Causes and Diagnosis and Management of Gastroenterology bleeding by Dr Mohammed Hussien ( Kafrelsheikh University).

1. Gastrointestinal bleeding
Dr/ Mohammed Hussien
Assistant Lecturer of Gastroenterology &
Hepatology
Kafrelsheik University
Membership at American Collage of
Gastroenterology (ACG)
Membership at Egyptian association for
Research and training in
Dr/ Mohammed Hussien
Assistant Lecturer of Gastroenterology &
Hepatology
Kafrelsheik University
Membership at American Collage of
Gastroenterology (ACG)
Membership at Egyptian association for
Research and training in

2. • Bleeding from the gastrointestinal tract is one of the most
common reasons for admission to the hospital.
CAUSES OF GASTROINTESTINAL BLEEDING IN THE ADULT:
The commonest causes of upper GIT bleeding are varices,
erosive gastritis and peptic ulcer
The commonest causes of lower GIT bleeding are
hemorrhoids, dysentery, polyps and inflammatory bowel
diseases

3. Etiology and severity of upper gastrointestinal tract hemorrhage
[I] Local Causes: They usually cause GIT bleeding only
1- DISEASES OF THE ESOPHAGUS:
•Varices secondary to portal hypertension.
•Esophagitis and esophageal peptic ulcer.
•Benign and malignant tumors.
•Mallory-Weiss syndrome.
2- DISEASES OF THE STOMACH
• Gastric ulcer- Prepyloric ulcer -Pyloric channel ulcer
• Gastric erosion----- Gastritis
• Varices
• Portal-hypertensive gastropathy
• Gastric cancer
• Polyp
• Dieulafoy lesion
DOUDENUM:
• Ulcer
• Duodenitis
• Aortoenteric fistula
• Pancreatic pseudocyst
• Post-sphincterotomy

5. Esophagitis with bleeding

6. Esophageal ulcer

7. Mallory-Weiss tear

8. Esophageal varices (I(

9. Gastric ulcer

10. Prepyloric ulcer

11. Gastric varices

12. Bleeding gastric varix

13. Portal-hypertensive gastropathy

14. Gastric cancer

15. Gastric polyp
Hyperplastic polyp Inflammatory polyp Leiomyoma with bleeding

16. Dieulafoy lesion

17. Duodenal ulcer

18. NSAID-induced

19. Etiology of lower GIT bleeding
Source of hemorrhage Percentage
Colonic cancer 7
Colonic polyp 11
Diverticula 23
Colitis 11
Vascular ectasia 1
Large hemorrhoids only 12
Ulcer tear (rectum) 10
Upper gastrointestinal or small bowel
source
10
No site identified 14
100

20. 3- DISEASES OF THE SMALL INTESTINE:
•Ulcers.
•Erosions
•Vascular malformations
•Intussusception
4- DISEASES OF THE COLON AND RECTUM:
•Hemorrhoids and anal fissure
•Infections as Bilharziasis, amoebiasis, and bacillary dysentery.
•Inflammatory bowel disease
•Benign and malignant tumors
•Colonic polyposis
•Ischemic bowel disease
•Vascular telangiectasias. ( Vascular malformation )
•Diverticulosis and diverticulitis

21. Sessile Tubular Adenoma
A small, sessile,A small, sessile,
multilobulated lesionmultilobulated lesion
which proved to be awhich proved to be a
benign tubularbenign tubular
adenoma.adenoma.
A smooth sessile polypA smooth sessile polyp
on a broad base.on a broad base.

22. Pedunculated Tubular Adenoma
Benign tubular adenomaBenign tubular adenoma
on a long stalk .on a long stalk .
The stalk is severalThe stalk is several
times larger than thetimes larger than the
polyp itself.polyp itself.

23. Sessile Villous Adenoma
3-4 cm carpet-like3-4 cm carpet-like
tubulovillous adenoma of thetubulovillous adenoma of the
cecum.cecum.
The orifice of the appendix isThe orifice of the appendix is
visible in the image on the left.visible in the image on the left.
1 cm sessile tubulovillous1 cm sessile tubulovillous
adenoma of the sigmoid colon.adenoma of the sigmoid colon.

24. Polyposis syndromes
• Polyposis syndromes are hereditary conditions
that include:
• Familial adenomatous polyposis (FAP).
• Gardner syndrome.
• Turcot syndrome.
• Peutz-Jeghers syndrome.
• Cowden disease.
• Familial juvenile polyposis.
• Some of the syndromes have extraintestinal
features that help differentiate one syndrome
from the other.

25. Familial adenomatous polyposis
(FAP(
Hundreds of benignHundreds of benign
tubular adenomastubular adenomas
throughout the colon.throughout the colon.
Small and largeSmall and large
benign polypsbenign polyps
throughout the colon.throughout the colon.

