Hemetamesis and Hemetochezia(Acute GI Hemorrhage)

Dr. Wu ShuMing

GI Dept. RenJi Hospital

SSMU

Five Ways of GI Bleeding

Hematemesis ： vomitting of blood of altered blood （ coffee grounds ） indicates bleeding proximal to ligament of Treitz

Melena ： Tarry stool. Altered （ black ） blood per rectum （ >60ml ）

Hematochezia ： Bright red or maroon rectal bleeding implies bleeding beyond Lig.T.*

FOB+ and Iron deficiency anemia

Factors affect the way to manifest

Site of bleeding Speed of bleeding Amount of blood loss Flora of enterocolon

.

Differentiating Upper from Low GI Bleeding

Hematochezia usually represents a lower GI source bleeding

Upper GI lesion may bleed so briskly that blood doesn`t remain in bowl long enough to become melena

Bleeding lesion distal to T Lig.may be either M.or hematochezia, but never manifests hematemesis

Common cause of up GI bleeding

Peptic ulcer ；Gastropathy （ alcohol ， aspirin ， NSAI

Ds ， stress ）；GE varices ； Gastric cancer

Less common cause of up GI bleeding

Esophageal or intestinal neoplam

Esophagitis ； Malloy-weiss tear ，Hemoptysis: Swallowed blood

Anticoagulant fibrinoloytic therapy:

Telangiectases ； aneurysm ； vasculitis ； Dieulafoy ulcer ； AV malformation

Connective tissue disease ；Hemabilia （ biliary origin ； Crohn`s disease ； amylo

idosis , hematological diseases

BENIGN GASTRIC ULCER

The classical presentation of gastric ulcer :with weight loss and indigestion made worse by eati

ng, patients more often describe symptoms that would fit

equally well for duodenal ulcer - investigation with barium meal or (preferably) endoscopy is, of course, appropriate for either. Benign ulcers may occur at any site in the stomach, but are commonest on the lesser curve away from acid-secreting epithelium.

Location of benign gastric ulcers in relationship to the distance from the

pylorus. The majority of benign ulcers will be found on the lesser curvature within 3 cm of the angulus.

Duodenum Ulcer

The lesion most commonly affecting the duodenum is ulceration, and it is now known that both antral infection with Helicobacter pylori and the presence of gastric acid are virtual prerequisites for it..

Bleeding From EV

A number of cutaneous features (stigmata) may develop in a patient with cirrhosis, and these are important as they aid clinical recognition of chronic liver disease.

Bleeding Survey: Endoscopic Findings in 214 Patients With Clear Nasogastric AspiratesFINDING NUMBER OF PATIENTS INCIDENCE (%)Duodenaal ulcer 64 29.8Gastric erosions 57 6.5Gastric ulcer 47 21.9Esophagitis 23 10.7Duodenitis 21 9.8Varices 11 5.1Mallory-Weiss tear 10 4.7Neoplasm 8 3.7Stomal ulcer 7 3.3Esophageal ulcer 2 0.9Telangiectasia 0Other 18 8.4

Clinical manifestation of GI Bleeding

Abdominal disconfort

Nausea, Hemadynamic change: reduction in blood v

olume (syncope,light-headedness, sweating,therst) or shock

Laboratory changes: HCT, BUN

Hematemesis with other symptoms

Hematemesis with upper abdominal pain Hematemesis with hepatomegly and spleenomegly Hematemesis with jaundice Hematemesis with Skin & mucosa hemorrhage Hematemesis with upper abdominal mass Others: NSAIDs, Stress, Burning, Brain operation,

Trauma, Vomiting

Lab.Examination in Localization & Diagnosis of GI Bleeding Endoscopy Barium Radiographs Angiography Radionuclide imaging

Approach to the patient with acute upper gastrintesttinal hemorrhage

Acute upper Gastrointestinal Hemorrhage Rapid assessment Monitor hemodynamic status

Fluid resuscitation Gastric lavage(?)

self-limited (80%) bleeding (10-20%) Empiric medical therapy

Urgent endoscopy

recurrent hemorrhage

endoscopy Site not localized Localized

further assessment

enteroscopy, radioisotope s scan, angiography,

exploratory surgery

Definitive therapy Definitive therapy

Endoscopic view of a Mallory-Weiss tear with active bleeding (gastric lumen is at top left). B, Endoscopic view of an organized clot adherent to a Mallory-Weiss tear (gastric lumen is at bottom left ).

