1. GASTROINTESTINAL BLEEDING

2. INTRODUCTION
Gastrointestinal bleeding describe every form of haemorrhage in the GIT, from the pharynx to the rectum.
Can be divided into 2 clinical syndromes:-
- upper GI bleed (pharynx to ligament of Treitz)
- lower GI bleed (ligament of Treitz to rectum)
LIGAMENT OF TREITZ

3. UPPER GASTROINTESTINAL BLEEDING

4. CLINICAL FEATURES
Haematemesis : vomiting of blood whether fresh and red or digested and black.
Melaena : passage of loose, black tarry stools with a characteristic foul smell.
Coffee ground vomiting : blood clot in the vomitus.
Hematochezia : passage of bright red blood per rectum (if the haemorrhage is severe).

5. CLINICAL FEATURES
Haematemesis without malaena is generally due to lesions proximal to the ligament of Treitz, since blood entering the GIT below the duodenum rarely enters the stomach.
Malaena without haematemesis is usually due to lesions distal to the pylorus
Approximately 60mL of blood is required to produced a single black stool.

6. ETIOLOGY Oesophagus -Oesophageal varices -Oesophageal CA Stomach
-Mallory-Weiss syndrome
LOCAL
Stomach
-Gastric ulcer
Erosive gastritis
-Gastric CA
-Haemophilia
-Leukemia
-Thrombocytopenia
-Anti-coagulant therapy
GENERAL
Duodenum
-Duodenal ulcer
-Duodenitis

8. OESOPHAGEAL VARICES
Abnormal dilatation of subepithelial and submucosal veins due to increased venous pressure from portal hypertension (collateral exist between portal system and azygous vein via lower oesophageal venous plexus).
Most commonly : lower esophagus.

9. Esophageal varices: a view of the everted esophagus and gastroesophageal junction, showing dilated submucosal veins (varices).

10. SENGSTAKEN TUBE

11. (Deflate every 4 hours for 15 minutes )

12. Mallory-Weiss Tears
Mallory-Weiss syndrome refers to bleeding from tears (a Mallory-Weiss tear) in the mucosa at the junction of the stomach and esophagus, usually caused by severe retching, coughing, or vomiting.
Mallory-Weiss tears account for 5% to 10% of cases of upper GI bleeding.

13. MALLORY-WEISS TEAR: MANAGEMENT
- Bleeding from MWTs stops spontaneously in 80-90% of patients
Endoscopic band ligation (use of elastic bands )
- Endoscopic hemoclipping (a metallic mechanical
device used in endoscopy in order to close two
mucosal surfaces without the need for surgery )

14. Endoscopic band ligation

15. Endoscopic hemoclipping

16. ESOPHAGEAL CANCER 8th most common cancer seen throughout the world.
40% occur in the middle 3rd of the oesophagus and are squamous carcinomas.
adenoCA (45%) occur in the lower 3rd of the oesophagus and at the cardia.

17. CLINICAL FEATURES Dysphagia
Odynophagia : retrosternal pain on swallowing.
Regurgitation
Weight loss
Anorexia
Anemia

18. PEPTIC ULCER gastric ulcer & duodenal ulcer
Caused by imbalance between secretion of acid and pepsin, and mucosal defence mechanism.
AETIOLOGY
-Helicobacter pylori infection
-NSAIDs
-others: stress, smoking,alcohol, steroid
SIGNS & SYMPTOMS
epigastric pain
haematemesis
Melaena
heartburn

19. PEPTIC ULCER Feature Gastric ulcer Duodenal ulcer Onset
Soon after eating
2-3 hours after eating
Relieving factor
vomiting
Eating
Precipitating factor
eating
Missing a meal, anxiety, stress
Duration of attack
A few weeks
A month or two

20. GASTROINTESTINAL BLEEDING LOWER

21. LOWER GI BLEED: ETIOLOGY
SMALL INTESTINE
COLON
Carcinoma of colon
Haemorrhoids
Anal carcinoma
Crohn’s disease Rectal carcinoma
ANUS
RECTUM

22. Crohn's disease
Crohn's disease (also spelled Crohn disease) is a chronic inflammatory disease of the intestines. It primarily causes ulcerations (breaks in the lining) of the small and large intestines
The cause of Crohn's disease is unknown. Some scientists suspect that infection by certain bacteria, such as strains of mycobacterium

23. Sign and symptom
abdominal pain, diarrhea, and weight loss. Less common symptoms include poor appetite, fever, night sweats, rectal pain, and occasionally rectal bleeding.

24. Treatment
There is no medication that can cure Crohn's disease. Patients with Crohn's disease typically will experience periods of relapse (worsening of inflammation) followed by periods of remission (lessening of inflammation) lasting months to years.
Medications for treating Crohn's disease include anti-inflammatory agents and corticosteroids, topical antibiotics, and immuno-modulators.

