Syndrome Of Gastrointestinal Bleeding Flashcards
Syndrome of acute and chronic gastrointestinal bleeding
Occurs due to arrosion of vessels or diapedesis of vascular blood through the vessel wall into the lumen of the gastrointestinal tract resulting in clinical and laboratory signs of anemia and hypovolemic shock.
In clinical manifestations of acute or chronic bleeding into the lumen of the gastrointestinal tract
urgent hospitalization in the surgical unit is indicated.
The most common causes of acute and chronic bleeding into the lumen of the gastrointestinal
tract are gastroesophageal reflux disease, varicose esophageal veins, gastric and duodenal ulcer,
Mallory-Weiss syndrome, tumor of the stomach or intestines, bleeding gastritis and hemorrhoids.
Definition of Bleeding into the lumen of the gastrointestinal tract
Characterized by acute or chronic issue of blood in the presence of pathological processes in the esophagus, stomach, small intestine or colon.
Types of bleeding into the lumen of the gastrointestinal tract:
A) Acute bleeding bleeding rate of 5-7% of the circulating blood volume per hour (blood loss of 250 ml or more).
B) Chronic bleeding slow flow of blood into the lumen of the gastrointestinal tract.
Diseases of the abdominal cavity organs, complicated by bleeding (syndrome of gastrointestinal bleeding)
1) Gastroesophageal reflux disease, complicated by bleeding.
2) Bleeding from the esohageal varices
3) Mallory-Weiss syndrome
4) Peptic ulcer, complicated by bleeding
5) Hemorrhagic gastritis
6) Cancer of the stomach, complicated by bleeding
7) Cancer of the bowels, complicated by bleeding
8) Hemorrhoids, complicated by bleeding.
Clinical evidence of acute bleeding:
A) External signs of gastrointestinal bleeding depend on:
a) the rate and volume of blood loss;
b) the nature of the pathologic process that is complicated by bleeding;
c) patient’s age;
d) the presence and nature of associated diseases;
e) volemic violations and hypoxia;
f) signs of hemorrhagic shock.
Clinical manifestations of bleeding into the lumen of the gastrointestinal tract:
A) Complaints:
- general weakness;
- dizziness;
- tachycardia;
- nausea;
- coffee ground vomitus (hematemesis);
- dry mouth;
- the presence of dark liquid stool “melena“, scarlet (arterial) or dark (venous) blood in the stool;
- the presence of red blood at the end of defecation or feces mixed with blood.
B) History of the disease:
- a history of peptic ulcer disease and possible “silent” ulcer;
- episodes of heartburn, drinking of soda, pain at night;
- pain in the epigastrium, which disappears with the appearance of bleeding (Finsterer’s sign);
- signs of portal hypertension;
- excessive intake of alcohol on the day before.
C) Objective manifestation:
- Pale skin;
- Tachycardia, lowering of the blood pressure;
- Moist tongue;
- Abdomen symmetrical, participates in the act of breathing;
- palpation no stress, pain and peritoneal signs;
- percussion hepatic dullness at sloping areas of the abdomen - tympanitis;
- auscultation increasing of peristaltic sounds;
- rectal examination presence of melena or formed black feces on the glove, the discharge from the rectum appears as “raspberry jelly”, or dark red blood.
The main tasks of medical care for gastrointestinal bleeding:
A) Identification of the source of bleeding, bleeding activity and quality of hemostasis:
a) an urgent endoscopic examination of the esophagus, stomach and duodenum:
- the presence of blood in the esophagus, stomach and duodenum;
- the amount of blood and its nature;
- the source of bleeding, its location and size;
- evaluation for signs of active bleeding by Forrest;
b) endoscopic examination of rectum and colon:
- preliminary preparation for the examination of the colon;
- availability of the source of bleeding in the anal canal, rectum or colon;
- evaluation for signs of active bleeding.
B) Assessment of the severity of blood loss and adequate its replenishment:
a) laboratory diagnostics (determination of hemoglobin, erythrocyte count, blood hematocrit,
calculation of circulating blood volume deficiency, the definition of Allgower’s shock index - the
ratio of the pulse / systolic blood pressure).
C) Pathogenic effects on disease complicated with bleeding.
N.B.! It is mandatory to perform the first two tasks in an emergency; the third task can be
postponed to a later time in cases of high surgery and anesthesia risks.