26. Colon cancer

27. diverticula

28. Colitis
Pseudomembranous colitis

29. Colitis
Crohn’s disease Ulcerative colitis

30. Hemorrhoid

31. Angiodysplasia

32. Presentations & Definition
1-HEMATEMESIS:
It is bloody vomitus, either fresh and bright red
It results from upper GIT bleeding up to the 2nd part of the duodenum
proximal to ligament of Treitz at duodeno-jejunal junction.
Most frequently follows bleeding from the esophagus, stomach, or
duodenum
Melenemesis
“coffee grounds” vomiting
occurs when blood is in contact with gastric acid for at least 1 hour
Usually bleeding at a slower rate than those who have grossly bloody
emesis

33. 2-MELENA:
It is tarry, shiny, black, sticky stool
It usually occurs when bleeding is slow enough to allow time for degradation of
blood.
It results from slow upper GIT bleeding but occasionally hemorrhage into the jejunum,
ileum, or even right colon can cause melena if gastrointestinal transit is slow.
It should be distinguished from the black stools caused by ingestion of iron or bismuth.
3-Hematochezia
• The passage of bright red stools
• Usually a sign of distal small bowel or brisk colonic hemorrhage
• 10% : actively bleeding from an upper GIT lesion, and have accelerated GI transit
times

34. 4- OCCULT BLOOD IN STOOL:
•Stool appears normal, but blood is detected when tested with guaiac test
and patients present with anemia. Microscopic blood when RBC are present
microscopically
5- ANEMIA:
•Patient may present without any objective signs of bleeding but rather with
symptoms of blood loss, such as dizziness, dyspnea on mild exertion, anginal
pain or fainting.

35. [II] Generalized causes: GIT bleeding is usually part of generalized
bleeding tendency.
1- Defects of platelet and coagulation factors: ITP, leukemia,
hemophilia and hypoprothrombinemia.
2- Disorders of the blood vessels: Hereditary hemorrhagic
telangiectasia and vascular malformations.

36. Severity of hemorrhage
• The most accurate non-invasive indicator of the severity of
acute blood loss
 Shock : acute blood volume loss of at least 15 to 20%
 Postural vital sign changes
 Upright tachycardia, Widening of the pulse pressure &/or upright
systolic hypotension
 Acute intravascular volume loss of at least 10 to 15%
 Nasogastric lavage is helpful but highly inaccurate in
estimating the severity of upper GIT bleeding (esp. duodenal
bleeding)
Presence of shock or postural changes in vital sign

37. Hypovolemic shock
Mild Moderate Severe
(<20% blood volume) (20-40% blood volume) (>40% blood volume)
Cool extremiyies Same, plus : Same, plus :
Increased capillary
refill time
Tachycardia Hemodynamic
instability
Diaphoresis Tachypnea Marked tachycardia
Collapsed veins Oliguria Hypotension
Anxiety Postural changes Mental status
deterioration (coma)

38. Severity of hemorrhage
 With acute hemorrhage – the hematocrit and hemoglobin levels are
not reliable indicators of the severity of bleeding
 For the hematocrit to fall, the blood plasma must have equilibrated
with ECF or with administered intravenous fluids, and this
equilibration may require 24 to 48 hours to occur

39. Initial evaluation and treatment
• Vital signs
• Supine and upright blood pressure
• Pulse
• If blood loss is significant
 iv fluids must be started immediately
• Brisk bleeding  Packed RBC

40. The History
• Bleeding episode
• Any previous GIT hemorrhage
• Peptic ulcer
• Cancer
• Vascular ectasia
• Alcohol abuse
• Chronic liver disease – painless hematemesis of from esophageal varices
• Reflux esophagitis
• Substernal burning pain
• Regurgitation
• Reflux symptom
• Mallory-Weiss tear
• Forceful, dry retching or multiple episode of vomiting of food before the onset of
hematemesis

41. The history
• PUD
• Epigastric burnng pain promptly relieved by food or antacid
• Nocturnal pain
• Use of NSAID
• Diverticular disease
• Colorectal cancer
• Gradual weight loss
• Intermittent blood in the stools
• Altered bowel habits
• IBD
• Long-standing mucous and bloody diarrhea
• Hemorrhoid
• Presence of bright red blood surrounding well-formed, normal-appearing stools

42. Physical examination
• Chronic liver disease
• Spider angioma
• Ascites
• Gynecomastia
• PUD or gastritis
• Localized epigastric tenderness on palpation
• LGIT malignancy
• Palpable lower abdominal mass
• Hepatomegaly
• Weight loss
• Adenopathy
• Anorectal mass lesion (polyps, cancers, or large hemorrhoids)
• Digital examination

43. Management
• Nasogastric tube lavage
• Using room temperature water
• Indication the rate of ongoing bleeding
• Decrease the bleeding rate by constricting smaller gastric vessels
• Hct, Hgb, PT, PTT, ABO & Rh
• Shock or postural hypotension
• 4 to 6 units of packed RBC should be cross-matched

