1. GIT Bleeding

2. GIT Bleeding Acute Upper Lower GIT GIT Hemorrhage Bleeding Occult GIT

3. Acute Upper GIT Hemorrhage
This is the most common GIT emergency
Accounting for admissions to hospital per of the population each year in the United Kingdom.

5. Causes of acute upper GIT Bleeding
Comments %
Diagnosis
Dyspepsia or history of peptic ulcer
Bleeding may be precipitated with NSAIDs or alcohol
35-50%
Peptic ulcer
Associated with NSAIDs & Alcohol
10-20%
Gastric erosions
Heartburn not invariable & bleeding usually not severe
10%
Esophagitis
Follows vomiting or retching e.g. after alcohol binge 5%
Mallory Weis tear

6. Causes of acute upper GIT Bleeding
Comments %
Diagnosis
Associated with aortic valve disease or hereditary hemorrhagic telangiectasia 5%
Vascular malformations
Usually with evidence of liver disease
2-4%
Varices
Chronic blood loss usually present 2%
Carcinoma
(esophagus or stomach)
Consider in any patient who presents after aortic graft surgery 1%
Aorto-enteric fistula

7. Acute Upper GIT Hemorrhage-Clinical Features
Hematemesis may be:
Red with clots when bleeding is profuse OR
Black “Coffee ground” when bleeding is less severe.
Syncope
Symptoms of anemia (chronic bleeding).
Melaena is the term used to describe the passage of black, tarry stools containing altered blood. It is due to:
Bleeding from the upper GIT (usually)
Hemorrhage from the right side of the colon (occasionally)
Hematochezia (maroon or bright red stool) may be found sometimes in cases of severe acute upper GIT bleeding.

8. Acute upper GIT Bleeding
Intravenous
access
Monitoring
Initial clinical
assessment
Endoscopy
Acute upper GIT
Bleeding
Blood Tests
Oxygen
Resuscitation

9. Intravenous Access
The first step is to gain intravenous access using at least one large bore canula.

10. 2- Initial Clinical Assessement
Define circulatory status:
Severe bleeding causes tachycardia, with hypotension and oliguria
The patient is cold, sweating and may be agitated.
Seek evidence of liver disease:
Jaundice
Cutaneous stigmata
Hepatomegaly
Ascites
Define comorbidity (cardio-respiratory, cerebrovascular & renal):
They might be worsened by upper GIT bleeding
They increase the hazards of Endoscopy & surgical operations.

11. 3- Blood Tests: Full Blood Count: Urea & electrolytes.
Chronic or Subacute bleeding may cause anemia
Hb concentration might be normal in cases of sudden , major bleeding until hemodilution occurs.
Urea & electrolytes.
Liver function tests
Prothrombin time: (if there is clinical suggestion of liver disease or in anticoagulated patients)
Cross matching of at least 2 units of blood.

12. 4- Resuscitation: IV crystalloid or colloid: Blood transfusion if:
They are given to restore blood volume:
Blood transfusion if:
The patient is shocked
Hb concentration < 10 gm/dl.
Normal saline must be avoided in patients with liver disease
Central Venous Pressure (CVP) monitoring (severe bleeding, patients with heart disease)
It help to define the volume of fluid replacement
It help in identification of rebleeding.

13. 5- Oxygen
This should be given by facemask to all patients in shock

14. 6- Endoscopy: Should be carried out after adequate resuscitation
Can reach diagnosis in 80% of cases
Can be used in treatment of patients with major endoscopic stigmata of recent hemorrhage including:
Active spurting hemorrhage
Visible vessel (pseudo-aneurysm)
Endoscopic treatment modalities include:
Thermal modality e.g. heater probe
Injection of dilute adrenalin into the bleeding point
Application of metallic clips

15. 6- Endoscopy: Endoscopic therapy are useful for:
Stopping active bleeding
Preventing rebleeding
Avoiding the need for surgery
Endoscopic therapy is also used for:
Varices
Vascular malformations
Mallory-Weiss tears.

16. 6- Endoscopy: 7- Monitoring:
If endoscopy is normal despite active bleeding:
Radiolabelled red cell scanning or visceral angiography (if the patient is actively bleeding by at least 1 ml/minute)
Colonoscopy (for bleeding of lesser severity) – the most common cause is vascular malformations
99Tc-pertechnate scan may show bleeding from Meckel’s diverticulum. Wireless cap.prior to enterosc.
7- Monitoring:
Patients are closely observed with hourly:
Pulse rate
Blood pressure
Urine output

17. 8- Surgical operation:
An urgent surgical operation is undertaken when:
Endoscopic hemostasis fails to stop active bleeding
Rebleeding occurs on:
One occasion in an elderly or frail patient
Twice in younger, fitter patients.

18. ACUTE UPPER GIT HEMORRHAGE role of endoscopic therapy
Meta-analysis of 21 RCTs shows that endoscopic therapy (injection of adrenalin into the bleeding point, application of thermal energy or electrocoagulation) reduces:
Ulcer rebleeding rate
The need for urgent surgery
Hospital mortality rates.

