Diagnostic characteristics of upper Gastrointestinal Bleeding:
A-Hematemesis:
Hematemesis (excluding hemoptysis or swallowed blood from epistaxis) is
observed. blood or material in the nasogastric lavage tests positive for blood.
the aspirate will be negative in approximately 10% of patients with a duodenal
source of GI hemorrhage. A duodenal source can not be excluded unless
gastric lavage contents reveal bile, even if bile is returned the bleeding may
have resolved spontenously prior to arrival.
B-MELENA AND HEMATOCHEZIA:
Melena is usually due to bleeding from an upper GI source. hematochezia from
an upper source usually indicates severe hemorrhage and corresponds with
significant increases in mortality, need for transfusion applications and need
for surgery.
C-ABSENCE OF BLEEDING:
If nasogastric lavage reveals bile and no blood then active bleeding from an
upper GI source is less likely between 80% and 85% of bleeding resolves
spontanously prior to the patient`s arrival then in otherwise stable patients,
close follow-up with an endoscopist should be arranged.
Diagnostic characteristics of lower Gastrointestinal Bleeding:
A-HEMATOCHEZIA:
An upper GI source is found for suspected lower GI bleeding in up to 15% of
patients presenting with hematochezia. in these instances consider
aortoentenc fistula (in patients with abdominal aortic aneurysm repair) or
duodenal ulcer. otherwise, bleeding distal to the ligament of Treitz is usually
associated with hematochezia.
B-MELENA:
melena is rarely associated with lower GI bleeding except when motility in the
intestinal tract is decreased. Melena occurs more commonly as a result of an
upper GI bleed.
C-BRIGHT RED BLOOD:
when seen as streaks on stool or on toilet paper after wiping, bright red blood
usually indicates a hemorrhoidal source of bleeding. consider anal fissures as
well if the patient complains of painful bowel movements and bright red blood
on the stool.
Causes of upper gastrointestinal bleeding
Condition Incidence (%)
Ulcers 60
Erosions 26
Oesophageal 6
Gastric 21
Oesophageal 13
Gastric 9
Duodenal 33
Duodenal 4
Mallory–Weiss tear 4
Oesophageal varices 4
lesions, e.g. Dieulafoy’s disease 0.5
Others 5
Tumour 0.5
Vascular
Medical and minimally interventional treatments
Medical treatment has limited efficacy. All patients are commonly started on a
proton pump antagonist, but such treatments do not influence rebleeding,
operation rate or mortality. tranexamic acid, an inhibitor of fibrinolysis, reduces
the rebleeding rate.
Numerous endoscopic devices are now available that can be used to achieve
haemostasis, ranging from expensive lasers and argon diathermy to
inexpensive injection apparatus. they will probably never be effective in
patients who are bleeding from large vessels, with which the majority of the
mortality is associated.
Surgical treatment
Criteria for surgery are well worked out. A patient who continues to bleed
requires surgical treatment. The same applies to a significant rebleed. Patients
with a visible vessel in the ulcer base, a spurting vessel or an ulcer with a clot
in the base are statistically likely to require surgical treatment. Elderly and unfit
patients are more likely to die as a result of bleeding than younger patients;,
they should have early surgery. In general, a patient who has required more
than 6 units of blood needs surgery.
. The most common site of bleeding from a peptic ulcer is the duodenum. In
tackling this, it is essential that the duodenum is fully mobilised makes the
ulcer much more accessible and also allows the surgeon’s hand to be placed
behind the gastroduodenal artery, which is commonly the source of major
bleeding. Following mobilisation, the duodenum, and usually the pylorus, are
opened longitudinally as in a pyloroplasty. This allows good access to the
ulcer, which is usually found posteriorly or superiorly. Accurate haemostasis is
important. It is the vessel within the ulcer that is bleeding and this should be
controlled using well-placed sutures that under-run the vessel.. Following
under-running, it is often possible to close the mucosa over the ulcer. The
pyloroplasty is then closed with interrupted sutures in a transverse direction in
the usual fashion.The principles of management of bleeding gastric ulcers are
essentially the same. The stomach is opened at an appropriate position
anteriorly and the vessel in the ulcer under-run. If the ulcer is not excised then
a biopsy of the edge needs to be taken to exclude malignant transformation.
Sometimes the bleeding is from the splenic artery and if there is a lot of
fibrosis then the operation may be challenging. However, most patients can be
managed by conservative surgery. Gastrectomy for bleeding but is associated
with a high perioperative mortality, even if the incidence of recurrent bleeding
is less. Most patients nowadays are elderly and unfit, the minimum surgery
that stops the bleeding is optimal. Acid can be inhibited by pharmacological
means and appropriate eradication therapy will prevent ulcer recurrence.
