acute gastrointestinal bleeding /hematemesis/melena
DESCRIPTION
hematemesis melena gastrointestinal bleedingTRANSCRIPT
الرحيم الرحمن اللله بسم
Gastrointestinal bleeding
Draz MY , Egypt 2008Mb. Bch, D. Sc (Alazhar) .,M. Sc (Cairo) ,M. Sc
(Ain shams).Surgeon ,Internist, Emergency Registrar.
bleeding from gastrointestinal tract
Bleeding from GIT presents in 5 ways:
1 -Hematemesis 2 -Melena
3 -Hematochezia 4 -Occult blood in stools
5 -Chronic blood loss and anemia.
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.
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.
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).
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.
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.(
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)
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.
COMMON CAUSES OF UPPER GIT BLEEDING: PEPTIC ULCER.
GASTRITIS AND EROSIONSVARICES
COMMON CAUSES OF LOWER GIT BLEEDING: CHILDREN:
MECKEL,S DIVERTICULUMPOLYPSULCERATIVE COLITIS
ADULTS: HEMORRHOIDSVASCULAR ECTASIADIVERTICULOSISPOLYPSCARCINOMACONGENITAL ARTERIOVENOUS MALFORMATIONS
SOME VIDEO SCENES OF GIT
DISEASES
EVALUATION OF THE CASEEVALUATION OF THE CASE: :
11 – – IS THERE HEMODYNAMIC CMPROMISEIS THERE HEMODYNAMIC CMPROMISE? ?
22 – – IS THERE ACTIVE BLEEDINGIS THERE ACTIVE BLEEDING??
33 – – IS THIS A HIGH RISK PATIENTIS THIS A HIGH RISK PATIENT? ?
44 – – IS THIS UPPER OR LOWER GIT BLEEDINGIS THIS UPPER OR LOWER GIT BLEEDING??
CALCULATION OF AMOUNT OF BLOOD LOSS AND
RESUSCETAION FLUIDS MARINO ( 1998):
STEP 1
1 – CALCULATION OF BLOOD VOLUME AND BODY FLIUDS:
STEP 22 – CALCULATION
OF VOLUME DEFICIT
USE OF OXYGEN EXTRACTION % TO EVALUATE HYPOVOLAEMIA:
*MEASURE ) SaO2( BY PULSE OXIMETRY.
*Measure O2 SATURATION IN VENOUS BLOOD GASES
Clinical picture of hypovolaemic shockRapid 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.
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:
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
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
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.
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
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 PATIENTSPLATELETS 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.
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.
Low risk criteria : Low risk criteria : Henneman,2003Henneman,2003..
11 – – No co morbid diseasesNo co morbid diseases . .22 – – Normal vital signsNormal vital signs..
33 – – Normal or trace positive stool Normal or trace positive stool guaiacguaiac . .
44 - - Negative gastric aspirateNegative gastric aspirate . .55 – – Normal or near normal HBNormal or near normal HB
%&hematocrit%&hematocrit..66 – – No problem to ask for medical No problem to ask for medical
help on needhelp on need . .77 – – Proper understanding of S. &S. Proper understanding of S. &S.
of bleedingof bleeding..88 – – No high risk factors and easy No high risk factors and easy
medical follow upmedical follow up..
HIGH RISK PATIENTS : HIGH RISK PATIENTS : VELAYO,2003VELAYO,2003..
11 – – AGE > 60 YEARSAGE > 60 YEARS. . 22 – – COMORBID CONDITIONS : COMORBID CONDITIONS : D.M. , D.M. ,
RENAL, CARDIAC, HEPATIC FAILURE, RENAL, CARDIAC, HEPATIC FAILURE, IHD,CANCERIHD,CANCER..
33 – – PERSISTENT HYPOTENSIONPERSISTENT HYPOTENSION . . MORE THAN 4 UNITS OF TRANSFUSION.MORE THAN 4 UNITS OF TRANSFUSION.- -
44 55 – – BLEEDING OR REBLEEDING BLEEDING OR REBLEEDING DURING DURING
HOSPITALISATIONHOSPITALISATION . .66 – – BLOODY NASOGASTRIC ASPIRATEBLOODY NASOGASTRIC ASPIRATE. . 77 – – NEED FOR EMERGENCY SURGERYNEED FOR EMERGENCY SURGERY. . 88 – – HIGH RISK LESIONS : HIGH RISK LESIONS : ESPGHAGIAL ESPGHAGIAL
VARECES ,VARECES ,A-E FISTULAA-E FISTULA,BIGACTIVELY ,BIGACTIVELY BLEEDING ULCERS IN POSTERIOR PULP BLEEDING ULCERS IN POSTERIOR PULP
OF DUODINUMOF DUODINUM..
Band ligationBand ligation
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