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Presentation on theme: "GASTROINTESTINAL BLEEDING"— Presentation transcript:

Part 1 Stephanie Faith C. Bautista

2 DEFINITION of Gastrointestinal (GI) Bleeding
refers to any bleeding that starts in the gastrointestinal tract, which extends from the mouth to the anus. can occur from abnormal blood clotting can be caused by vitamin K deficiencies and thrombocytopenia — a drop in platelets (the blood cells that normally initiate the clotting process). The amount of bleeding can range from nearly undetectable to acute, massive, and life threatening.

3 SITE Divided into: Upper GI bleeding: The upper GI tract is located between the mouth and the upper part of the small intestine. Lower GI bleeding: The lower GI tract is located between the upper part of the small intestine and the anus. The lower GI tract includes the small and large bowels.

4 CONSIDERATIONS can range from microscopic bleeding and massive bleeding important to be aware, because it may point to many significant diseases and conditions. Prolonged microscopic bleeding can lead to loss of iron, causing anemia. Acute, massive bleeding can lead to hypovolemic shock, and even death. can occur at any age from birth on. the degree and suspected location of the bleeding determines what tests should be performed to find the cause. once a bleeding site is identified, many therapies are available to stop the bleeding.

5 COMMON CAUSES Some of the possible causes of GI bleeding include:
Anal Fissure Gastric (stomach) ulcer Aorto-enteric fistula Hemorrhoids Arterio-venous malformations (angiodysplasias) Bleeding diverticulum Ischemic bowel Intestinal polyps Cancer of the small intestine Intestinal obstruction (twisted bowel) Celiac sprue Intestinal vasculitis Colon cancer Intussusception Cow's milk allergy Mallory-Weiss tear Crohn’s disease Meckel’s diverticulum Dieulafoy's lesion Nosebleed Duodenal ulcer Portal hypertensive gastropathy Dysentery Radiation injury to the bowel (infectious diarrhea that causes bleeding) Ruptured appendicitis Esophageal varices Stomach cancer Esophagitis Ulcerative colitis

6 Upper Gastrointestinal Bleeding
Upper GI bleeding originates in the first part of the GI tract - the esophagus, stomach, or duodenum (first part of the intestine). Upper GI bleeding is caused by one of the following: Peptic ulcers Gastritis Esophageal varices Mallory-Weiss tears

7 Lower Gastrointestinal Bleeding
Lower GI bleeding originates in the portions of the GI tract farther down the digestive system-the segment of the small intestine farther from the stomach, large intestine, rectum, and anus. Lower GI bleeding is caused by one of the following: Diverticular disease Angiodysplasia Polyps Hemorrhoids Anal fissures Blood in the stool can result from cancers, inflammatory bowel disease, and infectious diarrhea.

8 SYMPTOMS Acute gastrointestinal bleeding first will appear as vomiting of blood, bloody bowel movements, or black, tarry stools. Blood may look like "coffee grounds." Symptoms associated with blood loss can include the following: Fatigue Weakness Shortness of breath Abdominal pain Pale appearance Vomiting of blood usually originates from an upper GI source. Bright red or maroon stool can be from either a lower GI or an upper GI source. Long-term GI bleeding may go unnoticed or may cause fatigue, anemia, black stools, or a positive test for microscopic blood.

Call for an appointment with your doctor if: You have black, tarry stools (this may be a sign of upper GI bleeding) You have blood in your stool You vomit blood or you vomit material that looks like coffee grounds Any presence of blood in the stool or the upper gastrointestinal tract is significant and needs medical investigation. Black or dark stools may represent slow bleeding into the GI tract and should be investigated by a physician. Any significant bleeding into the GI tract, either vomited blood or blood through the rectum, should be evaluated.

10 What to expect at your health care provider's office:
GI bleeding is diagnosed by a doctor GI bleeding can be an emergency condition requiring immediate medical attention. You will also be asked questions about your symptoms, including: When did you first notice symptoms? Did you have black, tarry stools or red blood in the stools? Have you vomited blood? Did you vomit material that looks like coffee grounds? Do you have a history of peptic or duodenal ulcers? Have you ever had symptoms like this before? What other symptoms do you have?

11 EXAMS AND TESTS Tests that may be done include: Abdominal CT scan
Abdominal MRI scan Abdominal x-ray Angiography Bleeding scan (tagged red blood cell scan) Capsule endoscopy (camera pill that is swallowed to look at the small intestine) Colonoscopy Complete blood count (CBC) EGD (Esophagogastroduodenoscopy) Enteroscopy Sigmoidoscopy

Serious gastrointestinal bleeding can destabilize your vital signs. The physician may need to resuscitate you with IV fluids and medicine through a vein Blood transfusions In some cases, you may need surgery. Tube through the mouth into the stomach to drain the stomach contents (gastric lavage) Once the condition is stable, a physical examination, including a detailed abdominal examination, will be performed. FOLLOW-UP Maintain a proper diet and take the medications prescribed to you as your doctor directs. Follow up with your physician on a regular basis to monitor progress, so that your doctor can prevent further progression and complications of your gastrointestinal bleeding.