Classification of blood loss in the degree of hypovolemia:
A) Mild degree
B) Moderate degree
C) Severe degree
D) Most severe degree
Differential diagnosis between bleeding from the upper and lower gastrointestinal tract:
A) Bleeding from the upper gastrointestinal tract (esophagus, stomach, duodenum):
a) acute (profuse) bleeding:
- vomiting red blood, possibly with clots;
- vomiting contents with the appearance of “coffee grounds”;
- liquid, formed or black tarry stool (“melena”);
- clinical signs of acute hemorrhage (dizziness, weakness, syncope, a flickering of “flies“ before the eyes, decreased blood pressure, increased heart rate);
- laboratory signs of rapidly increasing anemia (reduced RBC count, Hb, Ht, blood volume);
b) chronic (slow) bleeding:
- clinical signs of anemia (weakness, pale skin and mucous membranes, normal color of stool);
- laboratory signs of chronic (slow) hemorrhage (reduced amount of RBC, Hb, Ht, positive samples for the presence of blood in the stool).
B) Bleeding from the lower GI tract (anal canal, rectum, colon, small intestine), as a rule, is not profuse in character. Bleeding from the anus, rectum and colon:
- clinically: crimson blood in the feces located on the side of the source of bleeding (anal fissure), blood stream which discharge at the end of defecation (hemorrhoids), scarlet or dark blood, mixed with feces (bleeding from the left side of the colon), the discharge of liquid contents with dark color (bleeding from the right side of the colon);
- laboratory signs of chronic (slow) hemorrhage (reduced amount of RBC, Hb, Ht, positive samples for the presence of blood in the stool).
Definition of Gastroesophageal reflux disease complicated with bleeding:
Bleeding from erosive areas in abdominal part of esophagus, which arises due to the presence of gastroesophageal reflux disease that is manifested by episodes of spontaneous regurgitation of gastric contents into the esophagus.
Leading role in the development of bleeding gastroesophageal reflux disease (GERD) play:
A) Effect of acidic gastric or duodenal alkalic content on the esophageal mucosa.
B) Disorder of esophageal and stomach motility, which contributes to the development of pathological (permanent) reflux.
C) Reduced clearance (cleansing) of the esophagus.
D) Reduction of the lower esophageal sphincter tone.
Factors contributing to the development of GERD:
A) Increased intraabdominal pressure (exercise, work in an inclined position).
B) Increase in intragastric pressure (rapid fullness during a meal, overeating, stenosis of the gastric outlet, the adoption of the horizontal position after a meal).
C) Hiatal hernia.
Methods of study of the esophagus in GERD:
A) esophagogastroscopy with biopsy of the esophageal mucosa (gives the opportunity to evaluate the presence of esophagitis, the degree of its severity and possible complications)
B) Upper gastrointestinal contrastenhanced (barium) radiography (reveals regurgitation of gastric contents into the esophagus, esophageal stenosis, the presence of a hiatal hernia).
C) Esophageal pH monitoring (pH drop is registered at 5.2-6.9 to 3.0-4.0).
D) Chromoendoscopy to detect the signs of intestinal metaplasia (Barrett’s esophagus).
- different staining with methylene blue unaltered and damaged with metaplasia mucosal epithelium of the esophagus.
Clinical signs of GERD complicated by bleeding:
A) Complaints:
- general weakness;
- dizziness;
- heartbeat;
- nausea;
- vomitus with “coffee ground” or blood (hematemesis);
- dry mouth;
- dark liquid stool “melena”.
B) Medical history:
- heartburn, which is worsening after meal, during the working in a tilted position, in horizontal position of the patient;
- epigastric or chest pain;
- regurgitation of acidic contents or air;
- regurgitation of gastric contents into the esophagus.
C) Objective manifestation:
- there are no specific objective manifestations of GERD;
- for bleeding - objective signs of acute blood loss (general weakness , dizziness, pallor, tachycardia, increased heart rate, etc.).
Formation of the preliminary diagnosis is based on clinical data (GERD)
Preliminary diagnosis is formed on the basis of the identified patient complaints, medical history, and objective manifestations of disease, confirmed by methods of physical examination.
The methods to confirm or clarify the diagnosis are: esophagogastroscopy, laboratory studies, aimed at identifying the source of bleeding and blood loss.
Diagnostic program in GERD:
A) Laboratory tests:
- CBC (determination of hemoglobin, erythrocyte count, hematocrit);
- calculation of blood circulation volume deficiency, globular volume;
- blood type and Rh factor test.
B) Additional methods of investigations:
- urgent fibrogastroduodenoscopy;
- upper gastrointestinal contrastenhanced (barium) radiography.
Differential diagnosis:
GERD
A) Differentiation from esophageal diseases:
- cancer of the esophagus;
- diverticulosis of the esophagus;
- esophageal varices.
