Diagnosis of Gastrointestinal Bleeding Liu Zhenhua

Hematemesis and Hematochezia

The approach to gastro- intestinal (GI) bleeding is tailored to the manner of appearance

Is bleeding acute or chronic? Intensive care Where is the source of bleeding? Empiric therapyDiagnosis Treatment What is the causes of bleeding? Recognition of hemorrhage

Intensive care Where is the source of bleeding? Empiric therapyDiagnosis Treatment ( 经验治疗 ) What is the causes of bleeding? Is bleeding acute or chronic? Recognition of hemorrhage

Clinical Manifestations 1 Manner of bleeding presentation 2 Hypovolemia or shock 3 Anemia Recognition of hemorrhage

Patients manifest blood loss 1) Hematemesis Bloody vomitus, either fresh and bright red or older and “coffee - ground” (Acidic hematin) in character Hemoptysis? Nosebleeding? Manner of bleeding presentation from the GI tract in five ways:

2) Melena  Shiny, black, sticky (tarry stool), foul- smelling  Degradation of blood  Exogenous stool darkeners iron bismuth Manner of bleeding presentation

3) Hematochezia bright red or maroon blood from the rectum  pure blood  blood intermixed with formed stool  bloody diarrhea

Manner of bleeding presentation 4)Occult detected only by testing the stool with a monoclonal antibody for human hemoglobin

Estimate amount of bleeding from upper GI tract 5~10 ml/d OB + 50~70 ml/d Melena 250~300 ml in short time Hematemesis

Manner of bleeding presentation 5) other symptoms of blood loss dizziness, dyspnea, angina or even shock

Blood loss

Hypovolemia or shock  Speed and volume of blood loss  Weakness, giddiness, oliguria, cold extremity, sweating  Vital signs: tachycardia, hypotention

Anemia pale fatigability dizziness dyspnea palpitation angina

Is bleeding acute or chronic? 1) Bleeding speed Hematemesis of fresh blood generally indicates a more severe bleeding episode than melena, which occurs when bleeding is slow enough to allow time for degradation of blood

Is bleeding acute or chronic? 2) Blood pressure and heart rate depend on  amount of blood loss  suddenness of blood loss  extent of cardiac and vascular compensation

postural hypotension ---- early physical finding tachycardia ---- greater loss, compensate recumbent hypotension ---- final results Is bleeding acute or chronic?

Postural hypotension A postural drop in blood pressure of 10 to 20 mm Hg

Is bleeding acute or chronic? 3) Bowel sound Active bowel sound usually be presented in acute bleeding from GI tract

Is bleeding acute or chronic? 4) Hematocrit  bleeding slowly  hypochromic microcytic red blood cells  mean corpuscular volume (MCV ) of the cells may be low

Is bleeding acute or chronic? If blood loss is acute, the hematocrit dose not change during the first few hours after hemorrhage About 24 to 72 hours later, plasma volume is larger than normal and the hematocrit is at its lowest point

Volume (Liters) 45 % 27 % AB C Is bleeding acute or chronic? Hematocrit changes A Before bleeding B Immediately after bleeding C 24~72 hours after bleeding

Emergent and intensive care Initially vital signs supine and upright blood pressure pulse

If blood loss is significant, intravenous fluids must be started Saline or other balanced electrolyte solutions are most rapidly available

 Blood is sent to the lab complete blood count clotting studies routine chemistry studies  Blood for typing and cross-matching is sent to the blood bank

Where is the source of bleeding? Localization Upper GI bleeding: bleeding from a source proximal to the ligament of Treitz. Lower GI bleeding: bleeding from a site distal to the ligament of Treitz.

Localization Treitz: The ligament of Treitz is an anatomic landmark for the duodenal-jejunal junction

Localization Differentiating features of upper GI and lower GI bleeding Upper GILower GI ManifestationHematemesisHematochezia melena Nasogastric aspirateBloodyClear BUNElevatedNormal Bowel soundHyperactiveNormal

Hematemesis Melena Hematochezia

More proximal lesions produce hematemesis or melena, whereas more distal lesions are more likely to produce hematochezia

If hematochezia is from an upper GI source, it usually reflects a massive bleed (i. e., greater than 1000 ml).

What is the causes of bleeding? 90% upper GI bleeding is due to four lesions: 1)peptic ulcer 2)hemorrhagic gastritis 3)esophageal or gastric varices 4)gastric cancer

peptic ulcer

hemorrhagic gastritis

esophageal varices

gastric cancer

Causes of gastrointestinal bleeding Mallory-Weiss tear Portal-hypertensive gastropathy Ancylostomiasis Post-sphincterotomy

Causes of gastrointestinal bleeding Colorectal cancer Colitis Large hemorrhoid Rectum tear Vascular anomalies Hematologic diseases

Diagnostic approach to gastrointestinal bleeding 1 History and physical examination 2 Endoscopy 3 Barium radiography 4 Angiography 5 Nuclear scintigraphy

History and physical examination A history of previously documented GI tract disease determined by radiography, endoscopy, or surgical procedures is very useful. Diagnostic approach to GI bleeding

A history of epigastric burning pain promptly relieved by food or antacids or nocturnal pain suggests peptic ulcer disease, particularly duodenal ulcer

Diagnostic approach to GI bleeding Localized epigastric tenderness to palpation may indicate peptic ulcer disease or gastritis

Diagnostic approach to GI bleeding Patients with hepatitis B or chronic active liver disease may present with painless hematemesis from esophageal varices.

Diagnostic approach to GI bleeding Patients with stigmata of chronic liver disease [e.g., spider angioma, ascites, gynecomastia] and upper GI bleeding often bleed from esophageal varices or erosion

Diagnostic approach to GI bleeding Patients with forceful, retching or multiple episodes of vomiting of food prior to the onset of hematemesismay be bleeding from Mallory － Weiss tears of the gastroesophageal junction.

Diagnostic approach to GI bleeding Colorectal malignancy is often suggested by a history of gradual weight loss intermittent blood in the stools altered bowel habits

Diagnostic approach to GI bleeding Hemorrhoidal bleeding is often suggested by the presence of bright red blood surrounding well-formed, normal- appearing stools.

Diagnostic approach to GI bleeding A rectal examination is essential to document stool color as well as to palpate for gross ano-rectal mass lesions such as polyps, cancers, or large hemorrhoids.

Diagnostic approach to GI bleeding Endoscopy Endoscopy is the diagnostic procedure of choice because of its high accuracy and immediate therapeutic potential Endoscopy, however, must be performed only following adequate resuscitation

Diagnostic approach to GI bleeding Barium radiography Barium radiography is noninvasive but has significant disadvantages, particularly in patients who are bleeding briskly (actively)

Diagnostic approach to GI bleeding Angiography Angiography may localize the site of bleeding

Diagnostic approach to GI bleeding Angiography Bleeding must be active because angiography detects only extravasation of contrast into the GI tract

Think about ：  What is the clinical manifestations of GI tract bleeding ？  What are the possible causes of GI tract bleeding?