Gastrointestinal bleeding( type,cause,management) .pptx

This lecture discusses the types and causes of GIT bleeding ,diagnosis and management

1. Gastroen terology Gastrointestinal b leeds

2. 56 - year-old Man with Chronic Knee Pain Mr. Gibb is a 56 year old man with chronic knee pain who presents to the ED with 2 days of coffee ground emesis. He complains of dull epigastric pain and nausea. He takes 800 mg of ibuprofen 3 times a day for knee pain. He drinks 3 to 6 beers a day. His only medications are a baby aspirin, metoprolol, and ibupr ofen. Vitals: T 37.0 ° C (98.6°F), BP 89/55 mm Hg, HR 106/min, SpO 2 98% on room air. Physical exam reveals conjunctival pallor and tenderness to palpation in the epigastric region without rebound or guarding. A nodular liver edge is palpated 5 cm below the costal margin. His hemoglobin is 11 g/dL (prior 1 4 g/dL). Platelets are normal and his INR is 1.2. What is the best next step in management? Test case Concerning GI symptoms NSAID & alcohol use Signs of hypovolemia, anemia, and localizing sym ptoms Hgb low (normal 14 18 g/dL for adult male)

3. What Is the Difference Between an Upper and Lower GI Bleed ? Upper GI bleeds present with melena or hematemesis . A brisk upper GI bleed may sometimes also present with hematochezia . Lower GI bleeds present with hematochezia . © by Lecturio

4. Differential Diagnosis Upper GI bleed Lower GI bleed Gastric or duodenal ulcers Diverticulosis Erosive esophagitis, gastritis, duodenitis Hemorrhoids Esophageal or gastric varices Inflammatory bowel disease Portal hypertensive gastropathy Ischemic colitis Arteriovenous malformations Arteriovenous malformations Mallory Weiss tear Infectious colitis Malignancy Malignancy

5. Best Steps in Initial Management 1 Establish adequate IV access : 2 large bore (1 8 gauge or larger) peripheral IVs or centrally placed large bore catheter ? Shorter length and wider radius is associated with increased flow. Viscosity and Laminar Flow; Law, OpenStaxCollege , https://opentextbc.ca/physicstestbook2/chapter/viscosity and laminar flow poiseuilles law /, CC BY 4.0, no changes

6. Best Steps in Initial Management 1 Establish adequate IV access : 2 large bore (1 8 gauge or larger) peripheral IVs or centrally placed large bore catheter 2 3 Fluid resuscitate ( Transfu se • pRBC transfusion if Hgb < 7 g/dL solution ) ( Hgb < 8 g/ dL for patients with unstable coronary artery disease or active bleeding) • Platelet transfusion if plt < 50,000/µL 4 5 Give medications • PPI • Vasoactive medications (octreotide if variceal bleed) • Reversal agents for anticoagulants if available Consult GI specialist

7. Diagnostic (and Therapeutic) Studies Gold standard Other options • Upper endoscopy • Colonoscopy • Push enteroscopy • Nuclear scintigraphy (tagged RBC scan) • CT angiography • Standard angiography

8. 56 - year-old Man with Chronic Knee Pain Mr. Gibb is a 56 year old man with chronic knee pain who presents to the ED with 2 days of coffee ground emesis. He complains of dull epigastric pain and nausea. He takes 800 mg of ibuprofen 3 times a day for knee pain. He drinks 3 to 6 beers a day. His only medications are a baby aspirin, metoprolol, and ibupr ofen. Vitals: T 37.0 ° C (98.6°F), BP 89/55 mm Hg, HR 106/min, SpO 2 98% on room air. Physical exam reveals conjunctival pallor and tenderness to palpation in the epigastric region without rebound or guarding. A nodular liver edge is palpated 5 cm below the costal margin. His hemoglobin is 11 g/dL (prior 1 4 g/dL). Platelets are normal and his INR is 1.2. What is the best next step in management? Test case Concerning GI symptoms  upper GI bleed NSAID & alcohol use  risk for peptic ulcer disease, gastritis, malignancy Signs of hypovolemia, anemia, and localizing sym ptoms Hgb low (normal 14 18 g/dL for adult male)