19. Bleeding Ulcers adjunctive drug therapy
“intravenous proton pump inhibitor” infusions, when given to patients who have been subjected to endoscopic therapy for major peptic ulcer hemorrhage, reduce:
Rebleeding rate
Need for surgery
BUT NOT mortality

20. Prognosis
Mortality after admission to hospital is approximately 10%

21. Risk factors for death in patients who present with acute upper GIT bleeding
Comments
Factor
Risk increases over age 60 & especially in very elderly
Increasing age
Advanced malignancy, renal & hepatic failure are associated with particularly high mortality
Comorbidity
Defined as:
pulse > 100/min,
BP < 100 mm Hg
Shock

22. Risk factors for death in patients who present with acute upper GIT bleeding
Comments
Factor
Varices & cancer have the worst prognosis
Diagnosis
Active bleeding & non-bleeding visible vessel at Endoscopy are associated with a high risk of continuing bleeding
Endoscopic findings
Associated with 10 folds rise in mortality
Rebleeding*
*defined as fresh hematemesis or melena associated with shock or fall of Hb > 2 gm/dl over 24 hours

23. Lower GIT Bleeding

24. Lower GIT Bleeding It may be due to hemorrhage from:
Small bowel
Colon
Anal canal
You must distinguish between:
Profuse acute bleeding
Chronic or subacute bleeding

25. Causes of Lower GIT Bleeding
Severe acute:
Diverticular disease
Angiodysplasia
Ischemia
Meckel’s diverticulum
Moderate, chronic/subacute:
Anal disease e.g. fissure, hemorrhoids
Inflammatory bowel disease
Carcinoma
Large poylps
Angiodyplasia
Radiation enteritis
Solitary rectal ulcer

26. Severe Acute Lower GIT Bleeding
This is an unusual medical emergency
Patients present with profuse red or maroon diarrhea and with shock
Diverticular disease:
It is the most common cause
Acute bleeding is due to erosion of an artery within the mouth of a diverticulum
Bleeding almost always stops spontaneously.

27. Severe Acute Lower GIT Bleeding
Angiodysplasia:
It is disease of elderly, in which vascular malformations develop in the proximal colon
It is most commonly seen in patients receiving anticoagulants following aortic valve replacement.
Can be acute and profuse bleeding
It usually stops spontaneously but usually recurs.
Diagnosis:
Colonoscopy: vascular spots (reminiscent of spider naevi)
Visceral angiography: Bleeding into the intestinal lumen & an abnormal large draining vein
Laparotomy with on-table colonoscopy
Treatment:
Endoscopic thermal ablation
Right hemicolectomy (sometimes necessary in severe cases).

28. Severe Acute Lower GIT Bleeding
Ischemia:
It is due t occlusion of the inferior mesentric artery
It presents with abdominal colic and rectal bleeding
It should be considered in patients (particularly the elderly) who have evidence of generalized atherosclerosis.

29. Severe Acute Lower GIT Bleeding
Meckel’s diverticulum:
Meckel’s diverticulum with ectopic gastric epithelium may ulcerate and erode into a major artery.
The diagnosis should be considered in children or adolescent present with profuse or recurrent lower GIT bleeding
Meckel’s scan is sometimes positive
The diagnosis is commonly made by laparotomy only at which time the diverticulum is excised

30. Subacute or Chronic Lower GIT Bleeding
It is extremely common at all ages
It is usually due to hemorrhoids or anal fissures
Hemorrhoidal bleeding is:
Bright red
Occurs during or after defecation
Proctoscopy is used to reach diagnosis
Colonoscopy or barium enema is necessary to exclude coexisting colorectal carcinoma, is indicated in:
Patients who also have altered bowel habits
All patients presenting over 40 years of age.
Anal fissure should be suspected when fresh rectal bleeding and anal pain occur during defecation

31. Occult GIT Bleeding
Occult means that blood or its breakdown products are present in the stool but can not be seen
It may reach 200 ml/day
It causes iron deficiency anemia
It signifies serious GIT disease
The most important cause is colorectal carcinoma
Diagnosis initially by fecal occult blood (FOB) test

32. DIARRHOEA Acute Diarrhea
< 10 d infective ,drugs ( antibio. , NSAID, PPI,Cytotoxic )
Chronic or Relapsing Diarrhea
Colonic Small Bowel Malabsorption
Clinical feature ,causes , investigation

35. Loss of weight

37. Gastro Esophageal Reflux Disease GERD

38. GERD
GERD resulting in heartburn affects approximately 30% of the general population

39. Factors Associated with the Development of GERD
Gastroesophageal reflux
Defective
Esophageal Clearance
Dietary
Factors
Hiatus Hernia
Abnormal lower Esophageal Sphincter
Reduced tone
Abnormal relaxation
Delayed gastric
Emptying
Increased
intra-abdominal
pressure
Reflux of
acid pepsin
(bile)
Factors Associated with the Development of GERD

40. Abnormalities of Lower Esophageal sphincter
reduced lower esophageal sphincter tone
inappropriate sphincter relaxation

41. Hiatus Hernia Occurs in 30% of the population over the age of 50 years
Often asymptomatic
Heartburn & regurgitation may occur
Gastric volvulus may complicate large para-esophageal hernias
It causes GERD because:
The pressure gradient between the abdominal & thoracic cavities is lost
The oblique angle between the cardia and esophagus disappears
Almost all patients who develop esophagitis, Barret’s esophagus or peptic strictures have hiatus hernia

42. Delayed esophageal clearance
Defective esophageal peristaltic activity
It is a primary abnormality
Poor esophageal clearance leads to increased acid exposure time

43. Defective gastric emptying
Gastric Contents
Gastric acid is the most important esophageal irritant
There is close relationship between acid exposure time & symptoms
Defective gastric emptying

44. Dietary & environmental factors
Material that cause relaxation of the lower esophageal sphincter:
Dietary fat
Chocolate
Alcohol
Coffee
There is little evidence to incriminate smoking or NSAIDs as causes of GERD

45. Clinical features Heartburn & Regurgitation:
Often provoked by:
Bending
Straining
Lying down
Waterbrash (Salivation due to reflex salivary gland stimulation as acid enter the gullet)
History of weight gain
Chocking due to laryngeal irritation by refluxed fluid
Odynophagia & dysphagia
Atypical chest pain which:
Might be severe
Might mimic anginal chest pain
Is due to reflux induced esophageal spasm.