NOLAN E.

PECHO, MD, FPCS, FPSGS Assistant Professor FEU-Nicanor Reyes Medical Foundation

Outline
Things to consider in patients with GI bleeding
1. 2. 3. 4. 5. 6. 7.

Site of bleeding Clinical History Physical Examination Laboratory Evaluation Diagnostic Procedures Initial Management Treatment

1. Site of Bleeding
Ligament of Treitz anatomic landmark Fold between the duodenum and jejunum

2. Clinical History
Consider a. Initial presentation of bleeding b. Bowel habits c. Associated abdominal pain d. Risk and precipitating factors e. Systemic complaints f. Past history g. Social history

a. Initial presentation of bleeding

Hematemesis Bright red Coffee ground Hematochezia Free blood Blood streaked Formed or watery Melena Black tarry stool Occult blood

b. Bowel Habits
Recent changes in habits Constipation Diarrhea Alternating constipation and diarrhea Change in stool color
Change in consistency

Change in size

c. Associated abdominal pain

Painless bleeding
Epigastric / Periumbilical / Hypogastric

pain Crampy abdominal pain Pain out of proportion to abdominal findings Severe, acute, sudden onset

d. Risk and precipitating factors

Ulcerogenic agent
Severe stress GI instrumentation

Severe vomiting or retching

Blunt or penetrating trauma

e. Systemic complaints
Fever and chills
Weight loss, anorexia, fatigue Dizziness Orthostatic symptoms

f. Past History
Prior episodes of GI bleeding
Prior surgeries Prior GI complaints

Significant medical history

g. Social history
Drug use
Alcohol intake Smoking

Nature of work
Personality

3. Physical Examination
a. General appearance
b. Vital signs c. Skin d. Head and neck e. Abdomen f.

Rectal examination

a. General appearance
Pallor
Diaphoresis Anxious

Cold clammy skin

b. Vital signs
Blood pressure Hypotension Orthostatic changes (systolic bp drop > 20 mm Hg) Pulse Tachycardia Orthostatic changes (pulse increase > 20 bpm) Temperature Respiration

c. Skin
Signs of liver cirrhosis and/or portal hypertension Jaundice Palmar erythema Spider angiomata Gynecomastia Atrophic testicles asterixis Signs of coagulopathy or thrombocytopenia Ecchymosis Petechia

d. Head and neck

Pallor
Dry and pale mucous membranes Oro-pharyngeal bleeding

Collapse neck veins

e. Abdomen
Distension Caput medusa,

jaundice Bowel sounds hyperactive Localization of abdominal tenderness Fluid wave Hepatosplenomegaly Intra-abdominal masses

f. Rectal examination
Stool Melena Hematochezia Occult blood Hemorrhoids
Rectal mass Anal fissure Anal fistula Anal tenderness

4. Laboratory Examination
Blood typing and crossmatching
Complete blood count Platelet count Bleeding / Clotting time Prothrombin time Partial thromboplastin time Renal profile Liver function test Radiologic imaging

5. Diagnostic Procedures
Nasogastric tube

insertion Endoscopy
Esophagogastgroduode

noscopy Colonoscopy

Angiography Bleeding > 0.5 cc/min RBC-Te99 Tagged Scan > 0.1 cc/min bleeding

6. Initial Management
Assess magnitude of bleeding
Stabilize hemodynamic status Two large bore IVs Cystalloids Type specific blood Insert foley catheter Insert nasogastric tube Monitor for continued blood loss

7. Treatment
Non-surgical Sclerotherapy Electrocautery Vasopressin infusion Epinephrine injection Embolization

7. Treatment
Surgery
Indications
a.

b. c. d.

Need to transfuse more than 3 units of blood during a 24 hour period Re-bleeding on maximal medical therapy Occurrence of second significant bleeding Failure of non-surgical management

7. Treatment
Surgery
Upper GI Bleeding
a. b.

c.

d.

Gastric ulcer: Excision, Gastrectomy Esophagogastric ulcer: Ligation of bleeders, Gastrotomy with Pyloroplasty, Gastrectomy Duodenal ulcer: Vagotomy with antrectomy Gastric malignancy: Radical Total or Subtotal Gastrectomy

7. Treatment
Surgery
Lower GI Bleeding
a. b. c.

Segmental colon resection Subtotal colectomy Total colectomy

Summary

Integration.

GI Bleeding
Clinical History and PE Laboratory Exams

Resuscitation
Nasogastric Tube Insertion

Blood from NGT

NO Blood from NGT

Upper GI Bleed

Lower GI Bleed

Upper GI Bleed
Bleeding Esophageal Varices

Endoscopy Surgery
No bleeding source Identified Selective Angiography
Arterial Embolization Bleeding not controlled

Massive

Manage

Gastroduodenal Source

Bleeding controlled

Endoscopic Hemostasis

Medical Management

Bleeding controlled

Surgery

Lower GI Bleed
Ano-rectal Pathology
Treat locally

Digital Rectal Exam Proctoscopy Colonoscopy

Localization of bleed

NO Ano-rectal Pathology

Stable pt Hemorrhage in unstable pt

Unable to localize bleed Brisk bleed Slow bleed

Surgery

Endoscopic/Other Treatment
Re-Bleed

Mesenteric Angiography
Localize active bleeding

RBC-Te99 Tagged Scan

Unable to localize bleeding

Surgery

Outline
Things to consider in patients with GI bleeding
1. 2. 3. 4. 5. 6. 7.

Site of bleeding Clinical History Physical Examination Laboratory Evaluation Diagnostic Procedures Initial Management Treatment

NOLAN E. PECHO, MD, FPCS, FPSGS Assistant Professor FEU-Nicanor Reyes Medical Foundation