Upper And Lower GI Bleeding Flashcards
GI bleeding=
Refers to any bleeding that starts in the GIT
-divided into upper ( esophagus , stomach and duodenum) and lower ( small and large intestine rectum and anus)
Acute vs chronic bleeding signs :
Acute= may include weakness, dizziness , shortness of breath, abdominal pain and cramping and /or diarrhea Chronic= fatigue, lethargy , shortness of breath and can also lead to anemia
Major presenting factors of upper GI bleeding:
*Upper GI bleeding 5 times more common than lower
1) hematemesis - suggests bleeding proximal to the ligament of treitz
2) Melena (90% of cases) from upper GI bleeding 
3) hematochezia -10% of cases are from upper GI bleeding
Severity of bleeding the amount of blood loss:
🔸minor= <10% of intravascular volume —> hemodynamically normal 🔸moderate= 10-20% —> orthostatic hypotension or tachycardia 🔸massive= 20-25%—> shock
Classification of blood loss :
🔸class 1: up to 750ml 🔸class2: 750-1500 🔸class 3: 1500-2000 🔸class4: >2000
Upper GI bleeding diagnosis is mainly related to :
▪️peptic ulcer disease
▪️portal hypertension
We transfuse blood in:
Hemodynamically unstable pts , any signs of poor tissue oxygenation, continued bleeding , persistent low Hct level
* blood test should be done: INR, PTT
🔸O(-) full cross match : is an option for blood transfusion
What is a unit of packed cell?
▪️250ml volume
▪️contains citrate (anticoagulant) and preservative
▪️1unit of packed cells will⬆️ the Hb concentration by approx. 0.5mg/dL
What means massive transfusion?
More than 1 blood volume ( 10units) transfused in 24 hrs
-may dilute platelets and clotting factors
Treatment of dilution coagulopathy?
✅plasma/Fresh frozen plasma 10-15 mL/kg
Usual adults dose 2 units
- 5-8ml /kg dose for warfarin reversal
✅platelets -keep the count greater than 50,000 in the bleeding pt
- 1unit should increase the count by 5,000-10,000
Dose: 6pack
In massive transfusion so parameters may go wrong ?!:
1) hypothermia
2) potassium
3) citrate toxicity ( hypocalcemia )
Upper GI bleeding etiology:
🔸peptic ulcer 50%
🔸gastritis 20%
🔸esophageal varices 10%
The rest : tears , AVM, CA…20%
Things could be done before endoscopy for GI bleeding;
1) NG lavage - 15-20% of UGIB have negative aspirate
2) Drug
3) ABC
4) patient and family consent
Endoscopy:
Diagnostic , prognostic , therapeutic
We can see :
- active vessel bleeding
- non bleeding visible vessel
- adherent clot
- flat spot
- clean base
Peptic ulcer bleeding treatment:
✅PPI’s
-raise gastric PH
-better platelet activity
-pepsinogen requires acid to become activated to pepsin
*high risk pts: elderly, co-morbidity, more severe bleeding
✅somatostatin/octreotide
Surgery in GI 🩸 bleeding:
▪️hemodynamically instability despite vigorous resuscitation (more than3 unit transfusion)
▪️recurrent hemorrhage after initial stabilization
▪️shock associated with recurrent hemorrhage
▪️continued slow bleeding with a transfusion requirement exceeding 3 units per day
Pharmacological treatment :
Drug of choice:
✅Glypressin (terlipressin) - control bleeding and reduce mortality rate
- analouge of vasopressin ( management of low bp)
✅sandostatin
✅pitressin
After endoscopic treatment that failed to achieve hemostasis or rebleeding?
✅balloon tamponade - is an effective way to achieve temporary hemostasis from bleeding esophagogastric varices (s-B tube ) , complications-> aspiration, perforation of esophagus
✅transjugular intrahepatic protosystemic shunt
✅surgery for shunt
Ulcers causes:
🔸idiopathic 🔸drug induced: aspirin NSAIDs drugs 🔸infections : H. Pylori, cytomegalovirus, Herpes simplex virus 🔸stress induced ulcer 🔸zollinger ellison syndrome
Portal hypertension- varices :
▪️esophageal varices ▪️gastric varices ▪️duodenal varices ▪️portal hypertensive gastropathy ▪️cirrhosis
Gastritis causes :
1) NSAIDs and other drugs
2) infections
3) crohn’s disease
4) illness and injuries
Esophagitis causes :
1) peptic
2) infections
3) pill-induced: alendronate, tetracycline, quinidine, potassium chloride , aspirin NSAIDs
Lower GI bleeding :
🔸hematochezia 90%
🔸melena 10%
Etiology of lower GI bleed:
Diverticulitis Angiodysplasia CA Colitis Ischemia Hemorrhoids
Lower GI bleed:
Usually painless
If painful-> mesenteric ischemia
Investigation of the lower GI bleed :
🔸-CBC -BUN -Creatinine -INR -PTT -T/S 🔸plain x ray and abd. CT
Diagnostic procedure for lower Gi bleed :
▪️endoscopy 80% accuracy
▪️angiography
▪️rbcs scans
Major causes of LGIB:
1) diverticulitis
2) Ischemia
3) Anorectal (hemorrhoids, fissures, rectal ulcera)
4) neoplasia (polyps and cancers)
5) angiodysplasia
6) postpolypectomy
7) inflamm. Bowel disease
8) radiation colitis
9) other colitis
10) small bowel/ upper GIB
11) other causes or unknown causes
Major presenting factors and symptoms of LGIB:
- black or tarry stool
- Dark blood mixed with stool
- stool mixed or coated with bright red blood
Diverticular disease :
- results from progressive injury to the artery supplying that segment
- as diverticulum herniates , the penetrating vessel responsible for the wall weakness at that point becomes draped over the dome of the bowel lumen only by mucosa
Colitis :
✅Inflammatory: crohn’s disease ✅infectious : C diff ✅collagenous: lymphocytic ✅colonic ischemia ✅diversion colitis : segment lacks short chain fa’s
Hemorrhoids :
External= arise from the inferior hemorrhoidal plexus and are located beneath the dentate line. Internal= arise from the superior hemorrhoidal cushion. Their three primary locations correspond to the end branches of the middle and superior hemorrhoidal veins
Anal fissures :
-tear in the lining of the anal canal distal to the dentate line , which most commonly occurs in the posterior midline
-most of the fissures are caused by local trauma
- seen in crohn’s disease , leukemia and tuberculosis
Medical therapy:
✅topical nitroglycerine
✅botulinum toxin
✅oral nifedipine/ diltiazem
✅topical diltiazem/ bethanechol
✅surgical intervention ( lateral sphincterotomy/ incontinence)
Angiodysplasia:
-most common vascular anomaly of the GIT
-vascular tumors or angiomas, vascular anomalies associated with congenital or systemic diseases , acquired or sporadic lesions
▪️most prominent feature is the presence of dilated , tortuous submucosal veins
Polyps:
Hyperplastic polyps Adenomatous polyps Tubular polyps Peutz jegher Familiar polyposis
