1. Diagnosis of Gastrointestinal Bleeding Prof. Chengwei Tang ( 唐承薇 教授 ) Dept. of Gastroenterology, West China Hospital Sichuan University

2. Hematemesis and Hematochezia 呕血与便血

3. The approach to gastro- intestinal (GI) bleeding is tailored to the manner of appearance.

4. Is bleeding acute or chronic? Intensive care Where is the source of bleeding? Empiric therapyDiagnosis Treatment ( 经验治疗 ) What is the causes of bleeding? Recognition of hemorrhage

5. Intensive care Where is the source of bleeding? Empiric therapyDiagnosis Treatment ( 经验治疗 ) What is the causes of bleeding? Is bleeding acute or chronic? Recognition of hemorrhage

6. Clinical Manifestations 1 Manner of bleeding presentation 2 Hypovolemia ( 低血容量 ) or shock 3 Anemia ( 贫血 ) Recognition of hemorrhage

7. Patients manifest blood loss 1) Hematemesis 呕 血 Bloody vomitus, either fresh and bright red or older and “coffee - ground” (hematin 酸化正铁血红素 ) in character Hemoptysis? Nosebleeding? Manner of bleeding presentation from the GI tract in five ways:

8. 2) Melena 黑 便 Shiny, black, sticky, foul-smelling stool degradation of blood exogenous stool darkeners iron bismuth ( 铋剂 ) Manner of bleeding presentation

9. 3)Hematochezia 便 血 bright red or maroon blood from the rectum pure blood blood intermixed with formed stool bloody diarrhea

10. Manner of bleeding presentation 4)Occult 隐 血 detected only by testing the stool with a monoclonal antibody for human hemoglobin

11. Estimate amount of bleeding from upper GI tract 5~10 ml/d OB + 50~70 ml/d Melena 250~300 ml in short time Hematemesis

12. Manner of bleeding presentation 5) without any objective sign of bleeding with symptoms of blood loss dizziness, dyspnea, angina cordis ( 心绞痛 ), or even shock digital examination ( 指检 ) of the rectum

13. Hypovolemia or shock Speed and volume of blood loss Weakness, giddiness ( 眩晕 ), oliguria, ( 少尿 ) cold extremity, sweating Vital signs: tachycardia, ( 心动过速 ) hypotention ( 低血压 )

14. Anemia pale dizziness palpitation easy fatigability dyspnea angina cordis

15. Is bleeding acute or chronic? 1) Bleeding speed Hematemesis of fresh blood generally indicates a more severe bleeding episode than melena, which occurs when bleeding is slow enough to allow time for degradation of blood

17. Is bleeding acute or chronic? 2) Hematocrit bleeding slowly hypochromic ( 血红蛋白过少 ) microcytic ( 小细胞 ) red blood cells mean corpuscular volume (MCV ， 平均血球压积 ) of the cells may be low

18. Is bleeding acute or chronic? If blood loss is acute, the hematocrit dose not change during the first few hours after hemorrhage About 24 to 72 hours later, plasma volume is larger than normal and the hematocrit is at its lowest point

19. 7 6 5 4 3 2 1 Volume (Liters) 45 % 27 % AB C Is bleeding acute or chronic? Hematocrit changes A Before bleeding B Immediately after bleeding C 24~72 hours after bleeding

20. Is bleeding acute or chronic? 3) Blood pressure and heart rate depend on  amount of blood loss  suddenness of blood loss  extent of cardiac and vascular compensation

21. postural hypotension ---- early physical finding tachycardia ---- greater loss, compensate recumbent ( 卧位 ) hypotension ---- final results Is bleeding acute or chronic?

22. Postural hypotension A postural drop in blood pressure of 10 to 15 mm Hg

23. Is bleeding acute or chronic? 4) Bowel sound Active bowel sound usually be presented in acute bleeding from GI tract

24. Emergent and intensive care Initially vital signs supine and upright blood pressure pulse

25. If blood loss is significant, intravenous fluids must be started Saline or other balanced electrolyte solutions are most rapidly available

26.  Blood is sent to the lab. complete blood count clotting studies routine chemistry studies.  Blood for typing and cross- matching is sent to the blood bank.

27. Where is the source of bleeding? Localization Upper GI bleeding: bleeding from a source proximal to the ligament of Treitz. Lower GI bleeding: bleeding from a site distal to the ligament of Treitz.

28. Localization Treitz: The ligament of Treitz is an anatomic landmark for the duodenal-jejunal junction.

29. Localization Differentiating features of upper GI and lower GI bleeding Upper GILower GI ManifestationHematemesisHematochezia melena Nasogastric aspirateBloodyClear BUNElevatedNormal Bowel soundHyperactiveNormal

30. Upper GI tract bleeding ? I.Clinical manifestation II.Bowel sound III.Nasogastric tube

31. Hematemesis Melena Hematochezia

32. More proximal lesions produce hematemesis or melena, whereas more distal lesions are more likely to produce hematochezia.

