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GI Bleeding

NICKLAUS RIVERA
YL8

CASE
70

yo, M

CC:

rectal bleeding

HPI:

Few hours PTC, patient felt rectal urgency


passed blood of unrecalled volume with soft stool

(+)

RLQ abdominal pain 3/10

No

nausea, vomiting, chest pain

Had

3 more episodes in the last 2 hours

GI Bleeding Presentation
Hematemesis
Melena

Hematochezia
Occult

GIB

Symptoms

of blood loss or anemia

Approach
UGIB

vs LGIB

Ligament

of Treitz

BUN
Bowel

sounds

Sources

Upper

GI
Small intestine
Colonic

Upper GI
Sources of Bleeding

Proportion of Patients, %

Ulcers

31-59

Varices

7-20

Mallory-Weiss tears

4-8

Gastroduodenal erosions

2-7

Erosive esophagitis

1-13

Neoplasm

2-7

Vascular ectasias

0-6

No source identified

8-14

Upper GI
Peptic
Most

Ulcers

common cause of UGIB (50%


of cases)

Peptic Ulcers
Features

Dyspepsia
Most

prominent symptom (80%)

Pain

after eating duodenal

Pain

while eating gastric

Peptic Ulcers
Features

Asymptomatic
70%

of ulcers are asymptomatic

Peptic Ulcers
Features

Bleeding
Nausea,
In

hematemesis, melena

rare cases, hematochezia and orthostatic


hypotension

Peptic Ulcers
Features

Gastric
Early

obstruction

satiety, bloating, indigestion, anorexia,


nausea, vomiting, epigastric pain, weight loss

Peptic Ulcers
Features

Perforation
Duodenal
Antral

60%

20%

Gastric

20%

Peptic Ulcers
Features

Penetration
Referred

to lower thoracic or upper lumbar


spine region

Peptic Ulcers
Features

Fistulization
Halitosis,

feculent vomiting, postprandial


diarrhea, dyspepsia, weight loss, abscess

Peptic Ulcers
Features

Associated

symptoms

Gastroesophageal

reflux 46%

Peptic Ulcers
Causes

H.

pylori
NSAIDs
Acid

Mallory-Weiss Tears
Longitudinal

mucosal lacerations in the


distal esophagus and proximal stomach

Mallory-Weiss Tears
Features

History

of retching

Vomiting

Coughing

preceding hematemesis

Mallory-Weiss Tears
Causes

Alcoholism
2

to sudden increased intraabdominal


pressure

Hiatal

hernia

Esophageal Varices
Dilated
Poorer

blood vessels

outcome compared to other


causes of UGIB

Esophageal Varices
Features

Melena
Low

BP

Rapid

HR

Symptoms

of chronic liver disease

Hemorrhagic and Erosive Gastropathy


Endoscopically

visualized subepithelial
hemorrhages and erosions

Mucosal

lesions and thus do not cause


major bleeding

Hemorrhagic and Erosive Gastropathy


Causes

NSAIDs
Alcoholism

Stress

Hemorrhagic and Erosive Gastropathy


Causes

Erosive

duodenitis

Neoplasms

Aortoenteric
Vascular

lesions

Dieulafoy's
Prolapse

fistulas

lesion

gastropathy

Hemobilia

and hemosuccus pancreaticus

Sources

Upper

GI
Small intestine
Colonic

Small Intestinal Sources of Bleeding


Uncommon
majority

of cases of obscure GIB

Small Intestinal Sources of Bleeding


Causes

Vascular
Tumor

ectasia

Small Intestinal Sources of Bleeding


Causes

Crohn's

disease

Infection

cyst

Intussusception

Vasculitis
Diverticula

diverticulum

Duplication

Ischemia
Small-bowel

Meckel's

varices

NSAIDs

Small Intestinal Sources of Bleeding


Causes

By

age group

Children

Meckels diverticulum

<

40-50 y/o small-bowel tumors

>

50-60 y/o vascular ectasia

Sources

Upper

GI
Small intestine
Colonic

Colonic Sources of Bleeding


Causes

Hemorrhoids
Anal

fissures

Colonic Sources of Bleeding


Causes

Diverticula
Vascular

ectasias

proximal

colon of patients > 70 years

Neoplasms
primarily

Colitis

adenocarcinoma

Colonic Sources of Bleeding


Causes

Post-polypectomy

Varices

Solitary

Lymphoid

NSAID-induced

Vasculitis

bleeding

rectal ulcer
syndrome
ulcers or colitis

Trauma

(most
commonly rectal)
nodular
hyperplasia

Aortocolic

fistulas

Colonic Sources of Bleeding


Causes
In

children and adolescents

Inflammatory
Juvenile

bowel disease

polyps

Approach
Measure
Bowel

HR and BP

sounds

Hemoglobin
BUN

Approach
Endoscopy

and
Colonoscopy/Sigmoidoscopy

Barium
Arteriography
Radio

isotope scanning