G.I. Bleeding,Presented by: Ahmed T. Al-Suwaidi Mohamed S. Al-Hoqani,G.I. Bleeding Case,50 yrs, Pakistani, male C/O: Bleeding/rectum & Abd. pain Painless bleeding, 1 yr excess bleeding, 1 month Black, 4-5 times/day, little quant. Abd. pain Vomiting, 1 week,G.I. Bleeding Case,M.H: * no peptic ulcer disease * no medications (NSAIDs) * no urinary symptoms * not known DM, HPTN, IHD * weight loss,G.I. Bleeding Case,O/E: * Afebrile * no pallor * not dyspneaic * no lymphoadenopathies * no S.C.L.N,G.I. Bleeding Case,Vital Signs: * Pulse: 78 bts/min * BP: 130/80 * RR: 18 br/min Heart: NAD Lung: NAD,G.I. Bleeding Case,Abd.: * not distended * no epigast. tenderness * tender, firm, partly mobile mass at Rt lumbar region. * spleen not palpable * Lt lobe liver palpable, mildly tender * bowel sounds present,G.I. Bleeding Case,PR: * no enlarged piles * no active bleeding * no palpable mass * no blood on finger ECG, CBC, Sr Amylase, Bleeding profile, Abd X-ray, fecal loading ascending colon,G.I. Bleeding Case,Lab Results: * Hb: 14.1 g/dl * Plt: 252 * 103 * Hypochromic, microcytic * PT: 17.3 sec * aPTT: 35.4 sec * Sr Amy: 129 U/l 106 U/l * Na+: 140 mmol/l * K+: 4.1 mmol/l * BUN: 17 mg/dl,G.I. Bleeding,Acute Vs Chronic Acute Upper G.I.Bleeding: Acute Lower G.I.Bleeding:,Acute Upper G.I. Bleeding,Haematemesis Melaena Site & Time,Acute U.G.I. Bleeding, Aetiology: 1. Drugs (Aspirin & NSAIDs) 2. Alcohol 3.Chronic peptic ulceration (50% of GI hemorrhage) 4.Others: reflux esophagitis, varices, gastric carcinoma, acute gastric ulcers & erosions.,Acute U.G.I. Bleeding, Clinical approach: 1. recent (24 hrs), then hospitalized. 2. if small amount, no immediate Tx, because CVS can compensate 3. 85% stop bleeding during 48 hrs 4. history helps in diagnosing the cause of the hemorrhage, eg: long history of indigestion, or previous hem. from ulcers.,Acute U.G.I. Bleeding, Clinical approach: 5. factors include: age (60 +) amount of bld lost continuing visible bld loss. signs of chronic liver disease classical clinical features of shock,Acute U.G.I. Bleeding, Clinical approach: 6. liver disease severe, recurrent bleeding (if from varices) 7. splenomegaly portal hypertension,Acute U.G.I. Bleeding, Immediate management: * Emergency management: History + exam. Monitor: pulse & BP /30 min Bld sample: haemoglobin, urea, electrolytes, grouping & cross-matching I.v. access,Acute U.G.I. Bleeding,* Emergency management (cntd): Bld transfusion in case of 1) shock 2) haemoglobin 10 g/dl Urgent endoscopy Surgery when recommended,Acute U.G.I. Bleeding,*Shock management: ABC Airway: endotracheal tube, oropharyngeal airway. *Give oxygen,Acute U.G.I. Bleeding,*Shock management (cntd): Breathing: support respiratory function * Monitor: resp. rate, bld gases, chest radiograph Circulation: expand circulating volume: blood, colloids, crystalloids support CVS function: vasodilators * Monitor: skin color, peripheral temp., urine flow, BP, ECG,Acute U.G.I. Bleeding, General Investigations: 1. Hb, PCV 2. CBC (WBC etc) 3. Bld glucose 4. Platelets, coagulation 5. Urea, creatinine, electrolytes 6. Liver biochem. 7. Acid-base state 8. Imaging: chest & abd. radiography, US, CT,Acute U.G.I. Bleeding,*General management: Blood volume 1. restore volume to normal 2. transfusion Endoscopy 1. shock, suspected liver disease or continued bleeding 2. control varices or ulcers to reduce re-bleeding,Acute U.G.I. Bleeding,*General management: Drug therapy 1. H2 receptor antagonists 2. proton pump inhibitors Factors in reassessment 1. age: 60 + greater mortality 2. recurrent hemorrhage: + mortality 3. re-bleeding: mostly within the 1st 48 hrs 4. surgical procedures in case of severe bleeding.,Lower gastrointestinal haemorrhage,Causes,Diverticular disease,Angiodysplasia,Inflammatory bowel disease,Ischaemic colitis,Infective colitis,Colorectal carcinoma,Investigation,May show angiodysplastic lesions even once bleeding has ceased,Most patients are stable and can be investigated once bleeding has stopped,In the actively bleeding patient consider,Colonoscopy - can be difficult,Selective mesenteric angiography,Requires continued bleeding of 1 ml/minute,Radionuclide scanning Uses technetium-99m labeled red blood cells,Management,If source of colonic bleeding unclear perform a subtotal colectomy and end-ileostomy,Acute bleeding tends to be self limiting,Consider selective mesenteric embolisation if life threatening haemorrhage,If bleeding persists perform endoscopy to exclude upper GI cause,Proceed to laparotomy and consider on-table lavage an panendoscopy,If right-sided angiodysplasia perform a right hemicolectomy,If bleeding diverticular disease perform a sigmoid colectomy,