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Surgery 6th year, Tutorial (Dr. AbdulWahid)


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Dec. 7th, 2011

Published in: Health & Medicine
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Surgery 6th year, Tutorial (Dr. AbdulWahid)

  1. 1. GI Hemorrhage ABDWAHID M SALIS, M.D
  2. 2. Incidence <ul><li>1-2% of all hospital admissions </li></ul><ul><ul><ul><li>Most common diagnosis of new ICU admits </li></ul></ul></ul><ul><li>5-12% mortality </li></ul><ul><ul><ul><li>40% for recurrent bleeders </li></ul></ul></ul><ul><li>85% stop sponateously </li></ul><ul><ul><ul><li>Those with massive bleeding need urgent intervention </li></ul></ul></ul><ul><ul><ul><li>Only 5-10% need operative intervention after endoscopic interventions </li></ul></ul></ul>
  3. 3. Site <ul><li>Upper </li></ul><ul><ul><ul><li>Esophageal </li></ul></ul></ul><ul><ul><ul><li>Stomach </li></ul></ul></ul><ul><ul><ul><li>Doudenum </li></ul></ul></ul><ul><ul><ul><li>Hepatic </li></ul></ul></ul><ul><ul><ul><li>Pancreatic </li></ul></ul></ul><ul><li>Lower </li></ul><ul><ul><ul><li>Small bowel </li></ul></ul></ul><ul><ul><ul><li>Colon </li></ul></ul></ul><ul><ul><ul><li>Anus </li></ul></ul></ul>
  4. 5. Gastric varices
  5. 6. Gastric varices Esophageal Varices
  6. 7. Gastric varices Bleeding ulcers Esophageal Varices
  7. 9. Gastritis
  8. 10. Gastritis Dieulafoy’s lesion
  9. 12. Mallory-weiss
  10. 16. Watermelon stomach
  11. 17. Upper GI hemorrhage <ul><li>Etiology </li></ul><ul><ul><ul><li>Peptic ulcer disease - 50% </li></ul></ul></ul><ul><ul><ul><li>Varices – 10-20% </li></ul></ul></ul><ul><ul><ul><li>Gastritis – 10-25% </li></ul></ul></ul><ul><ul><ul><li>Mallory-weiss – 8-10% </li></ul></ul></ul><ul><ul><ul><li>Esophagitis – 3-5% </li></ul></ul></ul><ul><ul><ul><li>Malignancy – 3% </li></ul></ul></ul><ul><ul><ul><li>Dieulafoy’s lesion – 1-3% </li></ul></ul></ul><ul><ul><ul><li>Watermelon stomach – 1-2% </li></ul></ul></ul>
  12. 18. Gastrointestinal Bleeding <ul><li>Hematemesis - Vomiting of blood from the oropharynx to the ligament of Treitz. </li></ul><ul><li>Gross Blood And Blood Clots: rapid bleeding </li></ul><ul><li>Coffee-ground Emesis : chronic bleeding. </li></ul><ul><li>Melena- Passage of black and tarry stool caused by digested blood. </li></ul><ul><li>Hematochezia- Passage of maroon to red blood and blood clots. </li></ul>
  13. 19. Melena <ul><li>usually the result of severe upper GI bleeding. </li></ul><ul><li>without hematemesis :severe bleeding distal to the ligament of Treitz. </li></ul><ul><li>50-60 mL of blood in the GI tract produces melena </li></ul><ul><li>after a 2 unit bleed : Melena can persist from 5- 7 days and stools can remain occult positive up to 3 weeks. </li></ul>
  14. 20. Nose bleeds- <ul><li>Rarely the cause of major bleeding. </li></ul>
  15. 21. Esophagitis <ul><li>Hiatus hernia Significant bleeding in para- esophageal hernias. </li></ul><ul><li>Reflux esophagitis </li></ul><ul><li>is more likely to result </li></ul><ul><li>in chronic occult </li></ul>
  16. 23. Varices <ul><li>Esophageal And Gastric : </li></ul><ul><li>in the presence of liver disease are life threatening situations precipitated by the inability of the liver to synthesize clotting factors </li></ul><ul><li>Alcoholism </li></ul><ul><li>hepatitis B and C </li></ul>
  17. 25. Mucosal tear (Mallory-Weiss) <ul><ul><li>Esophagogastric mucosal tear Initially the patient has vomiting without blood. Continued emesis leads to pain from the tear and eventually the patient develops hematemesis . </li></ul></ul>
  18. 27. Gastritis <ul><ul><li>Diffuse gastritis . </li></ul></ul><ul><ul><li>Erosions are usually multiple and found primarily in the fundus and body of the stomach. </li></ul></ul><ul><ul><li>Chronic slow bleeds are most commonly associated with H. pylori </li></ul></ul><ul><ul><li>Brisk Bleeding : ingested substances as NSAIDs, alcohol, steroids, or other drugs. </li></ul></ul>
  19. 29. Peptic ulcer <ul><ul><li>Most common cause of upper GI bleed 1/2- 2/3. </li></ul></ul><ul><ul><li>Causes:H. pylori 40-50%,NSAID’s 40-50% andOther (Z-E syndrome) </li></ul></ul><ul><ul><li>Duodenal bleed is four times more common than gastric ulcer bleed. </li></ul></ul><ul><ul><li>Duodenal ulcers are usually posterior and involve branches of the gastroduodenal artery. </li></ul></ul><ul><ul><li>Benign gastric ulcers bleed more than malignant ulcers. </li></ul></ul><ul><ul><li>There will be significant bleeding in 10-15% </li></ul></ul><ul><ul><li>surgical intervention is needed in 20% </li></ul></ul>
  20. 30. Duodenal ulcers <ul><li>located on the anterior wall are prone to perforation and present as peritonitis and free air. </li></ul><ul><li>Those on the posterior wall, which is the more common location, lead to bleeding The gastroduodenal artery </li></ul>
  21. 32. Gastric antral vascular ectasia (GAVE) watermelon stomach <ul><li>Dilated small blood vessels in the antrum , or the last part of the Streaky long red areas. </li></ul>
  22. 34. Stress ulcers <ul><ul><li>Acute gastroduodenal lesions that arise after episodes of shock, sepsis, surgery, trauma, burns (curling’s ulcer), </li></ul></ul><ul><ul><li>or intracrainial pathology or surgery </li></ul></ul><ul><ul><li>(cushing’s ulcer). </li></ul></ul><ul><ul><li>The result of bile reflux damage to the gastric protective barrier combined with decreased gastric blood flow secondary to splanchnic vasoconstriction. </li></ul></ul><ul><ul><li>Sepsis, coagulopathy , and activation of cytokines may also play a role. </li></ul></ul>
  23. 35. Dieulafoy’s vascular malformations <ul><ul><li>Dilated Arterial Lesions </li></ul></ul>
  24. 36. Other causes <ul><ul><li>Gastric neoplasms : </li></ul></ul><ul><ul><li>malignant and benign </li></ul></ul><ul><ul><li>usually mild and chronic. </li></ul></ul><ul><ul><li>Aorto-enteric fistulas : </li></ul></ul><ul><ul><li>As a herald bleed followed by a massive bleed </li></ul></ul><ul><ul><li>In patients with prior aortic reconstructions. </li></ul></ul><ul><ul><li>Hematobilia : </li></ul></ul><ul><ul><li>following hepatic injuries or manipulations. </li></ul></ul>
  25. 37. <ul><li>الحمد لله </li></ul>