Gastrointestinal Bleeding

Jarrett Lefberg South Pointe Hospital

Incidence 
Upper

GI bleed 100/100,000 Above the ligament of Treitz  Lower GI Bleed 20/100,000 Below the ligament of Treitz  Both are more common in males and elderly.

Causes of Upper GI Bleed 
1)

Peptic ulcer disease - most common cause A) duodenal ulcers 29% will rebleed in 10% of cases within 2424-48h B) gastric ulcers 16% more likely to rebleed C) stomal ulcers <5%

esophagitis. NSAID s 3) Esophageal and gastric varices causes by portal hypertension 4) Mallory-Weiss syndrome longitudinal Mallorymucosal tear in the cardioesophageal region caused by repeated retching . ASA.Causes of Upper GI Bleed    2) Erosive gastritis. duodenitis some causes are ETOH.

Causes of Upper GI Bleed  5) stress ulcers  6) arteriovenous malformation  7) malignancy  8) aortoenteric fistula .

3) Arteriovenous malformations common and seen in people with hypertension and aortic stenosis .Causes of Lower GI Bleeding    1) Hemorrhoids .most common cause 2) Diverticulosis common. and can be massive Caused from an erosion into a penetrating artery from the diverticulum. painless.

Causes of Lower GI Bleeding  4) CA/polyps A/polyps  5) inflammatory bowel disease  6) infectious gastroenteritis  7) Meckel diverticulum .

Any weight loss or changes in bowel habits.Diagnosis         Questions to ask in history Any hematemesis. Any history of iron or bismuth which can simulate melena and beets which can simulate hematochezia. or coffeehematochezia. steroids. Any history of ASA. Any ETOH abuse. NSAID s. . Any history aortic graft. coffee-ground emesis. Note stool guaiac testing will be negative. melena. Any vomiting and retching.

. clammy skin then in shock. and gynecomastia seen in liver disease. Proper abdominal exam and rectal exam. Cool. Petechiae and purpura seen in coagulopathy. jaundice. palmer erythema. Careful ENT exam to rule out causes that can mimic upper GI bleeds.Diagnosis Physical exam       Vital signs may show hypotension and tachycardia. Spider angiomata.

Diagnosis Lab        CBC Electrolytes Glucose BUN/Creatine BUN will be elevated in upper GI bleeds Coagulation studies Liver function studies Type and cross-match cross- .

1ml/min Colonoscopy .is diagnostic and therapeutic and more accurate than bleeding scans and angiography .5-2ml/min .not beneficial unless specific indications Angiography .Diagnosis Diagnostic      ECG Abdominal series .can be diagnostic and therapeutic but requires a brisk bleed at .5Bleeding scans .can only be diagnostic but are more sensitive then angiography and require a bleeding rate of only .

. Also NG tubes will not worsen varice bleeds. Class III + IV hemorrhage replace with crystalloid and blood. Foley catheter for hypotension patients to monitor output. NG tube should be placed and can determine upper GI from lower GI but not 100%.Treatment      LargeLarge-bore intravenous lines with fluid replacement. Class I + II hemorrhage replace with crystalloid.

inhibitor octretide for varices  Balloon tamponade  Surgery  Must get early consultation with gastroenterologist and general surgeon for significant GI bleeds. .Treatment  Proton-pump Proton Endoscopy  Somatostatin.

Peptic Ulcer Disease Jarrett Lefberg South Pointe Hospital .

 White Americans have a 10% prevalence of H.Epidemiology  10% US population >17 years of age have peptic ulcer disease at some time.  Black Americans have a 45% prevalence of H. . pylori by age 35 and 80% by age 75. pylori by age 25.

Peptic ulcer which is a defect beyond muscularis mucosa will develop if there is an imbalance. Note -stress ulcers do not extent through the muscularis mucosa. . Dyspepsia is the imbalance between the protective mucosa and acid/pepsin.Pathophysiology     Prostaglandins produce mucous and bicarbonate ions which protect the tissue in the stomach by being destroyed with hydrochloric acid and pepsin.

Pathophysiology  Two types of peptic ulcers 1) Duodenal ulcers which occur in the first portion of the duodenum. 2) Gastric ulcers which usually occur in the lesser curvature of the stomach. .

pylori will develop ulcers. cytotoxins. H. . proteases and other compounds disturb the gel and increase tissue exposure to acid and pepsin.Causes    H.a spiral. Note only 10-20% of patients who are 10infected with H. pylori is seen in 95% of patients with duodenal ulcers and 80% of gastric ulcers. Its production of urease. pylori . urease producing flagellated bacterium which lives between the mucus gel and mucosa.

  .inhibits bicarbonate ion production and increases gastric emptying.is a gastrin secreting tumor which creates such a high acid level it over rides the protective gel. ZollingerZollinger-Ellison syndrome . Cigarette smoking .Causes  NSAID s .inhibit prostaglandins which in turn increases tissue exposure to acid and pepsin.

.Causes salts  Emotional stress  Type O blood  Prolonged use of corticosteriods  Caffeinated beverages  Bile  Note diet and alcohol are not predisposing factors to the development of peptic ulcers.

