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    Approach To Patient With GI Bleed

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    Zaidatul Atiqah Mustafa
    This document provides guidance on evaluating and managing patients presenting with gastrointestinal bleeding. It outlines the relevant history to obtain, physical exam findings to look for, differential diagnoses, and investigations. Important considerations in the history include the location and characteristics of bleeding, risk factors, medications, and social history. The physical exam focuses on vital signs, signs of blood loss, abdominal exam, and rectal exam. Initial investigations include complete blood count, liver and renal tests, and ECG. Treatment involves fluid resuscitation, pharmacotherapy with PPIs and octreotide, endoscopic intervention for diagnosis and treatment, angiographic embolization if endoscopy fails, and surgery as a last resort.

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    Approach To Patient With GI Bleed

    Uploaded by

    Zaidatul Atiqah Mustafa
    249 views22 pages
    This document provides guidance on evaluating and managing patients presenting with gastrointestinal bleeding. It outlines the relevant history to obtain, physical exam findings to look for, differential diagnoses, and investigations. Important considerations in the history include the location and characteristics of bleeding, risk factors, medications, and social history. The physical exam focuses on vital signs, signs of blood loss, abdominal exam, and rectal exam. Initial investigations include complete blood count, liver and renal tests, and ECG. Treatment involves fluid resuscitation, pharmacotherapy with PPIs and octreotide, endoscopic intervention for diagnosis and treatment, angiographic embolization if endoscopy fails, and surgery as a last resort.

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    Approach to Patient With GI Bleed

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    This document provides guidance on evaluating and managing patients presenting with gastrointestinal bleeding. It outlines the relevant history to obtain, physical exam findings to look for, differential diagnoses, and investigations. Important considerations in the history include the location and characteristics of bleeding, risk factors, medications, and social history. The physical exam focuses on vital signs, signs of blood loss, abdominal exam, and rectal exam. Initial investigations include complete blood count, liver and renal tests, and ECG. Treatment involves fluid resuscitation, pharmacotherapy with PPIs and octreotide, endoscopic intervention for diagnosis and treatment, angiographic embolization if endoscopy fails, and surgery as a last resort.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    249 views22 pages

    Approach To Patient With GI Bleed

    Uploaded by

    Zaidatul Atiqah Mustafa
    This document provides guidance on evaluating and managing patients presenting with gastrointestinal bleeding. It outlines the relevant history to obtain, physical exam findings to look for, differential diagnoses, and investigations. Important considerations in the history include the location and characteristics of bleeding, risk factors, medications, and social history. The physical exam focuses on vital signs, signs of blood loss, abdominal exam, and rectal exam. Initial investigations include complete blood count, liver and renal tests, and ECG. Treatment involves fluid resuscitation, pharmacotherapy with PPIs and octreotide, endoscopic intervention for diagnosis and treatment, angiographic embolization if endoscopy fails, and surgery as a last resort.

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    APPROACH TO PATIENT WITH GI BLEED

    Zaidatul Atiqah Mustafa M000810

    Contents
    Relevant history taking of GI bleeding Relevant abdominal examination findings Differential diagnoses Relevant investigations

    Management options

    Upper GI bleeding vs. Lower GI bleeding


    Upper GI bleeding
    Source in the upper GI tract (above the ligament of Treitz)

    Lower GI bleeding
    Source in the small intestine or colon (below the ligament of Treitz)

    Bleeding from GI tract may present in 5 ways


    Hematemesis: vomitus of red blood or "coffee grounds" material Melena: black, tarry, foul-smelling stool Hematochezia: passage of bright red or maroon blood from the rectum Occult GI bleeding: blood in the stool in the absence of overt bleeding

    Symptoms of blood loss or anaemia (e.g. light-headedness or shortness of breath)

    HISTORY

    History Taking
    Upper or lower abdominal pain, and pattern of relief or exacerbation Rectal or anal pain Diaphoresis, light-headedness or syncope Black or grossly bloody stools Brown or grossly bloody emesis

    Bleeding from oral cavity/nasopharynx


    Forceful retching (Mallory-Weiss tear) Painless hematochezia (angiodysplasia, tumor) Painful hematochezia with or without tenesmus (colitis) Anorexia, loss of appetite, rapid weight loss (carcinoma) Any skin telangiectasia Any pigmentation (perioral/diffuse)