B) Differentiation from diseases of the stomach:
- gastritis;
- stomach ulcer;
- Mallory-Weiss syndrome
Clinical statistical classification of GERD:
ICD10 Diagnosis Code K21. Gastroesophageal reflux
Layout clinical diagnosis: Gastroesophageal reflux disease {IX} {complicated with OX}
Endoscopic evidence of esophagitis:
I1 without esophagitis
I2 with chronic esophagitis {TX stage of severity}
Oesophagitis severity (according endoscopy )
T1 1st stage
(one or more erosions in the mucosa of the esophagus smaller than 5 mm are separated from one another by folds of the unchanged mucosa)
T2 2nd stage
( mucosal defects in the esophagus larger than 5 mm,which do not spread beyond the two folds of mucous membranes)
T3 3rd stage
(mucosal defects in the esophagus , which spread beyond the limits of two folds of mucous membrane , but occupy less than 75 % of the circumference of the esophagus)
T4 4th stage
(mucosal defects in esophagus, which occupy 75% and more of its circumference)
Complications:
O1 acute bleeding {with blood loss of TX stage }
Severity of blood loss:
T1 mild
(blood loss 10-20%, pulse < 90 bpm, BP > 120 mm Hg)
T2 medium
(blood loss 21-30 % , pulse 90-110 bpm, BP 12080 mm Hg)
T3 severe degree
(31-40% blood loss, pulse 110-120 bpm, BP 80-70 mm Hg)
T4 the most severe degree
(blood loss 41-70%, pulse > 120 bpm, BP < 70 mm Hg)
O2 perforation of the esophagus O3 mucosal metaplasia (Barrett’s esophagus) O4 mediastinitis O5 obstruction of the esophagus O6 esophageal ulcer
Organizational principles of medical care to patients with GERD:
A) In clinical manifestations of GERD with complications by bleeding admission in the surgical
unit for treatment.
B) Encomplicated GERD treatment by general practitioner, gastroenterologist, internist.
Medical therapy of GERD complicated by bleeding:
A) Haemostatic therapy.
B) Replenishment of blood circulation volume and correction of anemia.
C) Reduction of acidogenic gastric function (one of the following):
- Proton pump blockers (omeprazole 40 mg, lansoprazole 60 mg, pantoprazole 80 mg, rabeprazole 20 mg, 40 mg esomeprazole once a day).
D) Protection of the mucosa from the corrosive influence of gastric contents:
- antacids (maalox, alyumag, almagel, gelusil, aluminium phosphate gel - 1 tablespoon
40-60 min. after meals and before bedtime).
Medical therapy of GERD , aimed at preventing complications:
A) Lifestyle changes:
- avoid leaning forward and stay in a horizontal position for 30-60 minutes after a meal;
- do not eat 3-4 hours before bedtime;
- sleep with raised head at 20 ° to the bed;
- do not wear constricting belts and clothing, which increases intraabdominal
pressure;
- avoid exercise stress and weight lifting;
- eliminate medication ( calcium antagonists, nitrates, anticholinergics ) and carbonated beverages that contributed to the reflux.
B) Reduction of stomach acid (one of the following):
- proton pump blockers (omeprazole 40 mg, lansoprazole 60 mg, pantoprazole 80 mg, rabeprazole 20 mg, esomeprazole 40 mg QD for 4 weeks) or
- histamine H2 blockers ( 20-40 mg famotidine, BID, ranitidine 150-300 mg BID for 4 weeks).
C) Protection of the mucosa from the corrosive effect of gastric contents:
- antacids (maalox, alyumag, almagel, Gelusil, Aluminium phosphate gel 1 tablespoon 40-60 min. after meals and before bedtime).
D) Drugs normalizing motility of the esophagus and stomach:
- prokinetics (metoclopramide, domperidone / motilium / cisapride / koordinaks / 10 mg TID for 4 weeks).
Examination of disability and rehabilitation of patients with GERD:
A) After achieving hemostasis in GERD, treatment is carried out in outpatient conditions.
B) In case of treatment failure the patient compliance is analyzed or the root cause of GERD is diagnosed.
Definition of Bleeding from esophageal varices
Damage to esophageal varices with bleeding into the lumen of esophagus and stomach.
Causes of esophageal varices:
A) Portal hypertension :
a) intrahepatic causes:
- cirrhosis of the liver;
- schistosomiasis;
- hemochromatosis (hepatic fibrosis, Wilson’s disease);
b) posthepatic causes:
- obstruction of the portal vein;
- compression of the portal vein;
c) prehepatic causes:
- hepatic vein thrombosis (Budd-Chiari syndrome);
- cardiac pathology that causes increased pressure in the inferior vena cava
Clinical manifestations of bleeding esophageal varices:
A) Complaints:
- general weakness;
- dizziness;
- tachycardia;
- nausea;
- vomiting with red blood and clots;
- dry mouth;
- the presence of dark liquid stool “melena“.
