This document provides an outline and definitions for upper and lower gastrointestinal hemorrhage presented by Sorawit Boonyathee, MD. It defines key terms like hematemesis, melena, and hematochezia. For upper GI bleeding, it discusses prevalence, initial assessment, risk stratification scores, and treatments for variceal and non-variceal bleeding. For lower GI bleeding, it reviews etiologies like diverticulosis, hemorrhoids, and anal fissures as well as their treatments.
Upper Gastrointestinal Bleeding (UGIB) - General ApproachMohamed Badheeb
What does the science & evidence say about UGIB ?
Introduction & Background on Upper GI Bleeding.
- Incidence and Epidemiology
- Etiologies
2. Guidelines on UGIB
- Resuscitation, Risk assessment
- Diagnostic Modalities
- Treatment Options
Upper Gastrointestinal Bleeding (UGIB) - General ApproachMohamed Badheeb
What does the science & evidence say about UGIB ?
Introduction & Background on Upper GI Bleeding.
- Incidence and Epidemiology
- Etiologies
2. Guidelines on UGIB
- Resuscitation, Risk assessment
- Diagnostic Modalities
- Treatment Options
G I bleeding with radiological interventions(ACR Appropriateness Criteria).Tc-99m RBC scintigraphy,Catheter-directed Angiography,Pharmacological control,Embolization,Arterial interventions,Endoscopy,CT Angiography
Seminar present the Upper Gastrointestinal Bleeding problems
Edited by : Dr. Inzar Yassen & Dr. Ammar L. Aldwaf
in Hawler Medical Uni. collage of medicine in 14/01/2014
Iraq - Kurdistan - Erbil
G I bleeding with radiological interventions(ACR Appropriateness Criteria).Tc-99m RBC scintigraphy,Catheter-directed Angiography,Pharmacological control,Embolization,Arterial interventions,Endoscopy,CT Angiography
Seminar present the Upper Gastrointestinal Bleeding problems
Edited by : Dr. Inzar Yassen & Dr. Ammar L. Aldwaf
in Hawler Medical Uni. collage of medicine in 14/01/2014
Iraq - Kurdistan - Erbil
Pure Matters puts your health and wellness first and foremost, insisting on supplements and vitamins crafted from the most wholesome, natural ingredients. Each formulation is perfectly balanced and tested to the standards of our company's century of pharmaceutical heritage.
Surgery Resident clinical seminar on the management of a 60yr old male with upper gastrointestinal bleeding presented to the department of surgery, Niger Delta University Teaching Hospital, Okolobiri, Bayelsa State
Approach to patient with upper GIT bleeding
Approach to patient with upper GIT bleeding
Approach to patient with upper GIT bleeding
Approach to patient with upper GIT bleeding
Inthis playlist, i discussed various causes for Lower GI Hemorrahage like Hemorrhoids, Fissure in ano, diverticulosis, inflammatory bowel disease and colorectal cancer
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The map views are useful for providing a geographical representation of data. They allow users to visualize and analyze the data in a more intuitive manner.
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The people of Punjab felt alienated from main stream due to denial of their just demands during a long democratic struggle since independence. As it happen all over the word, it led to militant struggle with great loss of lives of military, police and civilian personnel. Killing of Indira Gandhi and massacre of innocent Sikhs in Delhi and other India cities was also associated with this movement.
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The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
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2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
4. Definition
Upper and lower gastrointestinal bleeding
• Upper gastrointestinal bleeding (or hemorrhage) is that originating proximal to the
ligament of Treitz; in practice from the esophagus, stomach and duodenum.
• Lower gastrointestinal bleeding is that originating from the small bowel and colon.
6. Definition (Cont.)
Hematemesis
• Hematemesis is vomiting of blood from the upper gastrointestinal tract or
occasionally after swallowing blood from a source in the nasopharynx.
• Bright red hematemesis usually implies active hemorrhage from the esophagus,
stomach or duodenum. This can lead to circulatory collapse and constitutes a major
medical emergency.
Coffee-ground vomitus (Hb + acid)
• Coffee-ground vomitus refers to the vomiting of black material which is assumed to
be blood. Its presence implies that bleeding has ceased or has been relatively
modest.
7. Definition (Cont.)
Melena
• Melena is the passage of black tarry stools usually due to acute upper
gastrointestinal bleeding but occasionally from bleeding within the small bowel or
right side of the colon.
