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
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

May show angiodysplastic lesions even once bleeding

has ceased
Radionuclide scanning
Uses technetium-99m labeled red blood cells
Management
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
If source of colonic bleeding unclear perform a subtotal
colectomy and end-ileostomy