hematemesis melena GIT bleeding egypt Draz MY

lecture hematemesis melena GIT bleeding egypt Draz MY

1. ميحرلا نمحرلا هلللا مسب
Gastrointestinal bleeding
Draz MY , Egypt 2008
Mb. Bch, D. Sc (Alazhar) .,M. Sc (Cairo) ,M. Sc
(Ain shams).
Surgeon ,Internist, Emergency Registrar.
[email protected]

2. bleeding from gastrointestinal tract

3. Bleeding from GIT
presents in 5 ways:
1- Hematemesis
2- Melena
3- Hematochezia
4- Occult blood in stools
5- Chronic blood loss and
anemia.

4. 1 – Hematemesis:
* IS vomiting of bright red blood (=
profuse bleeding)
* Or coffee ground material (= altered
blood converted to acid hematin by
gastric HCL).
* It is due to bleeding from above
ligament of treitz.
* Hematemesis may be false due
swallow of blood e.g. from nose, mouth
or pharynx.
* Or true due to bleeding from any
place from esophagus down to
duodenojejunal junction.

5. 2 - Melena:
* the passage of black tarry
loose stools containing digested
blood by the action of digestive
enzymes and bacteria.
*It is due to bleeding from any place
above and including caecum .
*If bleeding is sever, red blood
clots may pass in stools.

6. 3 – Hematochasia: is
passage of red blood per rectum
due to bleeding from the
ascending colon downwards.
4 – Occult blood in stools
detected by laboratory methods.
5- Chronic interrupted
minimal blood loss
presents by signs and symptoms
of anemia.
(Laine, 2001.)

7. Bleeding from GIT may be

A- UPPER GIT BLEEDING:
above the ligament of treitz i.e. the
duodenojejunal junction
------------> hematemesis or melena .
A- LOWER GIT BLEEDING :
below ligament of Treitz leading to
melena and hematochazia but no
hematemesis.

9. True hematemesis(vomiting)
and naso-gastric tube
aspiration is a sign of upper git
bleeding.
BUT MELENA MAY OCCUR IN
UPPER OR LOWER GIT
BLEEDING .
( Marko and Pons ,2003).

10. Causes of upper GIT bleeding
A – General causes: e.g. bleeding diathesis
B – GIT causes:
1 - Esophageal causes:
Esophageal varicies - Esophagitis – tumours -
trauma.
Rupture aortic aneurysm into esophagus.
2 – Gastrodoudinal causes:
Peptic ulcer disease - Gastritis - gastric erosions .
Hiatus hernia - Mallory-Weiss tear.
Tumours - Angiodysplasia.
Hereditary hemorrhagic telangeactasia.
Aorto-enteric fistula.
(Edmundowicz and Zuckerman, 1992)

11. CAUSES OF LOWER GIT BLEEDING:
A – GENERAL CAUSES :
B – LOCAL GIT CAUSES :
1- SMALL INTESTINE : digested blood (melena)
enteritis (T.B. ,TYPHOID) – meckel,s diverticulitis –
crhon,s – tumours – vascular malformations .
2 – COLON : blood mixed with stools
diverticulosis coli – cancer & polypi –intussusception
vascular malformations –– ulcerative colitis.
3 – RECTUM : blood streaked on stools
cancer – polypi –prolapse- proctitis .
4 – ANAL CANAL: fresh blood after defecation
(with pain or not)
piles – fissure - cancer .

14. COMMON CAUSES OF UPPER GIT BLEEDING :
PEPTIC ULCER.
GASTRITIS AND EROSIONS
VARICES
COMMON CAUSES OF LOWER GIT BLEEDING :
CHILDREN:
MECKEL,S DIVERTICULUM
POLYPS
ULCERATIVE COLITIS
ADULTS :
HEMORRHOIDS
VASCULAR ECTASIA
DIVERTICULOSIS
POLYPS
CARCINOMA
CONGENITAL ARTERIOVENOUS MALFORMATIONS

15. SOME VIDEO
SCENES OF GIT
DISEASES

16. EVALUATION OF THE CASE :
1 – IS THERE HEMODYNAMIC CMPROMISE ?
2 – IS THERE ACTIVE BLEEDING?
3 – IS THIS A HIGH RISK PATIENT ?
4 – IS THIS UPPER OR LOWER GIT BLEEDING?