Hematochezia
• Hematochezia is the passage of fresh or altered blood per rectum usually due to
colonic bleeding. Occasionally profuse upper gastrointestinal or small bowel
bleeding can be responsible.
8. Definition (Cont.)
Varices
• Varices are abnormal distended veins usually in the esophagus
(esophageal varices) and less frequently in the stomach (gastric
varices) or other sites (ectopic varices) usually occurring as a
consequence of liver disease. Bleeding is characteristically severe
and may be life threatening.
• The size of the varices and their propensity to bleed is directly
related to the portal pressure, which, in the majority of cases, is
directly related to the severity of underlying liver disease.
http://quizlet.com/9551975/portal-hypertension-flash-cards/
12. Initial Assessment and
Supportive Treatment
- Maintain Airway
- Hx and PE for assessment of
severity and causes
- NG irrigations
- Fluid resuscitation
- Blood for CBC, Cross-match
blood group for blood transfusion
2
Resuscitation
13. Scoring for Categorized Patient (Cont.)
How Important to Classify patient
• For predicting of prognosis and progress of disease
• For planning of definite management
Scoring systems for Upper Gastrointestinal Bleeding
• Rockall Scoring System
• Forrest classification
• Glasgow-Blatchford Bleeding Score
14.
15. Risk
3
Stratification
Host Factor
Bleeding Characters
• Age ≥ 60
• Co-morbid conditions e.g.
Renal failure, Cirrhosis, CVD,
COPD
• Hemodynamic instability e.g.
orthostatic hypotension, pulse
> 100/min, SBP < 100 mmHg
• Coagulopathy including drugrelated
• Continuous red blood from NG
after irrigation
• Red blood per rectum
Patient Course
• Need blood transfusion
• Rebleeding
• Hemodynamic instability
16. How to differentiated to variceal or non-variceal
bleeding
Variceal Hemorrhage
Painless Bleeding
Usually Hematemesis
Non-Variceal Hemorrhage
Pain or Painless Bleeding
Hematemesis, Coffee ground,
Melena
> 90% Hemodynamic change or Vary
Hct < 30%
Sign of chronic liver disease
none
18. Medication Treatment for Non-variceal
Hemorrhage
Continuous or Bolus intravenous Proton pump inhibitor or oral
double doses PPI
• Continuous dose -> 80 mg iv bolus then iv drip 8 mg/hr for 72 hours
• Bolus dose -> 40 mg iv twice daily
• Both doses consider used in high risk
หมายเหตุ การให้ทั้งสองวิธี พบว่าสามารถเพิ่ม Gastric pH >4 และ 6 ได้เท่ากัน
Brunner G, Luna P, Hartman M, Wurst W. Optimising the intra gastric pH as supportive therapy in upper GI bleeding.
Yale J Biol Med 1996;69:225-31
19. Medication Treatment for Non-variceal
Hemorrhage
Role of PPI before endoscopy(1,2)
• Effect -> decrease stage of stigmata of recent hemorrhage
• Not effect -> rebleeding, surgery and mortality
Role of PPI after endoscopy(3,4)
For low dose can reduce risk of rebleeding
For high dose can reduce risk of rebleeding and surgery rate
Both low and high dose cannot reduce mortality rate
20. Medication Treatment for Variceal Hemorrhage
Mechanism for reducing venous blood flow and arterial flow to
stomach and small intestine
Can reduce risk of rebleeding and surgery rate
Somatostatin
250 microgram iv bolus then iv drip 250 microgram/hr
Octreotide
50 microgram iv bolus then iv drip 50 microgram/hr
21.
22. Sengstaken-Blakemore tube (S-B tube)
Suspected in Variceal bleeding
group and used somatostatin analog
1-2 hours that not improved bleeding
Esophageal Balloon Pressure ->
25 - 40 mmHg (20-30 ml of air)
Gastric Balloon volume ->
50 ml then 250 – 300 ml of air
26. Lower Gastrointestinal Hemorrhage
Sites
• Colon – 95-97%
• Small bowel – 3-5%
Only 15% of massive GI bleeding
Finding the site
• Intermittent bleeding common
• Up to 42% have multiple sites
29. Hemorrhoid
Definition:
• Dilated or enlarged veins in the lower portion of the rectum or anus.
