Gastrointestinal Bleeding

G MuthukumarasamySpecialist Registrar in General Surgery

Anatomy and Physiology

Oesophagus

Stomach

Duodenum

History taking

• Complaints Haematemesis Malena Haemotochezia Pain Light-headedness, syncope, dyspnoea, altered mental status (blood loss symptoms) occult blood loss (anaemia)

Malena and Coffee ground vomiting

Clinical Indicator Probability of Upper GI Source

Probability of Lower GI Source

Hematemesis Almost certain Rare

Melena Probable Possible

Hematochezia Possible Probable

Blood-streaked stool Rare Almost certain

Occult blood in stool Possible Possible

Contd.,

• H/o Drug intake – Aspirin, Anticoagulants (warfarin), NSAIDS, Clopidogrel, steroids

• H/o Alcohol intake, smoking• H/o Weight loss

Past History :Chronic liver disease, peptic ulcer, bleedingDisorders

Examination

• General ExaminationMental statusEyes – Pallor, JaundiceLiver disease – caput medusae, spider angiomas,

ascites, palmar erythema, flapBleeding disorders – Petechia, echymosis

Vital Signs – BP, HR, SaO2, RR, T⁰, CRF Urine output

Jaundice and Anaemia

Liver disease

Petechiae/Echymosis

Examination – contd.,

• Abdominal Inspection – Shape, symmetry, Dilated Veins, signs

of liver failure Palpation – tenderness, Splenomegaly, hepatomegaly Percussion – Shifting dullness, Fluid thrill Auscultation – BS, Bruit Rectal Examination – Fresh blood, MalenaCVS, RS, Neurological Examination

Investigation

• FBC, Coagulation profile, U&ES, LFT, CRP, Calcium• Type and Crossmatch Blood• ECG• CXR• OGD• Angiogram CT or Catheter• Nasogastric lavage• USS/CT (to assess liver disease)• Tc-99m-labeled erythrocyte scans (rarely)

Management

• RESUSCITATION – ABCDE• Fluid and BLOOD Replacement• Medical Management - PPIs, Vasoactive agents,

B-blocker, ISMN (to prevent re-bleeding)• Endoscopic management – Adrenaline,

coagulation, banding, clipping• Interventional Angiography – coiling, TIPS• Surgical Management

Haemorrhagic ShockEstimated Fluid and Blood Losses in Shock

Class 1 Class 2 Class 3 Class 4

Blood Loss, mL

Up to 750 750-1500 1500-2000 >2000

Blood Loss,% blood volume

Up to 15% 15-30% 30-40% >40%

Pulse Rate, bpm

<100 >100 >120 >140

Blood Pressure

Normal Normal Decreased Decreased

Respiratory Rate

Normal or Increased

Decreased Decreased Decreased

Urine Output, mL/ h

14-20 20-30 30-40 >35

CNS/ Mental Status

Slightly anxious

Mildly anxious

Anxious, confused

Confused, lethargic

Fluid Replacement, 3-for-1 rule

Crystalloid Crystalloid Crystalloid and blood

Crystalloid and blood

UpperGI Bleeding

Non variceal Upper GI bleeding 90% Variceal bleeding 10%

Causes

Esophageal Varices Bleeding esophageal varices

Oesophageal varices

Oesophagitis

Angiodysplasia

Gastric varices Mallory Weiss Tear Esophagitis

Other causes

Glasgow-Blatchford Score

Scores of 6 or more were associated with a greater than 50% risk of needing an intervention

Variceal bleeding

Sengstaken-Blakemore tube

Child Pugh classification

Further reading/References

• Clinical Anatomy: Applied Anatomy for Students and Junior Doctors by Prof H Ellis

• Review Of Medical Physiology by W F Ganong• Guidelines - http://guidance.nice.org.uk/CG141 - http://www.sign.ac.uk/guidelines/fulltext/105

Any questions ???

If you need e-copy of the presentation Email : g.muthukumarasamy@nhs.net