1. Bleeding from the Gut Clinical approach Severity Vital signs Haematocrit Beware ongoing losses Acute onset or chronic blood loss Fe deficiency Stigmata of disease Failure to thrive and grow Purpura Liver and spleen

2. Site of bleeding Haematemesis Fresh blood swallowed, rapid haemorrhage Altered - “coffee ground” gastric acid

3. Site of bleeding Bleeding per rectum Fresh blood not mixed with stool low rectum and anus Fresh blood with mucus - dysentery colon and rectum Jellied dark blood intussusception Melaena - tarry black bleeding from higher up

4. Bleeding from the gut Bleeding tendency Vitamin K deficiency Hepatic failure Disseminated intravascular coagulation septicaemia, necrotising enterocolitis Thrombocytopaenia haemolytic uraemic syndrome Vasculitis - Henoch Schonlein purpura

5. Bleeding from the Gut Swallowed blood Maternal blood swallowed intrapartum Apt test Nose bleed Mouth and pharynx Oesophagus Varices (portal hypertension) Oesophagitis (peptic or other) Mallory-Weiss tear

6. Bleeding from the Gut Stomach Gastritis and erosions Ulcer (peptic, stress) Small gut Meckel diverticulum Ulcers (peptic and inflammatory) Intussusception Volvulus Polyps

7. Bleeding from the Gut Large gut Dysentery (amoebic, bacterial) Intussusception Polyps Ulcerative colitis Rectum and anus Varices Polyps Trauma Anal fissure

8. Bleeding from the gut Management Resuscitation as required Stop the bleeding mostly spontaneous vitamin K blood component therapy emergency endoscopic approach

9. Bleeding from the Gut Management Identify the site of haemorrhage History Character of blood Upper gut: endoscopy Lower gut:contrast studies isotope scan “Meckel scan” endoscopy Identify and manage aetiology Follow-up for recurrence

10. Dysentery Mucosal invasion or toxin mediated inflammation with necrosis bacteria - shigella, Esch.coli, others Entamoeba histolytica, trichiuris Fever, abdominal pain, extraintestinal features Sometimes onset in “gastro-like” fashion Major complications