Bleeding from GIT presents in 5 ways: 1- Hematemesis 2- Melena 3- Hematochezia 4- Occult blood in stools 5- Chronic blood loss and anemia.
1 – Hematemesis: * IS vomiting of bright red blood (= profuse bleeding) * Or coffee ground material (= altered blood converted to acid hematin by gastric HCL). * It is due to bleeding from above ligament of treitz. * Hematemesis may be false due swallow of blood e.g. from nose, mouth or pharynx. * Or true due to bleeding from any place from esophagus down to duodenojejunal junction.
2 - Melena: * the passage of black tarry loose stools containing digested blood by the action of digestive enzymes and bacteria. *It is due to bleeding from any place above and including caecum . *If bleeding is sever, red blood clots may pass in stools.
3 – Hematochasia : is passage of red blood per rectum due to bleeding from the ascending colon downwards. 4 – Occult blood in stools detected by laboratory methods. 5- Chronic interrupted minimal blood loss presents by signs and symptoms of anemia. (Laine, 2001.)
Bleeding from GIT may be A- UPPER GIT BLEEDING: above the ligament of treitz i.e. the duodenojejunal junction ------------> hematemesis or melena . A- LOWER GIT BLEEDING : below ligament of Treitz leading to melena and hematochazia but no hematemesis.
True hematemesis(vomiting) and naso-gastric tube aspiration is a sign of upper git bleeding. BUT MELENA MAY OCCUR IN UPPER OR LOWER GIT BLEEDING . ( Marko and Pons ,2003).
Causes of upper GIT bleeding A – General causes : e.g. bleeding diathesis B – GIT causes: 1 - Esophageal causes: Esophageal varicies - Esophagitis – tumours - trauma. Rupture aortic aneurysm into esophagus. 2 – Gastrodoudinal causes: Peptic ulcer disease - Gastritis - gastric erosions . Hiatus hernia - Mallory-Weiss tear. Tumours - Angiodysplasia. Hereditary hemorrhagic telangeactasia. Aorto-enteric fistula . (Edmundowicz and Zuckerman, 1992)
CAUSES OF LOWER GIT BLEEDING: A – GENERAL CAUSES : B – LOCAL GIT CAUSES : 1- SMALL INTESTINE : digested blood (melena) enteritis (T.B. ,TYPHOID) – meckel,s diverticulitis – crhon,s – tumours – vascular malformations . 2 – COLON : blood mixed with stools diverticulosis coli – cancer & polypi –intussusception vascular malformations –– ulcerative colitis. 3 – RECTUM : blood streaked on stools cancer – polypi –prolapse- proctitis . 4 – ANAL CANAL : fresh blood after defecation (with pain or not) piles – fissure - cancer .
COMMON CAUSES OF UPPER GIT BLEEDING : PEPTIC ULCER. GASTRITIS AND EROSIONS VARICES COMMON CAUSES OF LOWER GIT BLEEDING : CHILDREN: MECKEL,S DIVERTICULUM POLYPS ULCERATIVE COLITIS ADULTS : HEMORRHOIDS VASCULAR ECTASIA DIVERTICULOSIS POLYPS CARCINOMA CONGENITAL ARTERIOVENOUS MALFORMATIONS
USE OF OXYGEN EXTRACTION % TO EVALUATE HYPOVOLAEMIA : *MEASURE ( SaO2) BY PULSE OXIMETRY . *Measure O2 SATURATION IN VENOUS BLOOD GASES
Clinical picture of hypovolaemic shock Rapid weak pulse : - 1 *catecholamine release , *mary,s law =tachycardia with hypotension , *stimulated cardiac accelerating center directly by hypoxia and reflexly by carotid and aortic body chemoreceptor . 2- Hypotension and low pulse pressure : Decrease in blood volume= decrease in venous return = decrease in cardiac output = decrease in ABP. 3 -Subnormal temperature : vasoconstriction and decreased tissue metabolism . 4 - Increased rate and depth of respiration : Due to tissue hypoxia and hypotension .