25. ADENOCARCINOMA OF COLON & RECTUM
Rare < 50 years old, Common > 60 years old
Common site- sigmoid colon, rectum
Clinical features:
-altered bowel habit & large bowel obstruction
-rectal bleeding
-iron deficiency anaemia
-tenesmus
-perforation
-anorexia & weight loss

26. HAEMORRHOIDS M > F Female- late pregnancy, puerperium
Supine lithotomy position- 3 ,7, 11 o’clock positions
Classification:
1st degree : never prolapse
2nd degree: prolapse during
defaecation but
return spontaneously
3rd degree : remain prolapse but
can be reduced digitally
4th degree : long-standing
prolapse cannot be
reduced

27. HAEMORRHOIDS: SIGNS & SYMPTOMS
Rectal bleeding
Perianal irritation & itching
Mucus leakage
Mild incontinence of flatus
Prolapse
Acute pain
Skin tags at anal margin

28. MANAGEMENT OF ACUTE GASTROINTESTINAL BLEEDING
Rapid history and examination.
Monitor the pulse and blood pressure half-hourly.

29. MANAGEMENT OF ACUTE GASTROINTESTINAL BLEEDING : HISTORY TAKING
- when? - have u vomited blood/passed black tarry stools? - had both haematemesis & malaena? - have u had, bleeding from the nose? Bloody expectoration? A dental extraction? - what is the color, the appearance of the vomited blood? - red? Dark red? Brown? Black? - ‘coffee ground appearance? - bright red & frothy? - what is the color of the stool? Bright red? Black tarry? - have u vomited blood only once/several times? - has the bleeding been abrupt/massive? - have u had >1 black, tarry stool within a 24-h period? - for how long have the tarry stools persisted?
MODE OF ONSET
CHARACTER
EXTENT AND RATE

30. MANAGEMENT OF ACUTE GASTROINTESTINAL BLEEDING : HISTORY TAKING
- retching & severe nonbloody vomiting? - lightheadedness? Nausea? Thirst? Sweating? - faintness when lying down/when standing/syncope? - following the haemorrhage did you have diarrhea? - aspirin? anticoagulant therapy? iron preparation? - age of the patient? - what is your smoke/alcohol intake? - have there been similar episode in the past? When? Diagnosis? - were u hospitalized on this occasion? Did u receive a transfusion? - are there any other members of your family who have intestinal disease/bleeding tendency/peptic ulcer/liver disease, History of Malignancy?
OTHER SYMPTOMS
IATROGENIC FACTORS
PREVIOUS EPISODES
FAMILY HISTORY

31. MANAGEMENT OF ACUTE GASTROINTESTINAL BLEEDING : PHYSICAL EXAMINATION
RECTAL
GENERAL INSPECTION
Perianal Skin Lesion
Masses
Melaena
Confusion ( Shock, liver failure….)
Neurological Deficit
Anaemic
Bruishing/ Purpura
Cachexic
Dehydrated
Jaundice
Inspection - distension, scar, prominent vein.
Palpation tenderness, mass/ organomegaly
Percussion - shifting dullness, fluid thrill.
Auscultation - hyperactive bowel sound.
CNS
ABDOMEN

32. MANAGEMENT OF ACUTE GASTROINTESTINAL BLEEDING : PHYSICAL SIGN
Clinical shock
Systolic BP < 100mmHg
Pulse rate > 100 bpm
Postural sign: patient place in a upright position
– pulse rate rises 25% or more
- systolic BP alls 20mmHg or more
Sign of liver disease & portal hypertension
Sign of GI disease
Sign of bleeding abnormalities
Bloody / black stools on per rectal examination.
Clinical shock: restlessness, acute hypotension, tachycardia, thready peripheral pulse, pallor, cold clammy skin.
Sign of liver disease & portal hypertension: spider naevi, bruising, palmar erythema, clubbing, jaundice, hepatomegaly, ascites.
Sign of GI disease: lymphadenopathy, Virchow’s node, abdominal tenderness or masses.
Sign of bleeding abnormalities: telangiectasis, purpura, ecchymoses, petichiae, bleeding gums, lymphadenopathy.
Bloody / black stools on per rectal examination.

33. MANAGEMENT OF ACUTE GASTROINTESTINAL BLEEDING
Take blood for haemoglobin, urea, electrolytes, ,liver functions ,blood grouping and crossmatching .
Establish intravenous access - central line if brisk bleed.
Stop drugs, e.g. NSAIDs, warfarin

34. MANAGEMENT OF ACUTE GASTROINTESTINAL BLEEDING : INVESTIGATIONS
BASELINE INVESTIGATION
Full Blood Count- Hb, Platelet
PCV*
Coagulation Profile
Liver Function tests
Serum urea and electrolytes
Blood urea nitrogen
Cross matching of blood.
Serial ECG
- Barium meal / Double- contrast barium meal
Ultrasound
CT scan
coagulation profile – primary or secondary clotting defects
RBC morphology – hypochomic, microcytic anemia, chronic blood loss
IMAGING

35. MANAGEMENT OF ACUTE GASTROINTESTINAL BLEEDING
Oxygen therapy for shocked patients.
Urgent endoscopy in shocked patients/liver disease.
Continue to monitor pulse and BP.
Re-endoscope for continued bleeding/hypovolaemia.
Surgery if bleeding persists.