Endoscopic view of a Dieulafoy lesion on the lesser curvature of the stomach

Endoscopic view of a vascular ectasia (angiodysplasia) in the duodenum.

Endoscopic view of the gastric antrum with watermelon stomach. The pylorus is at top center. Note the linear distribution pattern of the vascular lesions arranged radially around the pylorus.

Endoscopic views of ulcers with stigmata of recent hemorrhage. A, Duodenal ulcer with a visible vessel. B, Gastric ulcer with a red spot in the center of the crater. C, Duodenal ulcer with a red spot in the center of the crater. D, Purplish clot adherent to a gastric ulcer.

Typical picture of a trivial nonsteroidal anti-inflammatory drug (NSAID)-induced injury to the gastric mucosa. There are multiple small erosions with brown-black staining of the center as a result of local bleeding and pete

chiae.

Typical round gastric ulcer at the angulus (incisura) of the stomach.

ESOPHAGUS STOMACHDUODENUM

JEJUNUM ILEUM COLORECTUM

Esophageal varices AV malformations AngiodysplasiaEsophagitis Angiodysplasia AV malformationsGastritis Ulcers Ulcerative colitisGastric varices Anastomotic DiverticulosisMallory-Weiss tears Simple CancerPeptic ulcer Diverticula PolypsAV malformations Meckel's HemorrhoidsCancer Acquired Anal fissurePolyps Crohn's disease Stomal varicesLeiomyoma Varices PostoperativeSarcoma Ischemic ulcer PostpolypectomyBrunner's adenoma Tuberculosis AnastomoticAngiodysplasia Arteritis TraumaPancreatic rest Blind loop UlcersTrauma Angioma SimplePostoperative Leiomyoma StercoralRetained ulcer Cancer TyphoidResidual gastritis Sarcoma AmebicAnastomotic ulcer Polyps

Uremic ulcer Stomal varices Lymphoid hyperplasia Trauma

Causes of Low GI Bleeding

Differentiating Upper from Low GI Bleeding

Hematochezia usually represents a lower GI source bleeding

Upper GI lesion may bleed so briskly that blood doesn`t remain in bowl long enough to become melena

Bleeding lesion distal to T. Lig. may be either M.or hematochezia, but never manifests hematemesis

Hematochezia with other symptoms

Abdominal pain Fever Tenesmus Systemic Hemorrhage Dermal sign Abdominal mass

Lab. Examination For detecting Low GI Bleeeding

Anoscopy & sigmoidoscopy Barium Edema (BE) Angiography Radionuclide scanning

A, Linear ulcers of Crohn's colitis. B, Mucosa surrounding the ulcers is nodular (cobblestoning).

Shigella colitis. Patchy areas of erythema, spontaneous bleeding, and loss of the normal vascular pattern are evident

Salmonella colitis. Diffuse erythema, spontaneous bleeding, and loss of the vascular pattern with formation of telangiectasi

s are present.

Tuberculosis. Linear ulceration runs circumferentially along the interhaustral septum with tiny satellite ulcerations. This must be distinguished from the longitudinal linear ulcerations s

een in inflammatory bowel disease.

Pseudomembranous (antibiotic-associated) colitis. Numerous elevated yellowish plaques are present on th

e mucosal surface.

Amebiasis. Discrete punched-out ulcers are present i

n the right colon.

Severe acute ulcerative colitis. No vascular pattern is discernible. A severe degree of spontaneous bleeding is present

Large colonic ulcer in a patient with ischemic colitis.

Advantage colon carcinoma

Barium enema appearance of an ischemic stricture with features of carcinoma: asymmetry, mucosal destruction, and shouldering.

Summary of Acute GI Bleeding

Upper GI source bleeding--Hemetemesis Major upper GI bleding-- Hemetemesis & h

emetochezia The more distant from the rectum, the more

likely that melaena occurs The colon lesion--FOB+ or hemetochezia The small bowl lesion-- melena or hemetoc

hezia

The questions should be posed

Prior bleeding episode? Family history of GI diseases Dose the patient have the illness of ulcer?

Cirrhosis?cancer?bleeding disorder? Alcohol? NSAIDs? Any precedes symptoms or signs?