1. The document discusses gastrointestinal bleeding, describing its various presentations including hematemesis, melena, hematochezia, occult blood in stools, and chronic blood loss/anemia. 2. Upper GI bleeding occurs above the ligament of Treitz and can cause hematemesis or melena, while lower GI bleeding occurs below and causes melena and hematochezia but no hematemesis. 3. Common causes of upper GI bleeding include peptic ulcer disease, gastritis, and esophageal varices, while common causes of lower GI bleeding include hemorrhoids, diverticulosis, and polyps.

1. بسم اللله الرحمن الرحيم Gastrointestinal bleeding Draz MY , Egypt 2008 Mb. Bch, D. Sc (Alazhar) .,M. Sc (Cairo) ,M. Sc (Ain shams). Surgeon ,Internist, Emergency Registrar. [email_address]

2. bleeding from gastrointestinal tract

3. Bleeding from GIT presents in 5 ways: 1- Hematemesis 2- Melena 3- Hematochezia 4- Occult blood in stools 5- Chronic blood loss and anemia.

4. 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.

5. 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.

6. 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.)

7. 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.

9. 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).

10. 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)

11. 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 .

14. 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

15. SOME VIDEO SCENES OF GIT DISEASES

16. EVALUATION OF THE CASE : 1 – IS THERE HEMODYNAMIC CMPROMISE ? 2 – IS THERE ACTIVE BLEEDING? 3 – IS THIS A HIGH RISK PATIENT ? 4 – IS THIS UPPER OR LOWER GIT BLEEDING?

18. CALCULATION OF AMOUNT OF BLOOD LOSS AND RESUSCETAION FLUIDS MARINO ( 1998) : STEP 1 1 – CALCULATION OF BLOOD VOLUME AND BODY FLIUDS :

20. STEP 2 2 – CALCULATION OF VOLUME DEFICIT

23. USE OF OXYGEN EXTRACTION % TO EVALUATE HYPOVOLAEMIA : *MEASURE ( SaO2) BY PULSE OXIMETRY . *Measure O2 SATURATION IN VENOUS BLOOD GASES

26. 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 .

27. 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 :

29. 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

30. 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

31. 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 .

32. 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

33. 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.

34. 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.

36. 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.

37. 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.

39. Band ligation

42. الحمد لله رب العالمين