UPPER GASTROINTESTINAL

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

• general light palpation.

• (lightly, systematically, & non tender  tender spot)

• (mild  just pain

Guarding or tightening  severe pain

Sharp exacerbation  rebound tenderness)
 Palpation for masses.

(presence, position, shape, size, surface, edge, consistence, fluid thrill,

resonance, and pulsatility)
 palpation of the normal solid viscera.

 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.

Hepatic venous pressure gradient (HPVG)- difference between the

wedged/occluded hepatic venous pressure and the free hepatic
venous pressure,
UGIB : NON-VARICEAL BLEEDING

1. Peptic Ulcer Disease (PUD)

 The commonest cause of non-variceal upper GI bledding

in Malaysia. Occurs most commonly in duodenal bulb and
stomach.
Risk factors include Helicobacter Pylori , increased in older
aged, NSAIDs, smoking and ingestion of steroid and anti-
coagulants.
2. Gastritis

 Classified into 4 types ( Acute erosive gastritis, chronic

gastritis, reflux gastritis and hemorrhagic gastritis)
 Acute erosive gastritis can cause persistent hemorrhage
result of diffuse loss of mucosal epithelium and small ulcers.
 Associated with used of NSAIDs, steroid and intake of
alcohol
3. Malignancy

 Accounts for 3.6% of UGIB

 Carcinoma and lymphoma of stomach usually bleed at an
advanced ulcerated stage
 Risk factors include smoking, increase in age, Helicobacter
Pylori.
Investigation
Forrest classification of upper GI bleed
-a grading system to describe bleeding
lesions in the upper GIT; it is a useful
method in predicting risk of
rebleeding.
Ia-spurting
b-oozing
IIa-visible vessel
b-adherent clot
c-haematin on ulcer base
III-lesions without active bleeding
Management For UGIB
• The principles :
1) resuscitation
- for management of shock and replacement of blood loss
- haemostases to stop the 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,

maroon-colored stool with blood clots, light-

headed
 Began after urge to defecate and several

voluminous bowel movement

 Not associated with abdominal pain
 Previous borderline HPT with d/c and hernia

repair 2 years ago

Common Causes of Lower GI Bleed
According to Age
Infants/Toddlers Children/Teenagers Adults/Elderly

Volvulus Anal fissures Upper GI bleed

Intusseception Intussuception Angiodysplasia
Meckel diverticulum Meckel diverticulum Diverticulosis
Hirshsprung disease Polyps Neoplasm/polyps

Inflammatory bowel Anorectal disease

disease

Angiodysplasia Mesentric ischaemia

Hemolytic-uremic Inflammatory bowel
syndrome disease
Clinical presentation of acute GI Location
bleed
Hematemesis Proximal to ligament of Treitz
Melena Upper GI tract to right colon
Hematochezia Entire GI tract (massive, rapid
bleeding), usually lower such as
diverticular disease and
hemorrhoids
 Nature of rectal bleeding Possible diagnosis
(a) Painless bleeding
Blood mixed with stool Colon carcinoma
Blood streaked on stool with Rectal carcinoma, colitis
mucous
Blood after defecation Hemorrhoids
Blood alone (massive amount) Diverticular disease
(b) Painful bleeding
-anal fissures,
-if rectal carcinoma spreads below mucocutaneous junction
 Associated symptoms
 Abdominal pain
 Fever
 Loss of appetite and loss of weight
 Anemic symptoms
 Change in bowel habits

Relevant Medical History

-Ulcerative colitis, chrons disease lead to colon cancer
-Family history of malignancy
-Smoking (worsen Chrons), smoking cessation (worsen UC)
Investigation for lower GI bleed
- Protoscope
- Sigmoidoscopy
- Colonoscopy
MANAGEMENT OF LOWER GI
BLEEDING
DEFINITE TREATMENT ACCORDING TO CAUSES.
 Diverticular disease-high fibre, laxative,

antispasmodic, surgical resection

 Crohn’s disease &Ulcerative colitis-5-

aminosalicylates (reduce
inflammation),antibiotics, immunosupressants eg
aziothioprine, ileal/colon resection
 Colon cancer-Chemotherapy, radiotherapy, colon

resection
 Hemorrhoids-banding, stapled hemorrhoidopexy

 Angiodysplasia-endoscopic obliteration (cautery,

epinephrine injection)