    Relevant History
    Past Medical
    History of liver disease Previous history of peptic ulcer disease Known colonic diverticula History of vascular disease (ischemic colitis or bowel infarction)

    Past Surgical Family

    History of surgical intervention Hematemesis Carcinoma History of drug intake NSAIDs, aspirin or anti coagulants

    Drug

    Social
    Alcohol use (varices, mucosal bleeding) Smoking

    PHYSICAL EXAMINATION

    General Examination & Vital Signs


    Built & nourishment Pallor Jaundice Cyanosis

    Clubbing
    Lymphadenopathy (Ca Stomach) Edema

    Hemodynamic instability (Hypotension, tachycardia, postural changes in BP & HR)


    Temperature

    Assessment of Blood Loss


    Clinical Features No systemic signs except in elderly & anemic patient Tachycardia, orthostatic hypotension, syncope, light-headedness, nausea, sweating, thirst Profound shock & possibly death Blood Loss 500ml 1000ml (20% reduction in blood volume)

    2000ml (40% reduction in blood volume)

    Look for
    Any source of bleeding from oral cavity Telangiectasis in skin, conjunctiva, oral cavity Perioral/ diffuse pigmentation Stigmata of CLD

    Abdominal Examination
    Abdominal tenderness
    Unusual in uncomplicated GI bleeding, except occasionally with peptic ulcer disease Severe tenderness suggests GI bleeding associated with bowel ischaemia, obstruction or perforation

    Ascites Any mass lesion Hepatosplenomegaly Bowel sounds


    Hyperactive bowel sounds usual - blood in proximal gut stimulates peristalsis Normal bowel sounds suggest lower GI bleeding Hypoactive bowel sounds - suggest bowel ischaemia, ileus or obstruction

    Examination of Lymph nodes Rectal examination


    blood? melaena? haemorrhoids or fissures?

    Nasogastric aspiration
    frankly bloody aspirate - on-going upper GI bleeding

    coffee grounds - recent upper GI bleeding


    absence of blood or coffee grounds does not exclude upper GI bleed - duodenal bleeding with a closed pylorus will not result in blood or coffee grounds in the stomach. bile - suggests that reflux from the duodenum into the stomach is occurring. In this case the absence of blood or coffee grounds in the aspirate suggests that the bleeding is not from the upper GI tract or stopped many hours earlier

    Investigations
    complete blood count - useful for comparison of serial values. Initial haemoglobin concentration may be normal if taken early, before haemodilution has taken place

    liver function tests


    renal function tests - urea may be raised out of proportion to creatinine clotting

    serial ECGs and cardiac enzymes to exclude myocardial infarction (complicates ~10% of severe GI bleeds)
    Endoscopy Colonoscopy Angiography Radionuclide scanning

    TREATMENT

    Fluid resuscitation
    give blood, FFP and platelets in a 1:1:1 ratio for patients with massive bleeding to prevent dilutional thrombocytopaenia and coagulopathy beware over-transfusion, particularly in patients with variceal bleeding in whom over-transfusion may result in a significant rise in portal pressure

    Pharmacotherapy
    Proton pump inhibitor (IV)
    start even before endoscopy reduces risk of re-bleeding, need for surgery and need for transfusion but not mortality benefit greatest for those at high risk of recurrent bleeding

    Octreotide
    somatostatin analogue inhibits glucagon-induced mesenteric vasodilatation

    Endoscopy
    investigation and intervention of choice variety of endoscopic interventions can be used to stop bleeding complications include:
    GI perforation precipitation of bleeding missed pathology aspiration

    features of peptic ulcer associated with recurrent bleeding:


    spurting or oozing 85-90% risk of rebleeding protuberant vessel 35-55% adherent clot 30-40% flat pigmented spot on ulcer base 5-10%

    Embolization
    angiographic embolization is now treatment of choice for those patients in whom endoscopic treatment is unsuccessful angiography can usually successfully locate the site of bleeding when:
    haemorrhage is severe enough to cause shock transfusion requirement 3 units per 24h active haemorrhage seen endoscopically

    complications include:
    adverse effects of contrast puncture-related complications
    haematoma arterial thrombosis or dissection

    bowel ischaemia (5% of patients)

    Surgery Generally the last resort

    The indications for surgery include the following


    Persistent hemodynamic instability with active bleeding Persistent, recurrent bleeding Transfusion of more than 4 units packed red bloods cells in a 24-hour period, with active or recurrent bleeding

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