Continue,hypovol.shock: 5 -Pale (vasoconstriction of capillaries), cold (vasoconstriction of arterioles) , clammy skin (sweat secretion ) = sympathetic over activity . 6 -Collapsed viens and decreased CVP . 7 -Oliguria : decreased renal blood flow and ADH release . 8 -Thirst sensation : 9 - Restlessness early with mild to moderate hypovoleamia and lethargy with moderate to sever hypovoleamia . 10 – CLINICAL PICTURE OF THE CAUSE :
LABORATORY INVESTIGATIONS: 1- BLOOD GROUP AND CROSS MATCHING: FOR 4 – 8 UNITS ACCOIRDING TO SUSPECTING REBLEEDING STORE PLASMA FOR ONGOING CROSS MATCHING TAKE SAMPLE BEFORE COLLOID USE 2-CBC: HB%, PCV: CHANGED ONLY IN MASSIVE GIT BLEEDING, GIVES IDEA ABOUT PREVIOUS FITTNESS OF PATIENS. WBCS: IF MORE THAN 15000 CONFIRM ABOUT ANY SEPSIS. PLATELATS COUNT: if less than 50000 consider platelet support. 3-Urea and electrolytes: may be elevated inspite of normal creatinine due to increased protein absorption AND RETURNS AFTER VOLUME RESTORATION.. 4-Blood glucose : may decrease in liver disease. 5-PT, PTT AND LFTS : CHANGED IN LIVER DISEASE AND IN PATIENTS TAKING WARFARIN . 6-Monitor Arterial Blood . gases in morbid conditions. OCCULT BLOOD IN STOOL in minimal bleeding
DeterminATION OF SITE OF BLEEDING : 1 – History: DETERMINE DEGREE OF BLOOD LOSS BUT NOT SO ACCURATE ,LEVEL OF BLEEDING ,ETIOLOGY OF BLEEDING,PRECIPITATING FACTOR,PREVIOUS BLEEDING. 2 – Ryle tube and PR: 3 – Upper endoscopy, anorectosegmoidoscopy and colonoscopy : 4 – RADIOISOTOPIC Scanning by technetium labelled Rbcs: FOR SCREENING BEFORE ARTERIOGRAPHY ,IT CAN DETECT BLEEDING LESS THAN 0.5ML /MIN,A POSITIVE SCAN POINT TO CANDIDATE OF ARTERIOGRAPHY,NEGATIVE SCAN INDICATES SHORT TERM GOOD PROGNOSIS . 5 – Selective arteriography : DETERMINES THE SITE OF BLEEDING NOT THE CAUSE. USED FOR THERAPEUTIC INTRA-ARTERIAL INJECTION OF VASOPRESSIN OR ARTERIAL EMBOLISATION BY GELFOAM
PRIMARY EVALUATION AND RESSUSCITATION: IF IMPENDING HYPOVOLEMIC SHOCK: A airway protection and consider endotracheal tube if aspiration is suspected . B BREATHING SUPPORT C circulatory support : 1- wide pore venous access . 2 – appropriate fluid transfusion according to patient condition and facilities . 3 – contact with surgeons and emergency endoscopic team early . insert retained urinary cath.and calculate urine hourly. 4- insert ryle tube to detect hematemesis and or do gastric wash according to cause . 5 – in compromised patients cvp and intensive care measurements is considered according to every case .
Vasopressin : constrict splanchnic arterioles 0.4 u/min. for one day then 0.2 u /min . for another day. Better given with nitroglycerin. Glypressin:long duration ,less side effects 2mg iv every hour till bleeding stops then 1 mg every 6 hours octreotide : selective splanchnic arteriolar vasoconstriction 50 microgr iv bolus then 50 microgram every 6 hours for 48 hours
CERTAIN PRECAUTIONS * HB% OF 7-8 gm.WILL GIVE ADEQUATE OXYGENATION FOR NORMOVOLEMIC BUT IN HYPOVOLEMIC OR COMPROMISED PATIENT 9-10 gm. IS BETTER ACHIEVED. * GIVE PACKED RBS IN CARDIAC RISKY PATIENTS PLATELETS FOR MASSIVE BLOOD TRANSFUSION * FFP FOR COAGULATION DISORDERS * PLATELET CONCENTRATE FOR THROMBOCYTOPENIA less than 50,000. * BLOOD GROUP O NEGATIVE EVEN WITHOUT CROSS MATCHING FOTR LIFE THREATENING CONDITIONS . * CALCIUM ONE AMPULE FOR EVERY FOUR UNITS. * CHECK FOR BLOOD HAEMOLYSIS IN UNCONSCIOUS PATIENTS.
Hypovolaemia and shock: * 500 ml. of blood loss leads to minimal clinical finding. * 1000 ml. of blood loss causes positive tilt test. * 2000 ml. of blood loss presents with features of shock. * Rapid loss of 50% of blood volume is usually fatal. * Elders cannot accommodate for hypovolaemia properly. * Mild hypovolaemia = compensatory vasoconstriction to maintain blood pressure. * More hypovolaemia = hypotension, increase in peripheral vascular resistance, capillary and venous bed collapse, and all of these leads to more tissue hypoxia.
Low risk criteria : Henneman,2003 . 1 – No co morbid diseases. 2 – Normal vital signs. 3 – Normal or trace positive stool guaiac. 4 - Negative gastric aspirate. 5 – Normal or near normal HB%&hematocrit. 6 – No problem to ask for medical help on need. 7 – Proper understanding of S. &S. of bleeding. 8 – No high risk factors and easy medical follow up.
HIGH RISK PATIENTS : VELAYO,2003. 1 – AGE > 60 YEARS . 2 – COMORBID CONDITIONS : D.M. , RENAL, CARDIAC, HEPATIC FAILURE, IHD,CANCER. 3 – PERSISTENT HYPOTENSION . MORE THAN 4 UNITS OF TRANSFUSION. - 4 5 – BLEEDING OR REBLEEDING DURING HOSPITALISATION. 6 – BLOODY NASOGASTRIC ASPIRATE . 7 – NEED FOR EMERGENCY SURGERY . 8 – HIGH RISK LESIONS : ESPGHAGIAL VARECES , A-E FISTULA ,BIGACTIVELY BLEEDING ULCERS IN POSTERIOR PULP OF DUODINUM.