18. CALCULATION OF AMOUNT
OF BLOOD LOSS AND
RESUSCETAION FLUIDS
MARINO ( 1998) :

STEP 1
1 – CALCULATION OF BLOOD
VOLUME AND BODY FLIUDS :

20. STEP 2
2 – CALCULATION
OF VOLUME DEFICIT

23. USE OF OXYGEN EXTRACTION
% TO EVALUATE
HYPOVOLAEMIA :
*MEASURE ( SaO2) BY PULSE
OXIMETRY.
*Measure O2 SATURATION IN
VENOUS BLOOD GASES

26. Clinical picture of hypovolaemic shock
Rapid weak pulse : - 1
*catecholamine release , *mary,s law =tachycardia
with hypotension ,*stimulated cardiac accelerating
center directly by hypoxia and reflexly by carotid
and aortic body chemoreceptor .
2- Hypotension and low pulse pressure :
Decrease in blood volume= decrease in venous
return = decrease in cardiac output = decrease in
ABP.
3 -Subnormal temperature : vasoconstriction and
decreased tissue metabolism .
4 - Increased rate and depth of respiration : Due to
tissue hypoxia and hypotension .

27. Continue,hypovol.shock:
5 -Pale(vasoconstriction of capillaries), cold
(vasoconstriction of arterioles) , clammy
skin(sweat secretion ) = sympathetic over
activity .
6 -Collapsed viens and decreased CVP.
7 -Oliguria : decreased renal blood flow and
ADH release .
8 -Thirst sensation :
9 - Restlessness early with mild to moderate
hypovoleamia and lethargy with
moderate to sever hypovoleamia .
10 – CLINICAL PICTURE OF THE CAUSE :

29. LABORATORY INVESTIGATIONS:
1- BLOOD GROUP AND CROSS MATCHING:
FOR 4 – 8 UNITS ACCOIRDING TO SUSPECTING REBLEEDING
STORE PLASMA FOR ONGOING CROSS MATCHING
TAKE SAMPLE BEFORE COLLOID USE
2-CBC:
HB%, PCV:
CHANGED ONLY IN MASSIVE GIT BLEEDING,
GIVES IDEA ABOUT PREVIOUS FITTNESS OF PATIENS.
WBCS: IF MORE THAN 15000 CONFIRM ABOUT ANY SEPSIS.
PLATELATS COUNT: if less than 50000 consider platelet support.
3-Urea and electrolytes: may be elevated inspite of normal
creatinine due to increased protein absorption AND RETURNS AFTER
VOLUME RESTORATION..
4-Blood glucose: may decrease in liver disease.
5-PT, PTT AND LFTS: CHANGED IN LIVER DISEASE AND IN
PATIENTS TAKING WARFARIN .
6-Monitor Arterial Blood. gases in morbid conditions.
OCCULT BLOOD IN STOOL in minimal bleeding

30. DeterminATION OF SITE OF BLEEDING :
1 – History:
DETERMINE DEGREE OF BLOOD LOSS BUT
NOT SO ACCURATE ,LEVEL OF BLEEDING ,ETIOLOGY OF
BLEEDING,PRECIPITATING FACTOR,PREVIOUS BLEEDING.
2 – Ryle tube and PR:
3 – Upper endoscopy, anorectosegmoidoscopy
and colonoscopy :
4 – RADIOISOTOPIC Scanning by technetium
labelled Rbcs:
FOR SCREENING BEFORE ARTERIOGRAPHY ,IT CAN DETECT
BLEEDING LESS THAN 0.5ML /MIN,A POSITIVE SCAN POINT
TO CANDIDATE OF ARTERIOGRAPHY,NEGATIVE SCAN
INDICATES SHORT TERM GOOD PROGNOSIS .
5 – Selective arteriography :
DETERMINES THE SITE OF BLEEDING NOT THE CAUSE.
USED FOR THERAPEUTIC INTRA-ARTERIAL INJECTION OF VASOPRESSIN
OR ARTERIAL EMBOLISATION BY GELFOAM

31. PRIMARY EVALUATION AND RESSUSCITATION:
IF IMPENDING HYPOVOLEMIC SHOCK:
A airway protection and consider endotracheal tube if
aspiration is suspected .

