INTRODUCTION

• Gastrointestinal bleeding
describe every form of
haemorrhage in the GIT,
from the pharynx to the
rectum.

• Can be divided into 2

clinical syndromes:-
LIGAMENT OF TREITZ
- upper GI bleed
(pharynx to ligament of
Treitz)
- lower GI bleed
(ligament of Treitz to
rectum)
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CLINICAL FEATURES

• Haematemesis : vomiting of blood whether

fresh and red or digested and black.
• Melaena : passage of loose, black tarry
stools with a characteristic foul smell.
• Coffee ground vomiting : blood clot in the
vomitus.
• Hematochezia : passage of bright red blood
per rectum (if the haemorrhage is severe).
CLINICAL FEATURES
• Haematemesis without malaena is
generally due to lesions proximal to the
ligament of Treitz, since blood entering
the GIT below the duodenum rarely enters
the stomach.

• Malaena without haematemesis is usually

due to lesions distal to the pylorus

• Approximately 60mL of blood is required

to produced a single black stool.
ETIOLOGY
LOCAL

Stomach
Oesophagus -Gastric ulcer GENERAL
-Oesophageal varices -Erosive gastritis -Haemophilia
-Oesophageal CA -Gastric CA -Leukemia
-Mallory-Weiss syndrome -Thrombocytopenia
-Anti-coagulant therapy

Duodenum
-Duodenal ulcer
-Duodenitis
OESOPHAGEAL VARICES

• Abnormal dilatation of subepithelial and

submucosal veins due to increased venous
pressure from portal hypertension (collateral
exist between portal system and azygous
vein via lower oesophageal venous plexus).

• Most commonly : lower esophagus.

Esophageal varices: a
view of the everted
esophagus and
gastroesophageal
junction, showing
dilated submucosal
veins (varices).
SENGSTAKEN TUBE
 (Deflate
every 4
hours for
15
minutes )
• Mallory-Weiss syndrome refers to bleeding from tears (a Mallory-Weiss
tear) in the mucosa at the junction of the stomach and esophagus,
usually caused by severe retching, coughing, or vomiting.
• Mallory-Weiss tears account for 5% to 10% of cases of upper GI
bleeding.
 MALLORY-WEISS TEAR:
MANAGEMENT
- Bleeding from MWTs stops
spontaneously in 80-90% of patients
- Endoscopic band ligation (use of elastic bands )
- Endoscopic hemoclipping (a metallic mechanical
device used in endoscopy in order to close two
mucosal surfaces without the need for surgery )
Endoscopic band ligation
Endoscopic hemoclipping

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ESOPHAGEAL CANCER

• 8th most common cancer seen throughout

the world.
• 40% occur in the middle 3rd of the
oesophagus and are squamous
carcinomas.
• adenoCA (45%) occur in the lower 3rd of
the oesophagus and at the cardia.
CLINICAL FEATURES

1) Dysphagia
2) Odynophagia : retrosternal pain on
swallowing.
3) Regurgitation
4) Weight loss
5) Anorexia
6) Anemia
PEPTIC ULCER
• gastric ulcer & duodenal ulcer
• Caused by imbalance between
secretion of acid and pepsin,
and mucosal defence
mechanism.
AETIOLOGY
-Helicobacter pylori
SIGNS & SYMPTOMS
infection
-NSAIDs - epigastric pain
-others: stress, - haematemesis
smoking,alcohol, steroid - Melaena
- heartburn
PEPTIC ULCER
Feature Gastric ulcer Duodenal ulcer

Onset Soon after eating 2-3 hours after

eating
Relieving factor vomiting Eating

Precipitating eating Missing a meal,

factor anxiety, stress

Duration of A few weeks A month or two

attack
20/81
LOWER GI BLEED: ETIOLOGY
SMALL INTESTINE COLON
Crohn’s disease Carcinoma of colon

RECTUM ANUS
Rectal carcinoma Haemorrhoids
Anal carcinoma
 Crohn's disease
• Crohn's disease (also spelled Crohn
disease) is a chronic inflammatory disease
of the intestines. It primarily causes
ulcerations (breaks in the lining) of the
small and large intestines
• The cause of Crohn's disease is unknown.
Some scientists suspect that infection by
certain bacteria, such as strains of
mycobacterium
Sign and symptom

