （ biliary origin ； Crohn`s disease ； amyloidosis, hematological diseases

BENIGN GASTRIC ULCER The classical presentation of gastric ulcer : with weight loss and indigestion made worse by eating, patients more often describe symptoms that would fit equally well for duodenal ulcer - investigation with barium meal or (preferably) endoscopy is, of course, appropriate for either. Benign ulcers may occur at any site in the stomach, but are commonest on the lesser curve away from acid- secreting epithelium.

Duodenum Ulcer 4 The lesion most commonly affecting the duodenum is ulceration, and it is now known that both antral infection with Helicobacter pylori and the presence of gastric acid are virtual prerequisites for it..

GE Varices 4 A number of cutaneous features (stigmata) may develop in a patient with cirrhosis, and these are important as they aid clinical recognition of chronic liver disease.

Clinical manifestation of GI Bleeding 4 Abdominal discomfort Nausea, 4 Hemadynamic change: reduction in blood volume (syncope,light-headedness, sweating,therst) or shock 4 Laboratory changes: HCT, BUN

Hematemesis with other symptoms 4 Hematemesis with upper abdominal pain 4 Hematemesis with hepatomegly and spleenomegly 4 Hematemesis with jaundice 4 Hematemesis with Skin & mucosa hemorrhage 4 Hematemesis with upper abdominal mass 4 Others: NSAIDs, Stress, Burning, Brain operation, Trauma, Vomiting

Lab.Examination in Localization & Diagnosis of GI Bleeding 4 Endoscopy 4 Barium Radiographs 4 Angiography 4 Radionuclide imaging

Approach to the patient with acute upper gastrintesttinal hemorrhage Acute upper Gastrointestinal Hemorrhage Rapid assessment Monitor hemodynamic status Fluid resuscitation Gastric lavage(?) self-limited (80%) bleeding (10-20%) Empiric medical therapy Urgent endoscopy recurrent hemorrhage endoscopy Site not localized Localized further assessment enteroscopy, radioisotope s scan, angiography, exploratory surgery Definitive therapy

Summary of Acute GI Bleeding 4 Upper GI source bleeding--Hemetemesis 4 Major upper GI bleding-- Hemetemesis & hemetochezia 4 The more distant from the rectum, the more likely that melaena occurs 4 The colon lesion--FOB + or hemetochezia 4 The small bowl lesion-- melena or hemetochezia

The questions should be posed 4 Prior bleeding episode? 4 Family history of GI diseases 4 Dose the patient have the illness of ulcer? Cirrhosis?cancer?bleeding disorder? 4 Alcohol? NSAIDs? 4 Any precedes symptoms or signs?

2005 年中国急性上消化道出血诊治指南 中华内科杂志编委会. 急性非静脉曲张性上消化道出血诊治指南（草案）. 中华内科杂志 2005 ； 44(1): 口服 PPIs 静脉大剂量 PPIs 内镜检查与治疗 出血征象监测、液体复苏并止血治疗 监护病房 中高危 (Rockall 评分 ≥3 分 ) 上消化道出血病情严重度分级 (Rockall 评分 重复内镜治疗经血管造影介入治疗 手术治疗原发病治疗及随访 成功 失败

失血量的评估 失血量伴随症状 血压和脉搏 化验检查 脉搏血压休克指数 ＜ 400ml 无自觉症状 ＜ 100/min 正常 ＜ 0.58 ≥400ml 头晕、心慌、 口干 ＝1＝1 ≥800 ml 100 ～ 120 SBP70 ～ 80mmHg 脉压差＜ 30mmHg ≥1200ml 晕厥、尿少、烦躁 ＞1＞1 HGB≤70g/L 肠源性氮质血 症 ≥1600ml ≥120 体位低血压 SBP≤50 ～ 70mmHg ≥2000ml 气促、无尿、昏迷 急性非静脉曲张性上消化道出血诊治指南 中华内科杂志： Palmar KR. Guideline Gut 2002