44. UGIT bleeding
• ulcer disease
• TMC cause of UGI bleeding
• 50% of moderately severe bleeding
• 35% of severe bleeding
• Esophageal or gastric varices
• 1/3 of massive UGI hemorrhage
• Usually associated with chronic liver disease
• Alcoholic > viral
• Large, firm liver
• Enlarged spleen
• Gross ascites
• Scleral icterus
• Palmar erythema
• Peripheral muscle wasting

45. UGIT bleeding
• Mallory-Weiss tears
• Tears of GEJ
• 5% of minor UGI hemorrhage
• 20% of severe UGI hemorrhage
• Usually associated antecedent, forceful rething
• Nearly 50% - alcohol abuse
• Gastritis due to alcohol or NSAID
• Esophagitis
• GIT malignancies

46. Endoscopy
• Diagnostic procedure of choice
• High accuracy and immediate therapeutic potential
• Must be performed only after adequate resuscitation and
clinical assessment of the patient

47. Endoscopy
• Indication
• Postural vital sign changes or shock
• Multiple transfusion
• Hematocrit below 30%
• High index of suspicion of variceal hemorrhage
• Recurrent hemorrhage from unknown sources
• High risk for surgery
• Relative contraindication
• Acute myocardial infarction
• Severe chronic lung disease (SO2<90%)
• Hemodynamic instability
• Patient agitation

48. Endoscopy
• Therapeutic endoscopy
• Acute variceal bleeding
Endoscopic sclerotheray
Varix band ligation
• UGIT hemorrhage
Endoscopic bipolar electrocoagulation
Heater probe coagulation
Injection of dilute epinephrine soln.

49. Esophageal varices (II(

50. Bleeding control with heater probe

51. Bleeding control with hemoclip

52. Barium radiography
• “UGI series”, when performed by double-contrast
technique, identifies at least 70-80% of lesions confirmed to
be associated with UGIT bleeding
• Noninvasive
• Costs less than endoscopy
• Readily available but has significant disadvantages,
particularly in patients who are bleeding briskly
• Multiple lesions may be detected by barium radiography
and the actual site of bleeding may be difficult to assess

53. Angiography
• When the site of of UGIT bleeding is missed on endoscopy
• Selective infusion with vasopressin or coil embolization of
actively bleeding arteries may control bleeding
• Bleeding must be active (> 30 mL/h)
• Expensive, time-consuming, invasive
• Requires transporting the patient to a specialized unit

54. Nuclear scintigraphy
• When less active blood loss (3 mL/h)
• Technetium red cell nuclear scintigraphy (RBC scan)
• Non-invasive
• Portable gamma camera
• Often performed before any angiographic evaluation to prove
the presence of active bleeding and to assist in the localization
of the bleeding focus

55. LGIT bleeding
• Colonic diverticula
• 1/4 of all episodes of hemodynamically significant bleeding from
the LGIT
• Nearly always painless
• Acute large-volume hematochezia
• Colonic cancer and polyps
• 20% of LGI bleeding
• Often present as hematochezia , particularly with lesions in the
distal sigmoid colon and rectum
• Cf) proximal – IDA and frequently dark black or bloody stool
• UC and CD
• Bloody diarrhea, tenesmus, long-standing history of IBD
• Vascular ectasia

56. Proctoscopy
• Careful evaluation of the anorectal junction are the initial
diagnostic step for all patients with hematochezia
• Hemorrhoids or lacerations, diverticula, colitis, polyps, and
cancer

57. Double-contrast barium radiography
• If blood loss is modest (as evidence by a normal hematocrit and
vital sign), sigmoidoscopy may be followed by double-contrast
radiography
• Highly accurate for detecting even smaller polyps and
superficial mucosal abnormalities such as colitis

58. Colonoscopy
• Indicate LGIT hemorrhage with anemia
• Not only allows the site of hemorrhage to be determined
accurately but also allows biopsy of suspicious mass lesions
• Polypectomy
• Coagulation technique

59. Technetium RBC scintigraphy
• Detect active bleeding at a rate of at least 3 to 10 mL/h
• Usually localizes the site but not the cause of active hemorrhage
Angiography
• Bleeding at a rate exceeding 30 to 50 mL/h
• Vasopressin or embolization technique

60. Finally, Occult GIT hemorrhage
• 5%
• 3 general categories
• 1) Hematemesis or melanemesis but a “negative” upper
endoscopy
• 2) Hematochezia but a “negative” colonoscopy
• 3) Positive fecal OB testing and negative routine upper and
lower endoscopies
• Modalities
• Technetium RBC scintigraphy
• Small bowel enteroclysis
• Small bowel endoscopy
• Angiography
• Capsule endoscopy