B) History of the disease:
- bleeding occurs suddenly, can periodically recur;
- there could be history of hemorrhoidal bleeding;
- history of viral hepatitis, alcoholism.
C) Objective manifestation:
- pale skin;
- tachycardia , lowering blood pressure;
- moist tongue;
- abdomen symmetrical, participates in the act of breathing;
- during the inspection: distension of the subcutaneous veins of the anterior abdominal wall - “caput medusae”, also known as palm tree sign, signs of chronic hypoxia - clubbed fingers, hourglass shaped fingernails, on the skin - vascular spiders and sprockets;
- palpation: increased or decreased nodular liver;
- percussion: ascites;
- auscultation: increasing of peristaltic sounds;
- rectal examination: liquid or black formed stool on the glove, presence of hemorrhoids.
Formation of the preliminary diagnosis is based on clinical data. (bleeding esophageal varices)
Preliminary diagnosis is formed assuming the patient’s complaints, anamnesis and objective
manifestations, confirmed by the data of physical examination.
Confirmation or clarification of the diagnosis: esophagogastroscopy, laboratory studies that allow to specify the source of bleeding and severity of bleeding.
Diagnostic program in patients with bleeding varices esophagus:
A) Clinical signs:
a) complaints;
b) history of the disease;
c) objective data.
B) Laboratory tests:
a) clinical blood analysis (erythrocytes, hemoglobin, hematocrit, globular volume, deficit of circulating blood volume);
b) blood group and Rh factor;
c) urinalysis;
d) blood glucose level.
C) Additional instrumental methods of research:
a) emergency gastroduodenoscopy
b) ultrasonography (to assess the condition of the liver, signs of portal hypertension, the presence of fluid in the abdominal cavity)
Differential diagnosis of bleeding from esophageal varices:
Differentiation with diseases of the stomach:
- erosive gastritis;
- gastric ulcer complicated by bleeding;
- Mallory-Weiss syndrome.
Clinic statistical classification of esophageal varices:
ICD10 Diagnosis Code I.85 Esophageal varices
Layout of clinical diagnosis: Esophageal varices complicated by bleeding {IX} , {TX blood loss }
Bleeding activity:
I1 Forrest 1a (spurting hemorrhage)
I2 Forrest 1b (oozing hemorrhage)
I3 Forrest 2a (visible vessel or thrombosed vessel with risk of bleeding)
I4 Forrest 2b (adherent clot)
I5 Forrest 2c (flat pigmented hematin on ulcer base or small thrombosed vessels)
I6 Forrest 3 (lesions without signs of recent hemorrhage or fibrincovered clean ulcer base)
Severity of blood loss:
T1 mild
(blood loss 10-20%, pulse < 90 bpm, BP > 120 mm Hg
T2 medium
(blood loss 21-30%, pulse 90-110 bpm, BP 120-80 mm Hg
T3 severe degree
(31-40% blood loss, pulse 110-120 bpm, BP 80-70 mm Hg)
T4 the most severe degree
(blood loss 41-70%, pulse > 120 bpm, BP < 70 mm Hg)
Treatment of bleeding esophageal varices:
A) Conservative therapy:
a) Medication:
- haemostatic therapy;
- drugs that reduce portal blood flow (Pituitrin, Sandostatin);
- correction of the blood volume and anemia.
b) Tamponade of esophageal varices with Sengstaken–Blakemore tube:
- veins of the esophagus and gastric cardia compress with tube’s balloons, after its
inflation with air, using syringe;
- every 5-6 hours balloons should be deflated to avoid necrosis;
- total duration of the probe application up to 48 hours.
c) Endoscopic treatment of bleeding esophageal varices:
• Injection sclerotherapy:
- using a fibrogastroendoscope in varicose veins is are injected with sclerotherapy agent.
• Cling varices:
- cling of bleeding varthe sclerotherapy special clip
applicator through flexible endoscope.
B) Surgical treatment:
a) Indications for surgery fail of conservative therapy;
b) Contraindications to surgically treatment:
- hepatic insufficiency (coma);
- alcoholic liver disease;
c) types of operations
- portosystemic shunts,
- suturing of the abdominal esophagus veins.
Examination of disability and rehabilitation of patients:
bleeding esophageal varices
A) After stopping of the bleeding and compensation of anemia and hypovolemia, patients are transferred in the gastroenterological department for the treatment of liver cirrhosis.
B) Patients who have had bleeding from esophageal varices need in assessment of their disability and providing clinical supervision.
C) In the presence of liver cirrhosis as the cause of esophageal varices, liver transplantation is indicated.