出血严重程度评估 分级年龄伴发 病 失血量 (ml) 血压 (mmHg) 脉搏 ( 次 / 分 ) 血红蛋白 (g/L) 症状 轻度 ＜ 60 无 ＜ 500 基本正常正常无变化头昏 中度 ＜ 60 无 500~1000 下降＞ ～ 100 晕厥、口渴、少尿 重度 ＞ 60 有 ＞ 1500 收缩压＜ 80 ＞ 120 ＜ 70 肢冷、少尿、意识模 糊 急性非静脉曲张性上消化道出血诊治指南 中华内科杂志： Palmar KR. Guideline Gut 2002

急性上消化道出血患者 Rockall 再出血和死亡危险性评估系统 变量 评 分 0123 年龄 ( 岁 ) ＜ 6060 － 79 ≥80 休克 无休克（收缩压＞ 100mmHg ，脉率＜ 100 次／分） 心动过速（脉率＞ 100 次／分，收缩压 ＞ 100mmHg ） 低血压（收缩压＜ 100mmHg ），脉率＞ 100 次／分 伴发病无 心力衰竭、缺血性心脏 病及其他重要伴发病 肝衰竭、肾衰 竭和癌肿播散 内镜诊断 Mallory-Weiss 撕裂， 无病变 溃疡等其他病变上消化道恶性疾病 内镜下出 血征象 无或有黑斑 上消化道血液潴留、黏 附血凝块，血管显露或 喷血 高危： ≥5 ， 中危： 3 ～ 4 ， 低危： 0 ～ 2

Endoscopic view of a Mallory-Weiss tear with active bleeding (gastric lumen is at top left). B, Endoscopic view of an organized clot adherent to a Mallory-Weiss tear (gastric lumen is at bottom left ).

Endoscopic view of a Dieulafoy lesion on the lesser curvature of the stomach

Endoscopic view of a vascular ectasia (angiodysplasia) in the duodenum.

Endoscopic view of the gastric antrum with watermelon stomach. The pylorus is at top center. Note the linear distribution pattern of the vascular lesions arranged radially around the pylorus.

Endoscopic views of ulcers with stigmata of recent hemorrhage. A, Duodenal ulcer with a visible vessel. B, Gastric ulcer with a red spot in the center of the crater. C, Duodenal ulcer with a red spot in the center of the crater. D, Purplish clot adherent to a gastric ulcer.

Typical picture of a trivial nonsteroidal anti-inflammatory drug (NSAID)- induced injury to the gastric mucosa. There are multiple small erosions with brown-black staining of the center as a result of local bleeding and petechiae.

Typical round gastric ulcer at the angulus (incisura) of the stomach.

Causes of Low GI Bleeding

Differentiating Upper from Low GI Bleeding 4 Hematochezia usually represents a lower GI source bleeding 4 Upper GI lesion may bleed so briskly that blood doesn`t remain in bowl long enough to become melena 4 Bleeding lesion distal to T. Lig. may be either M.or hematochezia, but never manifests hematemesis

Hematochezia with other symptoms 4 Abdominal pain 4 Fever 4 Tenesmus 4 Systemic Hemorrhage 4 Dermal sign 4 Abdominal mass

Lab. Examination For detecting Low GI Bleeeding 4 Anoscopy & sigmoidoscopy 4 Barium Edema (BE) 4 Angiography 4 Radionuclide scanning

A, Linear ulcers of Crohn's colitis. B, Mucosa surrounding the ulcers is nodular (cobblestoning).

Shigella colitis. Patchy areas of erythema, spontaneous bleeding, and loss of the normal vascular pattern are evident

Salmonella colitis. Diffuse erythema, spontaneous bleeding, and loss of the vascular pattern with formation of telangiectasis are present.

Tuberculosis. Linear ulceration runs circumferentially along the interhaustral septum with tiny satellite ulcerations. This must be distinguished from the longitudinal linear ulcerations seen in inflammatory bowel disease.

Pseudomembranous (antibiotic-associated) colitis. Numerous elevated yellowish plaques are present on the mucosal surface.

Amebiasis. Discrete punched-out ulcers are present in the right colon.

Severe acute ulcerative colitis. No vascular pattern is discernible. A severe degree of spontaneous bleeding is present

Large colonic ulcer in a patient with ischemic colitis.

Advantage colon carcinoma