B BREATHING SUPPORT
C circulatory support :
1- wide pore venous access .
2 – appropriate fluid transfusion according to
patient condition and facilities .
3 – contact with surgeons and emergency
endoscopic team early .
insert retained urinary cath.and calculate urine
hourly.
4- insert ryle tube to detect hematemesis and or
do gastric wash according to cause .
5 – in compromised patients cvp and intensive
care measurements is considered according to
every case .

32. Vasopressin : constrict splanchnic arterioles
0.4 u/min. for one day then 0.2 u /min . for another day.
Better given with nitroglycerin.
Glypressin:long duration ,less side effects
2mg iv every hour till bleeding stops then 1 mg every 6
hours
octreotide : selective splanchnic arteriolar
vasoconstriction
50 microgr iv bolus then 50 microgram every 6 hours for 48
hours

33. CERTAIN PRECAUTIONS
* HB% OF 7-8 gm.WILL GIVE ADEQUATE OXYGENATION
FOR NORMOVOLEMIC BUT IN HYPOVOLEMIC OR
COMPROMISED PATIENT 9-10 gm. IS BETTER
ACHIEVED.
* GIVE PACKED RBS IN CARDIAC RISKY PATIENTS
PLATELETS FOR MASSIVE BLOOD TRANSFUSION
* FFP FOR COAGULATION DISORDERS
* PLATELET CONCENTRATE FOR
THROMBOCYTOPENIA less than 50,000.
* BLOOD GROUP O NEGATIVE EVEN WITHOUT CROSS
MATCHING FOTR LIFE THREATENING CONDITIONS .
* CALCIUM ONE AMPULE FOR EVERY FOUR UNITS.
* CHECK FOR BLOOD HAEMOLYSIS IN UNCONSCIOUS
PATIENTS.

34. Hypovolaemia and shock:
* 500 ml. of blood loss leads to minimal clinical
finding.
* 1000 ml. of blood loss causes positive tilt test.
* 2000 ml. of blood loss presents with features
of shock.
* Rapid loss of 50% of blood volume is usually
fatal.
* Elders cannot accommodate for
hypovolaemia properly.
* Mild hypovolaemia = compensatory
vasoconstriction to maintain blood pressure.
* More hypovolaemia = hypotension, increase
in peripheral vascular resistance, capillary and
venous bed collapse, and all of these leads to
more tissue hypoxia.

36. Low risk criteria :
Henneman,2003.
1 – No co morbid diseases.
2 – Normal vital signs.
3 – Normal or trace positive stool guaiac.
4 - Negative gastric aspirate.
5 – Normal or near normal HB%&hematocrit.
6 – No problem to ask for medical help on need.
7 – Proper understanding of S. &S. of bleeding.
8 – No high risk factors and easy medical follow up.

37. HIGH RISK PATIENTS :
VELAYO,2003.
1 – AGE > 60 YEARS .
2 – COMORBID CONDITIONS : D.M. ,
RENAL, CARDIAC, HEPATIC FAILURE,
IHD,CANCER.
3 – PERSISTENT HYPOTENSION .
MORE THAN 4 UNITS OF TRANSFUSION. -
4
5 – BLEEDING OR REBLEEDING DURING
HOSPITALISATION.
6 – BLOODY NASOGASTRIC ASPIRATE .
7 – NEED FOR EMERGENCY SURGERY .
8 – HIGH RISK LESIONS : ESPGHAGIAL
VARECES ,A-E FISTULA,BIGACTIVELY
BLEEDING ULCERS IN POSTERIOR PULP
OF DUODINUM.

39. Band ligationBand ligation

42. نيملاعلا بر ل دمحلانيملاعلا بر ل دمحلا