36. MANAGEMENT OF ACUTE GASTROINTESTINAL BLEEDING
Urgent resuscitation is required in patients with large bleeds and the clinical signs of shock.
Oxygen should be given by face mask and the patient should be kept by mouth until endoscopy has been performed.
The major principle is to rapidly restore the blood volume to normal. This can be best achieved by transfusion of whole blood via one or more large-bore intravenous cannulae; physiological saline is given until the blood becomes available .
The rate of blood transfusion must be monitored carefully to avoid overtransfusion and consequent heart failure.
The pulse rate and venous pressure are the best guides to transfusion rates.

37. RESUSCITATION airway and oxygen
Insert 2 large-bore (14-16G) IV cannulate take blood
IV colloid - crossmatched.
haemodynamically stable.
Correct clotting abnormalities
Monitor
Insert urinary catheter and monitor hourly urine output if shocked.
Consider a CVP line to monitor CVP and guide fluid replacement.
Organize a ECG, and check arterial blood gases in high-risk patient.
Arrange an urgent endoscopy.
Notify surgeon of all severe bleeds on admision.
Protect airway and give high-flow oxygen
Insert 2 large-bore (14-16G) IV cannulate take blood for FBC, U&E, LFT, clotting, cross-match 4-6 units (1 unit per g/dL < 14g/dL)
Give IV colloid while waiting for blood to be crossmatched. In a dire emergency, give group O Rh-ve blood.
Transfuse until haemodynamically stable.
Correct clotting abnormalities (vit K, FFP, platelet)
Monitor pulse, BP, and CVP at least hourly until stable.
Insert urinary catheter and monitor hourly urine output if shocked.
Consider a CVP line to monitor CVP and guide fluid replacement.
Organize a CXR, ECG, and check arterial blood gases in high-risk patient.
Arrange an urgent endoscopy.
Notify surgeon of all severe bleeds on admision.

38. MANAGEMENT OF ACUTE GASTROINTESTINAL BLEEDING
Endoscopy
should be performed within 24 hours in most patients. Early endoscopy helps to make a diagnosis and to make decisions regarding discharge from hospital, particularly in patients with minor bleeds and under 60 years of age.
Urgent endoscopy (i.e. after resuscitation) should be performed in patients with shock, suspected liver disease or with continued bleeding.
Endoscopy can detect the cause of the haemorrhage in 80% or more of cases. In patients with a peptic ulcer, if the stigmata of a recent bleed are seen (i.e. a spurting artery, active oozing, fresh or organized blood clot or black spots) the patient is more likely to re-bleed.

39. MANAGEMENT OF ACUTE GASTROINTESTINAL BLEEDING : ENDOSCOPY
Most important component of investigation
90% accuracy In diagnosis if done with in 24 hours

40. MANAGEMENT OF ACUTE GASTROINTESTINAL BLEEDING : ENDOSCOPY

41. MANAGEMENT OF ACUTE GASTROINTESTINAL BLEEDING
all bleeding ulcers should be either injected with epinephrine (adrenaline), the vessel coagulated either with a heater probe or with laser therapy or metallic clips applied. Epinephrine injection -reduces or stops bleeding via a mechanism of vasoconstriction and tamponade
These methods reduce the incidence of re-bleeding, although they do not significantly improve mortality as re-bleeding still occurs in 20% within 72 hours.
Intravenous omeprazole 80 mg followed by infusion 8 mg/h for 72 hours should be given to all patients in this group, as it reduces re-bleeding rates and the need for surgery.

42. MANAGEMENT OF ACUTE GASTROINTESTINAL BLEEDING : DRUG THERAPY
Antacid – aluminium/Mg hydroxide, Mg Trisiclate
Mucosal protective agents – sucralfate
H2 receptor antagonist – cimetidine & ranitidine
Proton pump inhibitor – omeprazole & lansoprazole
Somatostatin (which reduces the splanchnic blood flow as well as acid secretion) can be given as an infusion if the bleeding is difficult to stop
There is little evidence that H2-receptor antagonists or proton-pump inhibitors (PPIs) affect the mortality rate of GI haemorrhage, but PPIs are usually given to all patients with ulcers because of their longer-term benefits.

43. MANAGEMENT OF ACUTE GASTROINTESTINAL BLEEDING BLOOD TRANFUSION
INDICATION OF BLOOD TRANSFUSION
BLOOD TEST
Haemoglobin - May be normal during the acute stages until haemodilution occurs
Urea and electrolytes - Elevated blood urea suggests severe bleeding
Cross match for transfusion - Two units of blood are sufficient unless bleeding is extreme.
If the transfusion is not needed urgently, group the blood and save the serum
LFT and coagulation profile
1.Systolic BP < 110 mmHg
2.Postural hypotension
3.Pulse > 110/min
4.Haemoglobin <8g/dl
5.Angina or cardiovascular disease with a Haemoglobin <10g/dl