• abdominal pain, diarrhea, and weight

loss. Less common symptoms include poor
appetite, fever, night sweats, rectal pain,
and occasionally rectal bleeding.
Treatment
• There is no medication that can cure Crohn's
disease. Patients with Crohn's disease
typically will experience periods of relapse
(worsening of inflammation) followed by
periods of remission (lessening of
inflammation) lasting months to years.
• Medications for treating Crohn's disease
include anti-inflammatory agents
and corticosteroids, topical antibiotics, and
immuno-modulators.
 ADENOCARCINOMA OF COLON &
RECTUM
• Rare < 50 years old,
Common > 60 years old
• Common site- sigmoid colon,
rectum
• Clinical features:
-altered bowel habit & large
bowel obstruction
-rectal bleeding
-iron deficiency anaemia
-tenesmus
-perforation
-anorexia & weight loss
HAEMORRHOIDS
• M>F
• Female- late pregnancy, puerperium
• Supine lithotomy position- 3 ,7, 11
o’clock positions

• Classification:
1st degree : never prolapse
2nd degree: prolapse during
defaecation but
return spontaneously
3rd degree : remain prolapse but
can be reduced digitally
4th degree : long-standing
prolapse cannot be
reduced
HAEMORRHOIDS: SIGNS &
SYMPTOMS
• Rectal bleeding
• Perianal irritation & itching
• Mucus leakage
• Mild incontinence of flatus
• Prolapse
• Acute pain
• Skin tags at anal margin
MANAGEMENT OF ACUTE
GASTROINTESTINAL BLEEDING

• Rapid history and examination.

• Monitor the pulse and blood pressure half-
hourly.
MANAGEMENT OF ACUTE GASTROINTESTINAL
BLEEDING :
HISTORY TAKING
- when?
- have u vomited blood/passed black tarry stools?
MODE OF - had both haematemesis & malaena?
ONSET - have u had, bleeding from the nose? Bloody
expectoration? A dental extraction?

- what is the color, the appearance of the vomited

blood?
- red? Dark red? Brown? Black?
CHARACTER - ‘coffee ground appearance?
- bright red & frothy?
- what is the color of the stool? Bright red? Black
tarry?

- have u vomited blood only once/several times?

EXTENT AND - has the bleeding been abrupt/massive?
- have u had >1 black, tarry stool within a 24-h
RATE period?
- for how long have the tarry stools persisted?
MANAGEMENT OF ACUTE GASTROINTESTINAL
BLEEDING :
HISTORY TAKING
- retching & severe nonbloody vomiting?
OTHER - lightheadedness? Nausea? Thirst? Sweating?
SYMPTOMS - faintness when lying down/when standing/syncope?
- following the haemorrhage did you have diarrhea?

IATROGENIC - aspirin? anticoagulant therapy? iron preparation?

FACTORS - age of the patient?
- what is your smoke/alcohol intake?

PREVIOUS - have there been similar episode in the past? When?

Diagnosis?
EPISODES
- were u hospitalized on this occasion? Did u receive a
transfusion?
- are there any other members of your family who
FAMILY
have intestinal disease/bleeding tendency/peptic
HISTORY
ulcer/liver disease, History of Malignancy?
MANAGEMENT OF ACUTE GASTROINTESTINAL
BLEEDING : PHYSICAL EXAMINATION
RECTAL
GENERAL INSPECTION
 Perianal Skin Lesion
 Anaemic  Masses
 Bruishing/ Purpura  Melaena
 Cachexic
 Dehydrated CNS
 Jaundice  Confusion ( Shock, liver
ABDOMEN failure….)
 Inspection - distension, scar,  Neurological Deficit
prominent vein.
 Palpation - tenderness, mass/
organomegaly
 Percussion - shifting dullness,
fluid thrill.
 Auscultation - hyperactive
bowel sound.
MANAGEMENT OF ACUTE GASTROINTESTINAL
BLEEDING : PHYSICAL SIGN

• Clinical shock
• Systolic BP < 100mmHg
• Pulse rate > 100 bpm
• Postural sign: patient place in a upright
position
– pulse rate rises 25% or more
- systolic BP alls 20mmHg or more
• Sign of liver disease & portal hypertension
• Sign of GI disease
• Sign of bleeding abnormalities
• Bloody / black stools on per rectal
examination.
MANAGEMENT OF ACUTE
GASTROINTESTINAL BLEEDING
• Take blood for haemoglobin, urea,
electrolytes, ,liver functions ,blood
grouping and crossmatching .
• Establish intravenous access - central line
if brisk bleed.
• Stop drugs, e.g. NSAIDs, warfarin
MANAGEMENT OF ACUTE GASTROINTESTINAL
BLEEDING : INVESTIGATIONS

