GIT BLEEDING

• Intraluminal loss of blood anywhere from to

oropharynx to anus
• Upper gastrointestinal bleeding(UGIB)-above
ligament of treitz
• Lower gastrointesinal bleeding(LGIB)-below
• Cardinal symptoms
– Haematemesis
– Coffee ground vomitus
– Haematochyzia
– Melena stool
 UGIB ETIOLOGY
• Peptic ulcer disease 50%
• Varices 10-30%
• Gastritis/duodenitis 15%-NSAID,alcohol,Aspirin
• Erosive esophagitis/ulcer10-15% -GERD,radiotherapy,pills
eg biphosphonates
• Mallory weiss-10%
• Vascular
– Dieulafoy vessel-superfuicial ectstatic arter usually in
cardia.sudden onset,massive bleeding
– Arteriovenous malformations,angiodsplasistelangiectasia
– Gastric vascular ectasia(water melon stomach)-tortous dilated
vessels in cirrhosis,
– Artoenteric fistula with aortic aneurysm eroding to duodenum
• Neoplastic-Ca esophagus,stomach
• Oropharyngeal bleeding/bleeding-swallowed
blood
 investigations
• History to identify where (location)and
why(etiology)
• Acute vs chronic-episodes,other GI symptoms e.g
vomitingabdominal
pain,melena,hamatochzia,weight
loss,anorexia,changes in stool caliber and
frequency
• Drugs history-
NSAIDS,aspirin,anticoagulant,alcohol use,risk
factor for and present of liver disease
• Prior GI or aortic symptoms,radiotherapy
 examination
• Vitals-very important.orthostatic changes in
blood pressure and pulse rate.
• Localised abdominal pain eg epigastric in
PUD,peritonitis if generalised,masses,signs of
prior abdominal surgery,
• signs of liver disease e.g spider naevi,caput
medusae,ascites
• Rectal exam-haemorrhoids,tumors,fissure,stool
appearance
 laboratory
• Full Hemogram-
– haematocrit maybe normal in first 24hours of
bleeding. drop 2-3% signify loss of about 500mls
– Low MCV in chronic blood loss
– Low platelets in DIC,leukamia etc
• Coagulation profile-prothombin,APTT abnormal
in anti-coagulants use,liver failure
• Renal function test-elevated urea from
reabsorbed blood and acute kidney injury
• Liver function test- features of liver disease
 Diagnostic tests
• NG tube-can help localise bleeding if blood or
coffee ground aspirate then UGIB.if non blood
aspirate ?LGIB
• Esophagoduodenoscopy-diagnosis and
therapeutic e.g ulcer injection with epinephrine
• LGIB –rule out UGIB via OGD before colonoscopy
• CT or conventional arteriography-localises
bleeding if endoscopy non diagnostic
 treatment
• Varices-
– octreotide or terlipressin iv
– Prophylaxis antibiotics for all cirrhotic patients
– Endoscopic band ligation-90% success
– Balloon Sangsten blackemore
• PUD-if active bleeding/non bleeding visible vessel
use Proton pump inhibitors e.g omeprazole 80mg
stat then 8mg/hr for 72hours
• Gastritis/duodenitis-PPI
 LGIB
• Diverticular haemorrhage 53%
• Neoplastic disease 19%.usually occult
bleeding rarely overt
• Colitis-18%m-infectious
,ischemic,inflammattory bowel disease,post
radiation
• Angiodysplasia-8%
• Anorectal-4% fissure,haemorrhoids,rectal
ulcer
 management
• Assess severity
– Tachycardia 10% volume loss
– Orthostatic 20%
– Shock >30%
• Resuscitation
– 2 large bore branulas
– Fluid replacement using ringers lactate or normal
saline to achieve normal vitals signs
– type and cross match blood
– Transfuse and target haematocrit to 25-30
haemoglobin of 8-10g/dl
• Transfuse platelets to >50K
• Reverse coagulopathy-fresh frozen plasma and
vitamin K IV target normal prothombin time
and APTT
• ICU care-intubation if low mental
status,shock,poor respiratory status
• OPD if all of these: SBP >110, HR <100,hgb
>13/12