1. UPPER GI BLEEDS

2.  Bleeding from a gastrointestinal source proximal to the ligament of Treitz which occurs at the duodeno- jejunal flexture. Definition  Haematemesis or Malaena  Abdo pain, hypotension (fatigue etc), purpura, liver pathology stigmata (spleno-hepato- megaly, spider naevi, jaundice, hepatic flap

3. DDx

4. Rx – Upper Bleeds  Resuscitate/ABC - hypovolemia: Rapid history and examination, note age. Monitor pulse and BP every 30 mins Take blood for haemoglobin, urea, electrolytes and grouping; Establish IV access Give blood transfusion/colloid if necessary Indications: 1. If in shock: BP 100bpm 2.haemoglobin<10g/dL Oxygen therapy for shocked patients

5.  Correct any clotting abnormalities – Vit K? Warfarin?  Vasopressin  PPI  Urgent Endoscopy – adrenaline /banding (arrests bleeding)

6. LOWER GI BLEEDS

7. Definition  The loss of blood from the GI tract distal to the ligament of Trietz.  This is the anatomical marker for the junction between the duodenum and the jejunum.

8. Causes Causes of lower GI haemorrhage in adults Percentage of pts Diverticular disease -Diverticulosis/diverticulitis of small intestine -Diverticulosis/diverticulitis of colon 60% IBD -Crohn's disease of small bowel, colon, or both -Ulcerative colitis -Noninfectious gastroenteritis and colitis 13% Benign anorectal diseases -Hemorrhoids -Anal fissures -Anal fistulas 11% Neoplasia -Malignant neoplasia of small intestine -Malignant neoplasia of colon, rectum, and anus 9% Coagulopathy4% Arteriovenous malformations (AVM)3% TOTAL100% Meckel diverticulum, intussusception, polyposis syndromes, and IBD are the common causes of GI bleeding in children and adolescents

9. Signs and Symptoms  Maroon/red stained stools (hematochezia) or bright red blood from the rectum.  Malaena may also occur but it points more towards upper GI bleeds.  Hypotension; tachycardia  Pallour, weakness, fainting and other signs of anaemia (if chronic)  Perform History and ask about IBD, weight loss, FHx of Ca, stomach pain, bleeding disorders, last period.

10. Rx – Lower Bleeds  Resuscitation and initial assessment – same as in upper GIT bleeding  Localization of the bleeding site – using investigations such as rectal examination, proctoscopy, sigmoidoscopy, colonoscopy, etc)  Therapeutic intervention to stop bleeding at the site.  Rx Anaemia

11. H. Pylori and PUD  95 % DU assoc. With H. Pylori; 80% GU; 4:1  Risks: Smoking, NSAIDs, aspirin, steroids, increased acid secretion, increased gastric emptying, stress???, AGE (x>80)  Gram –ve, burrows into mucoid lining;  Dx: 13 C Urea breath test Serological tests – IgG antibodies – 80% sensitive & specific Endoscopy: Rapid urease test  gastric biopsies added to urea soln. with phenol red. If present  ph inc. ↑ & causes colour change Culture  biopsies cultured on special medium with antibiotic sensitivities.

12. Rx