Symptoms
• Rectal Bleeding, Bright red blood in stool, Pain during bowel movements, Anal
Itching, Rectal Prolapse, Thrombus
Cause
• Pressure -> Constipation, Diarrhea, Sitting or standing for long periods of time,
Obesity, Pregnancy
30.
31. Non-surgical Treatment
WASH regimen
• Warm water
• Analgesic agent
• Stool softeners
• High fiber diet
If prolapses, gently push back into anal canal
Use a sitz bath with warm water
Use moist towelettes or wet toilet paper instead
of dry toilet paper.
Increased fluid intake
Avoidance of straining
34. Complication
Reactions to medications of anesthesia
Bleeding
Infection
Narrowing of the anus
*The outcome is usually very good in the majority of cases.
35. Prevention
Eat high fiber diet
Drink Plenty of Liquids
Fiber Supplements
Exercise
Avoid long periods of standing or sitting
Don’t Strain
Go as soon as you feel the urge
36. Anal Fissure
Fissure is a tear in the anal canal
extending from just below the dentate line
to the anal verge.
Most commonly in young and middle age
adults.
The cardinal symptom is pain during and
for minutes to hours following defecation.
Bright red blood is common
37. Anal fissure (cont.)
90% in the posterior midline
25% anterior midline in women, 8% in men
3% have anterior and posterior fissures
Lateral positions should raise concern for other disease
processes—Crohn’s, TB, syphilis, HIV/AIDS, or anal ca
Early (acute) fissures appear as a simple tear in the anoderm
Chronic fissures (symptoms more than 8-12 wks) have edema
and fibrosis
38. Etiology
Trauma due to passage of a hard stool
History of constipation or diarrhea
Associated with increased resting pressures
• Sustained resting hypertonia
39. Symptoms
Hallmark is pain during, and particularly after, a BM
May be short-lived or last hours or all day
Described as passing razor blades or glass shards
Bleeding usually limited to bright red blood on the tissue
40. Conservative Management
Almost half will heal
Sitz baths
Fiber supplement
+/- topical anesthetics or anti-inflammatory ointments
WASH regimen
• Warm water
• Analgesic agent
• Stool softeners
• High fiber diet
41. Medical Management
Sphincter relaxants--“Chemical sphincterotomy”
Nitrate formulas
NTG, GTN, ISDN
Predominant nonadrenergic, noncholinergic neurotransmitter
Oral and topical calcium channel blockers
As effective as nitrates without the headache
Topical muscarinic agonists
Bethanechol
Phophodiesterase inhibitors
Botulinum toxin
42. Operative Treatment
Primary goal is to decrease abnormally high resting anal tone
Anal Dilatation
93-94% healing with few complications
Long term outcomes sparse
Incontinence can occur in around 12-27%
Lateral Internal Sphincterotomy
Keyhole deformity if done in posterior midline
Incontinence rates up to 36% but vary widely
Open or closed technique
45. Reference
1. Dorward S, Sreedharan A, Leonatiadis GI, et al. Proton pump inhibitor
treatment initiated prior to endoscopic diagnosis in upper
gastrointestinal bleeding. Cochrane Database Syst Rev.
2006;18(4):CD005415
2. Lau JY, Leung WK, Wu JCYN, et al. Omeprazole before endoscopy in
patients with gastrointestinal bleeding. N Engl J Med 2007;356:1631-40
3. Leontiadis GI, Sharma VK, Howden CW, et al. Proton pump inhibitor
treatment for acute peptic ulcer bleeding. Cochrane Database Syst Rev.
2006 Jan 25;(1):CD002094
46. Reference
4. Sung JJ, Chan FK, Lau JY, et al. The effect of endoscopic therapy in patients
receiving omeprazole for bleeding ulcers with nonbleeding visible vessels or
adherent clots: a randomized comparison. Ann Intern Med 2003;139:237-43.
5. Mallinkrodt Medical product information leaflet for Sengstaken-Blakemore
tube product no: 156-20.
6. Hudak C, Gallo B, and Morton P (1998).Critical Care Nursing A Holistic
Approach.(7th ed) Lippincott, New York.
7. Henneman PL (1998).”Gastrointestinal bleeding “ in Emergency Medicine, ed
Peter Rosen et al. Mosby.St Louis.
Editor's Notes
This Guideline used for UGIH within 48 hrs from onsetOral double dose of PPI until EndoscopePatient should be referred if - High risk of bleeding include -> recurrent bleed (no endoscopic or surgery treatment)