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Bleeding: oropharynx => Anus Acute: rapid loss of blood even shock Chronic: anemia, fatigue Maybe the first symptom of GI disease Self limited or need.

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Presentation on theme: "Bleeding: oropharynx => Anus Acute: rapid loss of blood even shock Chronic: anemia, fatigue Maybe the first symptom of GI disease Self limited or need."— Presentation transcript:

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2 Bleeding: oropharynx => Anus Acute: rapid loss of blood even shock Chronic: anemia, fatigue Maybe the first symptom of GI disease Self limited or need for intervention

3 Hematemesis, coffee-ground Melena (50 – 60 cc) Hemato chezia Occult blood in stool (10 cc)

4 Upper G I Bleeding Lower G I Bleeding Obscure G I Bleeding

5 UPPER GI BLEEDING

6 Causes of Upper GI Bleeding PUD 40% Oesophagitis 10% Varices 5% Mallory – Weiss Syndrome (longitudinal tear in the mucosa of the GE junction) 5% Erosive Disease 6% Neoplasm 4% Other 6% No Obvious Cause 24%

7 Massive Upper GI Bleeding Acute Bleeding Proximal to the ligament of treitz Requires blood transfusion

8 Massive Upper GI Bleeding PUD Gastritis Mallory weiss Syndrome Esophagogastric Varices

9 Massive Upper GI Bleeding ( Less Common Causes) Neoplasm (malignant – benign) Angiodysplasia Dieulafoy’s Lesion (Congenital arteriovenous malformation) Arterioenteric Fistula (Aortic Graft-Repair of visceral artery aneurysm)

10 History P. U. D-Heart burn – reflux Drugs (NSAID- stroid- anticoagulant) Alcohol Cirrhosis

11 Peptic ulcer disease Bleeding may be the first symptom DU: GU = 4 : 1

12 Upper GI Bleeding Most common complication of PUD Most peptic ulcer related death Typically Present with melena and/or hematemesis

13 Management Resuscitation - Large-bore IV access (2 IV line) - Foley catheterization - NGT + irrigation with normal saline (room temperature) Continuous IV PPI

14 Managment Lab test - CBC, Hb, HCT, Platelet - BUN - Cr – Na – K - PT, PTT - L.F.T - ABG + E.C.G

15 Upper GI Bleeding due to peptic ulcer Acid suppression + NPO - ¾ will stop - ¼ will continue to bleed or will rebleed All mortalities & operations occur in this group

16 Risk Stratification Magnitude of the Hemorrhage - Shock - Hematemesis - Transfusion > 4 units in 24 h - Hypotension - Tachycardia - Oliguria - Low Hct - Pallor - Altered Mentation

17 Risk Stratification Comorbidities - Lung - Liver - Kidney - Heart Age Anticoagulated or immunosuppressed

18 Risk Stratification Endoscopic Findings - Bleeding from varices - Active bleeding or Visible vessel

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21 High Risk Patients (25%) Type & Crossmatch Admit to ICU Consult Surgeon Consult gastroenterologist Start continuous infusion of PPI

22 High Risk Group (25%) Endoscopy within 12 hours after correction of coagulopathy (Diagnosis the cause – Assess the need for hemostatic therapy) Endoscpic hemostasis Arteriography (occasionally) Operation

23 Endoscopic Therapy Injection with epinephrine Electrocautery Clip (exposed vessel)

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26 Indications of Operation Massive Bleeding unresponsive to Endoscopic Therapy Transfusion requirement of > 4-6 Unit Persistent bleeding or rebleeding after one or more endoscopic therapy Lack of availability of a therapeutic endoscopist Lack of availability of blood for transfusion Repeat hospitalization for bleeding ulcer Concurrent indication: Perforation – Obstruction

27 Indications of Early Elective Operation After initially successful endoscopic treatment Elderly Patients Multiple comorbidity (don’t tolerate another episode of Hemorrhage) Deep ulcer overlying a large vessel :posterior duodenal bulb(Gastroduodenal Artery) or lesser gastric curve (left gastric artery)

28 LOWER GI BLEEDING

29 Symptoms Unexplained Iron – Deficiency Anemia (Occult Blood) Hematochezia Dark or Clot Rectal Bleeding Massive Shock

30 Causes Hemorrhoids Fissure SRU IBD Malignancy Polyps

31 Causes- Angiodysplasia Usually in cecum & R.T Side colon - Non congenital or Neoplastic but Degenerative - No relation with other skin & visceral vascular lesions - with age - Usually small < 5 mm

32 Causes- Angiodysplasia Colonoscopy or Angiography for diagnosis 80 % self limited 50 % Recurrence during 3 years Treatment options: laser, electrocoagulation,surgery

33 Causes - Diverticulosis Left sided colon Cause of > 50% massive lower GI Bleeding

34 Causes Meckel’s Diverticulum Infectious Colitis A-V malformation Ischemic colitis Mesenteric Thrombosis

35 History Weight loss Abdominal Pain / Cramp Recent Bowel Habit Change + Ve Family hx of colorectal CA Drug History

36 Management Resuscitation (2 IV Line) Correction of coagulopathy, thrombocytopenia Lab test - CBC, Hb, HCT, Platelet - BUN - Cr – Na – K - PT, PTT - L.F.T - ABG + E.C.G

37 Identify the Source NGT: - Return of Bile => Source of Bleeding is distal to the ligament of treitz - Blood => Upper GI Bleeding

38 Proctoscopy + DRE Rectal Tumors Hemorrhoids SRU Proctitis Rectal Polyps Varices

39 Colonoscopy Stable Patients Rapid Bowel Prep 4-6 h Therapeutic - Cautery - Injection of Epinephrine

40 99 mTC RBC Scintigraphy Massive Bleeding Responsive to conservative treatment (Stable Patients) Extremely Sensitive Detection of 0.1 ml/min bleeding Localization is imprecise Intermittent bleeding (can repeat till 30 h)

41 Positive TC => Angiogaphy To localize bleeding (the most definite for localization) Detection of 0.5 cc/min Infusion of vasopressin or angioembolization (Therapeutic) Catheter can left for laparotomy

42 Barium Enema Double contrast Difficult, poor prep, unsuccessful colonoscopy

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44 Obscure GI Bleeding

45 90% lesions for GI Bleeding are within the reach EGD and colon <10 % GI Bleeding, No source by endoscopic studies Overt 80 % : Hematemesis, Melena, Hematochezia Occult 20% : Iron-Deficiency Anemia, Positive Guaiac Most lesions in small intestine Angiodysplasia 75 % Neoplasms 10 % Meckel’s diverticulum: most common in children

46 Crohn’s Infectious enteritis NSAID induced ulcers & erosions Vasculitis Ischemia Varices Diverticula Intussusception

47 Enteroscopy Push => 60 cm Jejunum (+ therapeutic) Sonde => % of the small intestinal mucosa can be examined (No Biopsy or therapy) Wireless Capsule => Success rate 90% Radiotelemetry, portable, detectors attached to the patient’s body, stable patient but continues to bleed, success rate 90 %

48 Enteroscopy Intraoperative Enteroscopy Oral Cecum Enterotomy Exam during insertion rather than withdrawal

49 Enteroclysis Small Bowel follow – through MR Enterography Angiography (angiodysplasia, vascular tumors) 99 mTC – labeled RBC Scan (Meckel’s Diverticulum)

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