13 TREATMENT Early endoscopy is recommended, both as a diagnostic and therapeutic approach, as endoscopic treatment can be performed through the endoscope. Patients with esophageal varices typically have coagulopathy, plasma products may have to be administered. Vitals signs are continuously monitored. Endoscopic Therapy depends on the lesion identifies, and can include: Injection of adrenaline or other sclerotherapy Electrocautery Endoscopic clipping or Banding of varices Bleeding lesion are usually removed in order to determine the underlying pathology, and to determine the risk for rebleeding.

14 PHARMACOTHERAPY Includes the following: Proton pump inhibitors (PPIs) - reduce gastric acid production and accelerate healing of certain gastric, duodenal and esophageal sources of hemorrhage. Administered orally / intravenously Octreotide is a somatostatin - shunt blood away from the splanchnic circulation. Found to be a useful in management of both variceal and non-variceal upper GI hemorrhage. Terlipressin is a vasopressin - most commonly used for variceal upper GI hemorrhage. Antibiotics are prescribed in upper GI bleeds - associated with portal hypertension If Helicobacter pylori is identified as a contributant to the source of hemorrhage, then therapy with antibiotics and a PPI is suggested.

15 PREVENTION You can prevent some causes of gastrointestinal bleeding.
Avoid foods and factors, such as alcohol and smoking, that increase gastric secretions. Eat a high-fiber diet to increase the bulk of the stool, which helps prevent diverticulosis and hemorrhoids.

16 Ligament of Treitz

17 Upper gastrointestinal bleeding. Ulcer with a clean base.

18 Upper gastrointestinal bleeding
Ulcer with a black spot Ulcer with an overlying clot

19 Upper gastrointestinal bleeding. Ulcer with a visible vessel.

20 Upper gastrointestinal bleeding. Ulcer with active bleeding

21 Intussusception - x-ray:
Abdominal x-ray showing an intestinal condition in which a loop of bowel has slipped into another section of bowel called INTUSSUSCEPTION. causing swelling, reduced blood flow, obstruction, and tissue damage. Intussusception requires emergency treatment (barium enema or surgery) to prevent intestinal tissue death (necrosis), intestinal perforation, peritonitis, and death.

22 Patient with a twisted bowel (volvulus).
Volvulus - x-ray: Patient with a twisted bowel (volvulus).

23 Normal anatomy: The Gastrointestinal Tract starts at the mouth, which leads to the esophagus, stomach, small intestine, colon, & finally, the rectum and anus. The GI tract is a long, hollow, muscular tube through which food passes & nutrients are absorbed.

24 Indication: Bleeding from the GI tract is a common medical problem.
Patients usually notice either dark red blood or bright red blood in their stool. Ulcers of the stomach and duodenum are common causes of bleeding from the upper GI tract. Bleeding can also occur in the lower GI tract (colon). Diverticular bleeding is a common cause of lower GI bleeding.

25 ENDOSCOPY Procedure, part 1
The first step in the treatment of GI bleeding is to locate the source of the bleeding. Patients who have lost significant amounts of blood are transfused with blood. Next, an endoscopy is used to locate the source of the bleeding. Upper endoscopy is generally performed first, and if no bleeding source is located, then lower endoscopy is performed. During an endoscopy, the patient is usually sedated but awake.

26 Procedure, part 2 In many cases, GI bleeding will stop on its own, with no treatment. In other cases, treatment can be provided with the endoscope, most often in the form of cautery (electrocoagulation) of the site of bleeding.

27 Procedure, part 3: If the bleeding cannot be stopped using the endoscope, surgery may be required. The bleeding segment of intestine or stomach is removed. However, most cases of GI bleeding are managed succesfully with endsocopy.

28 Endoscopic Therapy

29 Endoscopic Therapy

Endoscopic image of a posterior wall duodenal ulcer with a clean base, which is a common cause of upper GI hemorrhage.

31 Gastric ulcer in antrum of stomach with overlying clot
Gastric ulcer in antrum of stomach with overlying clot. Pathology was consistent with gastric lymphoma.

32 Endoscopic image of small gastric ulcer with visible vessel
Same ulcer seen after endoscopic clipping

33 Mallory-Weiss Syndrome
34-year-old male physician who had been ingesting alcoholic beverages, presented with bleeding of the g.i. tract. 43-year-old male who presented with vomiting after ingestion of alcoholic beverages. Also note the signs of reflux esophagitis as well as a blood clot from a gastro esophageal tear.


35 Peptic ulcer

36 Peptic ulcer caused by excess acid in the stomach...



39 Acute Gastritis Chronic Gastritis

40 Esophageal Varices

41 Hematemesis and Melena


43 Hypovolemic Shock


45 Algorithm for Massive Lower Gastro-intestinal (GI) Bleeding

46 Basic Algorithm for the Management of Lower GI Bleed

47 Diverticular disease - a cause of LGIBs

48 Exact site of the bleeding of acute variceal bleeding
Endoscopy is an essential step in the diagnosis and treatment of acute variceal bleeding

49 Endoscopic Variceal Ligation (Banding)
ENDOSCOPIC VARICEAL LIGATION is like rubber-band ligation of hemorrhoids Esophageal mucosa and submucosa containing varices are ensnared, causing subsequent strangulation, sloughing, and eventual fibrosis, resulting in obliteration of the varices. Endoscopic ligation requires placement of an opaque cylinder over the end of the endoscope. This decreases the endoscopic field of view and may allow pooling of blood. Thus, in patients with active bleeding, visualization may be impaired more with ligation than with sclerotherapy. Local complications are less common with ligation compared to sclerotherapy.


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