Definitive acid lowering surgery is not now required.
If upper endoscopy is negative and bleeding has presumably stopped or
continues at a slow rate the colon can be prepared and colonoscopy performed
within hrs . the bleeding site is identified in 25-94%of cases .some bleeding
lesions can be treated colonoscopically with a bipolar probe,heater probe or
laser.colonoscopy with negative results probably means that bleeding has
stopped. barium enema discloses abnormalities such as diverticula but does
not reveal which lesions have been bleeding. if upper and lower endoscopy are
both negatives, a capsule videoendoscopy may be performed to evaluate for
small bowel source.
Selective mesenteric angiography identifies the bleeding site in 14-70 % of
patients(threshold 0.5 mL/min).if the bleeding site is seen, intraarterial infusion
of vasopresin controls bleeding ,at least transiently , in 35-90% of patients
.definitive treatment with highly selective arterial embolization may be
performed with success in 75% of patients.The other option for rapid bleeding
is emergency colonoscopy without preliminary bowel cleansing. blood is a
cathartic, and the colon may be free of stool . even so ,colonoscopy in this
situation is difficult.
Gastrointestinal Bleeding
For the majority of patients presenting with gastrointestinal bleeding,
Hematemesis, hemachezia( passage of bright red stools) or melena ( black
and tarry stools caused by the breakdown of large amount of blood will be the
chief complaint. Occasionally patients may present with only dizziness,
weakness or syncope. If no obvious cause of shock is present gastric lavage
and a rectal exam should be performed promptly as part of the initial
assessment. The severity of blood loss must be quickly assessed so that life
saving therapeutic interventions can be started.
Immediate management of life threatening bleeding
Assess the rate and volume of bleedingany patient presenting to the
emergency department with ongoing hematemesis or hematochezia is at
significant risk of exanguination, and prompt volume resuscitation must begin
at once. proceed with initial stabilization procedures.
Conduct initial assessment
place the patient in a monitored bed and obtain temperature, pulse
rate,respiratory rate and oxygen saturation by pulse oximetry. If the initial
systolic blood pressure is greater than 100, and the pulse is less than 100
beats /min in the supine position, consider obtaining orthostatic blood
pressure and pulse rate measurements.
Recognize risk factors for sever gastrointestinal bleeding
signs ,symptoms or history thatmay indicate ongoing hemorrhage are as
follows
- profuse hematemesis or hematochezia - hypotension,tachycardia or signs of
shock
-postural hypotension.tachycrdia or lightheadedness -possible aotoenteric
fistula(history of abdominl aortic repair,or palpable pulsating abdominal mass
-known or suspected varices -previous history of GI bleeding -history of
diverticulosis
Initial stabilization procedures
A- Obtain venous access
insert 2 i.v catheters into peripheral veins,preferably 18 gauge or larger in an
adult. if periph access can be obtained,consider placement of a central line.
B-Assess need for airway management
if the patient is having ongoing hematemesis or if signs of shoch are present
,consider securing airway with an endotracheal tube via rapid sequence
intubation. if immediate airway control is not needed,give oxygen via nasal
cannula or face mask as needed to maintain oxygen saturation at greater than
93%
c-Perform laboraory studies :
send blood for complete blood count (CBC). type and cross match blood for 26 units, depending on the extent of bleeding and the patient`s status. measure
prothrombin and partial thromboplastin time to assess for any coagulopathy.
measure serum electrolytes and renal and liver functions. blood urea nitrogen
is elevated in many patients with upper GI bleeding.venous blood gas and
lactate may be helpful in assessing tissue perfusion status.
D-Begin fluid resuscitation:
rapidly bolus either warmed lactated ringer`s or normal saline to restore
intravascular volume.
E-assess the need for immediate blood transfusion:
for persistent hypotention despite the infusion of 2L of crystalloid, consider
immediate transfusion of cross-matched blood if available.if not then transfuse
O-negative blood until cross-matched blood is available. contiue transfusion to
maintain systolic blood pressure at greater than90.
F-Perform electrocardiogram :
obtain an electrocardiogram (ECG) for any patient over 50years of age; for any
patient with a history of ischemic heart disease or signicicant anemia; and for
any patient with chest pain, shortness of breath , or severe hypontension. if a
patient`s initial hematocrit is less than 30% and he or she has a history of
ischemic heart disease, early transfusion is probably indicated.