33. If hematochezia is from an upper GI source, it usually reflects a massive bleed (i. e., greater than 1000 ml).

34. What is the causes of bleeding? 90% upper GI bleeding is due to four lesions: 1) peptic ulcer ( 消化性溃疡 ) 2) hemorrhagic gastritis ( 胃炎 ) 3) esophageal or gastric varices ( 静脉曲张 ) 4) gastric cancer

35. peptic ulcer

36. hemorrhagic gastritis

37. esophageal varices

38. gastric cancer

39. Causes of gastrointestinal bleeding Mallory-Weiss tear 食道 - 贲门撕裂伤

40. Causes of gastrointestinal bleeding Portal-hypertensive gastropathy 门脉高压胃病 Ancylostomiasis 钩虫病 Post-sphincterotomy 括约肌切开术后

41. Causes of gastrointestinal bleeding Colorectal cancer Colitis Large hemorrhoid 大痔 Rectum tear 肛裂 Vascular anomalies Hematologic diseases

42. Diagnostic approach to gastrointestinal bleeding 1 History and physical examination 2 Endoscopy 3 Barium radiography 4 Angiography 5 Nuclear scintigraphy

43. History and physical examination A history of previously docu- mented GI tract disease determined by radiography, endoscopy, or surgical procedures is very useful. Diagnostic approach to GI bleeding

44. Patients with hepatitis B or chronic active liver disease may present with painless hematemesis from esophageal varices.

45. Diagnostic approach to GI bleeding Patients with forceful, retching ( 干呕 ) or multiple episodes of vomiting of food prior to the onset of hematemesismay be bleeding from Mallory － Weisstears of the gastroesophageal junction.

46. Diagnostic approach to GI bleeding A history of epigastric ( 上腹部 ) burning pain promptly relieved by foodor antacids ( 抗酸剂 ) or nocturnal ( 夜间 ) pain suggests peptic ulcer disease,particularly duodenal ( 十二 指肠 ) ulcer.

47. Diagnostic approach to GI bleeding Colorectal malignancy is often suggeste by a history of gradual weight loss intermittent blood in the stools altered bowel habits

48. Diagnostic approach to GI bleeding Hemorrhoidal bleeding is often suggested by the presence of bright red blood surrounding well-formed, normal-appearing stools.

49. Diagnostic approach to GI bleeding Patients with stigmata ( 特征 ) of chronic liver disease [e.g., spider angioma ( 蜘蛛痣 ), ascites ( 腹水 ), gynecomastia ( 男性乳房发育 ) ] and upper GI bleeding often bleed from esophageal varices or erosion ( 糜烂 ).

50. Diagnostic approach to GI bleeding Localized epigastric tenderness ( 触痛 ) to palpation may indicate peptic ulcer disease or gastritis.

51. Diagnostic approach to GI bleeding Occasionally patients with lower GI tract bleeding from a malignancy have a palpable lower abdominal mass, hepatomegaly ( 肝肿大 ) ， signs of obvious weight loss.

52. Diagnostic approach to GI bleeding A rectal examination is essen-tial to document stool color as well as to palpate for gross ano-rectal ( 肛直肠 ) mass lesions such as polyps, cancers, or large hemorrhoids.

53. Diagnostic approach to GI bleeding Endoscopy ( 内镜 ) Endoscopy is the diagnostic procedure of choice because of its high accuracy and immediate therapeutic potential. Endoscopy, however, must be Performed only following adequate resuscita- tion ( 复苏 ).

54. Diagnostic approach to GI bleeding Endoscopy Contraindications ： acute myocardial infarction severe chronic lung disease hemodynamic instability patient agitation ( 焦虑不安 ) terminal malignancy

55. Diagnostic approach to GI bleeding Barium radiography ( 钡餐 ) Barium radiography is noninvasive but has significant disadvantages, particularly in patients who are bleeding briskly (actively).

56. Diagnostic approach to GI bleeding Angiography ( 血管造影 ) Angiography may localize the site of bleeding.

57. Diagnostic approach to GI bleeding Angiography Bleeding must be active because angiography detects only extravasation ( 外渗 ) of contrast ( 造影剂 ) into the GI tract.

58. 思考题： I. 胃肠道出血有哪些表现形式？ II. 胃肠道出血的病因有哪些？ III. 对胃肠道出血的诊断通常采用哪些方式？

59. References ： Textbook of physical diagnosis. 4th edition. MH Swartz.Elsevier science. 2002. Sleisenger & Fordtran's Gastrointestinal and liver disease. 6th edition. M Feldman, BF Scharschmidt, MH Sleisenger.W.B.Saunders, 2001. physical Diagnosis ， Fourth Edition, Jo-Ann Reteguiz,M.D., McGraw-Hill