GI Bleed
GI Bleed
GI Bleed
BLEEDING
Case Review
A 38 year-old man present at emergency department
with tarry stools and feeling of light-
headedness. The patient indicates that over the past
24 hours he ahs had several bowel Movements
containing tarry-colored stools and for the past 12
hours has felt light-headed.His past medical and surgical is
unremarkable.The patient complains of
frequent headaches caused by work-related stress
for which he has been self-medicating with 6-8
tablets of ibuprofen a day for the past 2 weeks.He
consumes 2-3 martinis per day and denies tobacco or illicit drug
use.
HISTORY TAKING
Chief complaint
History of presenting illness
Past medical history & past Surgical history
Family history
Social history
Common manifestation
1. Haematemesis
2. Melena
-colour
-frequency
-onset
-amount
-presence of blood clot
Associated Symptoms
Epigastric pain
Dyspepsia
Anaemic
symptoms(dizziness,pallor,tachycardia,syncope)
Dysphagia
Chest pain
Dyspepsia
Dyspnoea
Fatigue
PHYSICAL EXAMINATION
Upper Gastrointestinal Bleeding
Inspection
• look at whole (cachexia, pallor or jaundice)
• Asymmetry or distension.
• bulge (position, size, shape, changes in its shape, and moves with
respiration or increase with coughing)
• patient’s reaction with coughing or moving.
• dilated surface veins.
Palpation
liver
Spleen
Kidneys
Percussion
• Over any mass that may be missed on palpation.
• fluid thrill – tap on one side, feel the opposite side with other hand.
• shifting dullness – percuss the dullness in two position to see it moves or
changes (ascites)
• succussion splash – held pt at hips and shake the abdomen from side to
side. If positive, distension with a mixture of fluid and gas.
Auscultation
bowel sounds
• N: low-pitched, every few seconds
• absence: peristalsis has ceased
• paralytic ileus: can hear the heart and
• breath sounds, over 30 sec no bowel
• sound.
• systolic vascular bruits
Differential Diagnosis
Classified into 2 :
I. Variceal bleeding
• Peptic Ulcer
• Gastritis
• Malignancy
II. Non-variceal bleeding
UGIB- VARICEAL BLEEDING
Accounts for 7.8% of UGIB cases in Malaysia.
Majority of the patients have background history of liver
cirrhosis, which causes portal HPT that induce formation of
varices when HVPG >10mmHg
Variceal bleeding occurs when HVPG is more than 12mmHg.
Oesophageal variceal bleeding is more common that gastric
variceal bleeding. However, the severity of bleeding and
mortality are higher in gastric variceal bleeding.
2) Diagnosis of cause
3) Treatment of condition
General treatment :
Bed rest and vital signs monitoring
Resuscitation for blood loss (establish iv line and infusion of
crystalloid, colloid or blood)
Treat shock
Cathetherize
Establish diagnosis by endoscopy
Control varices with stengstaken tube or injection
Administer iv proton pump inhibitor
Eradication of h. pylori
Non-surgical intervention
Laser coagulation
Local cautery
Adrenaline injection
Gastric hypothermia for gastric erosions
Sclerotherapy for varices treatment
Octreotide infusion for varices
Embolization for treatment of angiomatous malformations
Surgical interventions
1) indications: -
Massive uncontrolled bleeding
Rebleeding, especially if bleeding vessels or clot has been seen at
endoscopy
More than 4 unit bleed in 24 hours unless the cause is varices
2) Operative :
Peptic ulcer : oversewing the ulcer with proton pump inhibition
and eradication of h pylori if appropriate. Partial gastrectomy
may be necessary
Acute erosions : partial gastrectomy if necessary
Esophageal varices : esophageal transection. Portocaval or distal
splenorenal shunting
Carcinoma: partial or total gastrectomy
Lower Gastrointestinal Bleeding
Definition: Bleeding from a gastrointestinal source
distal to ligament of Treitz
Example of case
67 year-old man
6-hour history of bleeding per rectum,
aminosalicylates (reduce
inflammation),antibiotics, immunosupressants eg
aziothioprine, ileal/colon resection
Colon cancer-Chemotherapy, radiotherapy, colon
resection
Hemorrhoids-banding, stapled hemorrhoidopexy
epinephrine injection)