Clinical Features     Epigastric pain . aching or burning) is the main complaint. Gastric ulcers usually develop pain shortly after eating. Physical exam of uncomplicated PUD. Duodenal ulcers usually develop pain 2-3 hours 2after eating and awaken patients at night. Pain can be relieved by food.(gnawing. . there may be a finding of epigastric tenderness.

 Endoscopy has the advantage of being able to take a biopsy which is definitely needed for gastric ulcers to rule out malignancy.  Definite .Diagnosis diagnosis can only be made by visualization with an upper GI or endoscopy.

c) stool antigens test can also be used to confirm cure. histologic study.   .  2) noninvasive a) serologic studies which can not be done as a follow up for cure due to antibodies being positive for several years after eradication of infection.Diagnosis Several ways to determine H. or culture can be done. pylori infection 1) invasive a) during endoscopy a rapid urease test. b) urea breath test can be used to confirm cure.

Treatment  Stop any offending agents such as NSAID s. diets with frequent feedings has not been shown to be effective.  Bland .

Treatment  Antacids neutralize gastric acids. digoxin. d) aluminum causes constipation and should not be given with renal failure patients due to accumulation which can cause osteoporosis and encephalopathy. . a) good for acute pain relief and healing ulcers. e) magnesium causes diarrhea. b) poor compliance due frequency of doses. c) inhibit absorption of some drugs such as warfarin. some anticonvulsants and antibiotics.

propranolol.Antagonists inhibit gastric acid secretion a) equally as effective as antacids with better compliance due to decreased frequency of doses. TCA s. c) renal excretion and therefore must adjust doses in patients with renal disease. phenytoin. b) cimetidine inhibits cytochrome p450 system greater than other H2-antagonists which H2will cause an increase in drugs such as warfarin. . diazepam.Treatment  H2H2. etc.

c) lansoprazole does not affect other drug metabolism.Treatment  Proton Pump Inhibitors . b) omeprazole has also been shown to affect the cytochrome p450 system.inhibit gastric acid secretion a) heal ulcers faster then H2-antagonists and H2antacids. d) pantoprazole has been shown to decrease bleeding from peptic ulcers. .

. inhibit pepsin activity. b) Needs an acidic environment to work therefore not beneficial to give antacids c) Causes constipation. and increase prostaglandin production.Treatment  Sulcralfate locally binds to the base of the ulcer and therefore protects it from acid a) Also has been shown to absorb bile acids. dry mouth and inhibits the absorption of many medications.

Treatment  Misoprostol prostaglandin E1 analogue which acts as natural prostaglandin in the body a) Only indicated for prevention of NSAID -induced gastric ulcers in high risk patients. b) contraindicated in pregnant women and women in childbearing age because it causes spontaneous abortion. . c) can cause diarrhea and crampy abdominal pain.

slow hydrogen ion diffusion across mucosal barrier. pylori bactericidal effect. form a barrier protection on ulcers. and H. . increase mucus secretion. a) Used in triple drug combinations for the treatment of H.Treatment  Bismuth compounds decrease pepsin activity. augment prostaglandin synthesis. pylori.

amoxicillin.  Usually done with triple or quadruple treatment regimens.  Some antibiotics in regimens are metronidazole.Treatment H. pylori positive then must be given antibiotics to prevent recurrence of ulcer. tetracycline. clarithromycin.  If .

Complications of PUD  GI bleeding is the most common complication of PUD and the most common cause of upper GI bleeding. .  Please see previous lecture on management of GI Bleeding.

NG tube.patients will develop back pain with no free air on x-ray and may mimic pancreatitis but xlipase will be normal or only slightly elevated. electrolyte corrections. 60-70% will 60demonstrate free air of x-rays. xPosterior perforation .Complications of PUD      Perforation Initially a chemical peritonitis develops which then progresses to a bacterial peritonitis. . Anterior perforation . xIV fluids. No free air on x-rays cannot rule our perforation.patients will have sudden abdominal pain with guarding and rebound. broad spectrum antibiotics and surgery.

succussion splash. NG tube.Complications of PUD      Gastric outlet obstruction Scaring from healed ulcers or edema from active ulcer with development of obstruction. Patients will develop upper abdominal pain with vomiting. weight loss. early satiety. . airIV fluids. electrolyte corrections. dehydration. Abdominal x-ray will show dilated stomach shadow with xlarge air-fluid level. and surgery if needed. vomiting. metabolic alkalosis. Obstruction will cause gastric dilation.

Questions  The most common cause of a lower GI bleed is? A) Diverticulosis B) Cancer C) Hemorrhoids D) AV malformations .

Questions  2) Colonoscopy is diagnostic and therapeutic and is more accurate than bleeding scans and angiography for GI bleeds. T/F . pylori will develop ulcers. T/F  3) Only 40% of patients who are infected with H.

pylori need? A) only a longer coarse of PPI B) addition of antibiotics C) need an inpatient coarse of treatment D) can be treated the same as ulcers that are negative for H.Questions  4) Treatment of ulcers which are positive for H. pylori .

Answers  1) C  2) T  3) F  4) B .

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