BASELINE INVESTIGATION
-Full Blood Count- Hb, Platelet
- PCV*
-Coagulation Profile
-Liver Function tests
-Serum urea and electrolytes
-Blood urea nitrogen
-Cross matching of blood.
-Serial ECG
IMAGING
- Barium meal / Double- contrast barium meal
-Ultrasound
-CT scan
MANAGEMENT OF ACUTE
GASTROINTESTINAL BLEEDING
• Oxygen therapy for shocked patients.
• Urgent endoscopy in shocked
patients/liver disease.
• Continue to monitor pulse and BP.
• Re-endoscope for continued
bleeding/hypovolaemia.
• Surgery if bleeding persists.
MANAGEMENT OF ACUTE
GASTROINTESTINAL BLEEDING
• Urgent resuscitation is required in patients with large
bleeds and the clinical signs of shock.
• Oxygen should be given by face mask and the patient
should be kept by mouth until endoscopy has been
performed.
• The major principle is to rapidly restore the blood volume
to normal. This can be best achieved by transfusion of
whole blood via one or more large-bore intravenous
cannulae; physiological saline is given until the blood
becomes available .
• The rate of blood transfusion must be monitored carefully
to avoid overtransfusion and consequent heart failure.
• The pulse rate and venous pressure are the best guides to
transfusion rates.
RESUSCITATION
• airway and oxygen
• Insert 2 large-bore (14-16G) IV cannulate take blood
• IV colloid - crossmatched.
• haemodynamically stable.
• Correct clotting abnormalities
• Monitor
• Insert urinary catheter and monitor hourly urine
output if shocked.
• Consider a CVP line to monitor CVP and guide fluid
replacement.
• Organize a ECG, and check arterial blood gases in
high-risk patient.
• Arrange an urgent endoscopy.
• Notify surgeon of all severe bleeds on admision.
MANAGEMENT OF ACUTE
GASTROINTESTINAL BLEEDING
Endoscopy
• should be performed within 24 hours in most patients.
Early endoscopy helps to make a diagnosis and to make
decisions regarding discharge from hospital, particularly
in patients with minor bleeds and under 60 years of age.
• Urgent endoscopy (i.e. after resuscitation) should be
performed in patients with shock, suspected liver disease
or with continued bleeding.
• Endoscopy can detect the cause of the haemorrhage in
80% or more of cases. In patients with a peptic ulcer, if
the stigmata of a recent bleed are seen (i.e. a spurting
artery, active oozing, fresh or organized blood clot or
black spots) the patient is more likely to re-bleed.
• Most important component of investigation
• 90% accuracy In diagnosis if done with in
24 hours
MANAGEMENT OF ACUTE GASTROINTESTINAL
BLEEDING : ENDOSCOPY
MANAGEMENT OF ACUTE
GASTROINTESTINAL BLEEDING
• all bleeding ulcers should be either injected with
epinephrine (adrenaline), the vessel coagulated either
with a heater probe or with laser therapy or metallic
clips applied. Epinephrine injection -reduces or stops
bleeding via a mechanism of vasoconstriction and
tamponade
• These methods reduce the incidence of re-bleeding,
although they do not significantly improve mortality as
re-bleeding still occurs in 20% within 72 hours.
• Intravenous omeprazole 80 mg followed by infusion 8
mg/h for 72 hours should be given to all patients in this
group, as it reduces re-bleeding rates and the need for
surgery.
MANAGEMENT OF ACUTE GASTROINTESTINAL
BLEEDING : DRUG THERAPY

• Antacid – aluminium/Mg hydroxide, Mg Trisiclate

• Mucosal protective agents – sucralfate
• H2 receptor antagonist – cimetidine & ranitidine
• Proton pump inhibitor – omeprazole &
lansoprazole
• Somatostatin (which reduces the splanchnic blood
flow as well as acid secretion) can be given as an
infusion if the bleeding is difficult to stop
There is little evidence that H2-receptor
antagonists or proton-pump inhibitors (PPIs) affect
the mortality rate of GI haemorrhage, but PPIs are
usually given to all patients with ulcers because of
their longer-term benefits.
MANAGEMENT OF ACUTE GASTROINTESTINAL
BLEEDING BLOOD TRANFUSION
BLOOD TEST INDICATION OF BLOOD
TRANSFUSION
– Haemoglobin - May be normal during 1.Systolic BP < 110
the acute stages until haemodilution mmHg
occurs
2.Postural
– Urea and electrolytes - Elevated blood hypotension
urea suggests severe bleeding
3.Pulse > 110/min
– Cross match for transfusion - Two
4.Haemoglobin
units of blood are sufficient unless
<8g/dl
bleeding is extreme.
5.Angina or
– If the transfusion is not needed
cardiovascular
urgently, group the blood and save
disease with a
the serum
Haemoglobin
– LFT and coagulation profile <10g/dl