9. 56 - year-old Man with Chronic Knee Pain Mr. Gibb is a 56 year old man with chronic knee pain who presents to the ED with 2 days of coffee ground emesis. He complains of dull epigastric pain and nausea. He takes 800 mg of ibuprofen 3 times a day for knee pain. He drinks 3 to 6 beers a day. His only medications are a baby aspirin, metoprolol, and ibupr ofen. Vitals: T 37.0 ° C (98.6°F), BP 89/55 mm Hg, HR 106/min, SpO 2 98% on room air. Physical exam reveals conjunctival pallor and tenderness to palpation in the epigastric region without rebound or guarding. A nodular liver edge is palpated 5 cm below the costal margin. His hemoglobin is 11 g/dL (prior 1 4 g/dL). Platelets are normal and his INR is 1.2. Answer: establishing adequate IV access, aggressive fluid resuscitation, PPI should be started. Test Answer ca se Concerning GI symptoms  upper GI bleed NSAID & alcohol use  risk for peptic ulcer disease, gastritis, malignancy Signs of hypovolemia, anemia, and localizing sym ptoms Hgb low (normal 14 18 g/dL for adult male)

10. Peptic Ulcer Disease Gastrointestinal Pathology

11. Definiti on Peptic Ulcer Disease Mucosal defect in the wall of the stomach or duod enum

12. P athophysiology Infectio ns Drugs (NSAIDs) Alcoh ol/Smoking Hormo nes Isch emia Chronic disease Str ess

13. Infection s: Helicobacter pylori (most common): 80% – 90% duodenal ulcers 70% – 80% gastric ulcers Viruses : Herpes simplex virus (HSV) Cytomegalovirus (CMV)

14. M edications: Non - steroidal anti - inflammatory drugs (NSAIDs; most common) Bisphosphona tes C lopidogrel Corticoste roids Chemother apies Rapamy cin

15. Al cohol: Chronic active gastritis Increased incidence of H. pylori Reduced mucus barrier Smo king: Decreased perfusion Increased acid secretion Increased reactive oxygen species Suppressed angiogenesis

16. Hormona l: Gastrinoma (Zollinger - Ellison sy ndrome) Antral G - cell hyperplasia (gast ritis) Post - sur gical: Antral exclusion Gastric bypass Ischemic: cocaine Decompensated chronic dise ases: Cirrh osis Renal failure Chronic obstructive pulmonary disease (COPD) Prolonged intensive care unit (ICU) stay for any reason Str ess

17. Clinical presentation Asympt omatic 70% of PUD patients Older adults Patients taking NSAIDs Bleeding or perforation may be the 1st clinical manifestation!

18. Sym ptomatic Other symptoms: Nause a/vomiting Early satiety Postprandial fullness/bloating Belching (eructation)

19. Esophagogastroduodenoscopy (EGD) (most accurate diagnostic test) Gastric ulcer: Solitary, discrete mucosal lesions, with punched - out smooth base Benign lesions have smooth, rounded edges (as opposed to irregular edges in malignancy). Typically in lesser curvature Duodenal ulcer: Small breaks in the mucosa, often < 1 cm Noted usually in the 1st part of the duodenum Issa H, et al,Ann Saudi Med. 2010 Jan - Feb, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2850185/figure/F0002/, CC BY 2.0 Moriya M, et al, J Med Case Reports. 201 1 , https://www.ncbi.nlm.nih.gov/pmc/articles/PMC31 41 705/figure/F1 /, CC BY 2.0

20. Tests for H. pylori Non - invasive : Stool antigen assay Urea breath test • Oral radioactive urea oral • Urease produced by H. pylori splits urea and liberates CO 2 detected in breath Serolog y: • IgG remains positive after eradicati on Biopsy (invasive): Biopsy urease test: ammonia from urea detected by pH reagent Hist ology • Curved, flagellated gram - negative rods are seen; silver stains have better sensitivity Bacterial culture and sensitivity

21. Manageme nt Risk factor modification Discontinue NSAIDs Stop smoking, and discontinue intake of alcohol and drugs Bland diet (maybe not so much)

22. Medicatio ns H. pylori eradication: A combination of an antibiotic regimen and proton pump inhibitors (PPIs): • Triple therapy: PPI + clarithromycin + amoxicillin or metronid azole • Bismuth - containing quadruple therapy: PPI + bismuth + tetracycline + metronidazole Surgical treatment: Uncommon because medical therapy is usually very effective