1. Gastrointestinal Bleeding G Muthukumarasamy Specialist Registrar in General Surgery

2. Anatomy and Physiology

3. Oesophagus

4. Stomach

5. Duodenum

6. History taking Complaints Haematemesis Malena Haemotochezia Pain Light-headedness, syncope, dyspnoea, altered mental status (blood loss symptoms) occult blood loss (anaemia)

7. Malena and Coffee ground vomiting

8. Clinical Indicator Probability of Upper GI Source Probability of Lower GI Source HematemesisAlmost certainRare MelenaProbablePossible HematocheziaPossibleProbable Blood-streaked stoolRareAlmost certain Occult blood in stoolPossible

9. Contd., H/o Drug intake – Aspirin, Anticoagulants (warfarin), NSAIDS, Clopidogrel, steroids H/o Alcohol intake, smoking H/o Weight loss Past History : Chronic liver disease, peptic ulcer, bleeding Disorders

10. Examination General Examination Mental status Eyes – Pallor, Jaundice Liver disease – caput medusae, spider angiomas, ascites, palmar erythema, flap Bleeding disorders – Petechia, echymosis Vital Signs – BP, HR, SaO2, RR, T⁰, CRF Urine output

11. Jaundice and Anaemia

12. Liver disease

13. Petechiae/Echymosis

14. Examination – contd., Abdominal Inspection – Shape, symmetry, Dilated Veins, signs of liver failure Palpation – tenderness, Splenomegaly, hepatomegaly Percussion – Shifting dullness, Fluid thrill Auscultation – BS, Bruit Rectal Examination – Fresh blood, Malena CVS, RS, Neurological Examination

15. Investigation FBC, Coagulation profile, U&ES, LFT, CRP, Calcium Type and Crossmatch Blood ECG CXR OGD Angiogram CT or Catheter Nasogastric lavage USS/CT (to assess liver disease) Tc-99m-labeled erythrocyte scans (rarely)

16. Management RESUSCITATION – ABCDE Fluid and BLOOD Replacement Medical Management - PPIs, Vasoactive agents, B-blocker, ISMN (to prevent re-bleeding) Endoscopic management – Adrenaline, coagulation, banding, clipping Interventional Angiography – coiling, TIPS Surgical Management

17. Haemorrhagic Shock

18. UpperGI Bleeding Non variceal Upper GI bleeding 90%Variceal bleeding 10%

19. Causes

23. Esophageal VaricesBleeding esophageal varices Oesophageal varices

24. Oesophagitis

25. Angiodysplasia

26. Gastric varices Mallory Weiss Tear Esophagitis Other causes

28. Glasgow-Blatchford Score Scores of 6 or more were associated with a greater than 50% risk of needing an intervention

35. Variceal bleeding

38. Sengstaken-Blakemore tube

42. Child Pugh classification

45. Further reading/References Clinical Anatomy: Applied Anatomy for Students and Junior Doctors by Prof H Ellis Review Of Medical Physiology by W F Ganong Guidelines - http://guidance.nice.org.uk/CG141http://guidance.nice.org.uk/CG141 - http://www.sign.ac.uk/guidelines/fulltext/105

46. Any questions ??? If you need e-copy of the presentation Email : g.muthukumarasamy@nhs.net