Hemetamesis and Hemetochezia (Acute GI Hemorrhage)

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Hemetamesis and Hemetochezia(Acute GI Hemorrhage)

• Dr. Wu ShuMing
• GI Dept. RenJi Hospital

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Five Ways of GI Bleeding

• Hematemesisvomitting of blood of altered
  blood(coffee grounds) indicates bleeding proximal
  to ligament of Treitz
• MelenaTarry stool. Altered (black) blood per
  rectum (gt60ml)
• Hematochezia Bright red or maroon rectal
  ,bleeding implies bleeding beyond Lig.T.
• FOB and Iron deficiency anemia

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Factors affect the way to manifest

• Site of bleeding
• Speed of bleeding
• Amount of blood loss
• Flora of enterocolon
• .

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Differentiating Upper from Low GI Bleeding

• Hematochezia usually represents a lower GI source
  bleeding
• Upper GI lesion may bleed so briskly that blood
  doesnt remain in bowl long enough to become
  melena
• Bleeding lesion distal to T Lig.may be either
  M.or hematochezia, but never manifests
  hematemesis

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Common cause of up GI bleeding

• Peptic ulcer
• Gastropathy (alcohol, aspirin, NSAIDs, stress)
• GE varices
• Gastric cancer

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Less common cause of up GI bleeding

• Esophageal or intestinal neoplam
• Esophagitis Malloy-weiss tear,
• Hemoptysis Swallowed blood
• Anticoagulant fibrinoloytic therapy
• Telangiectases aneurysm vasculitisDieulafoy
  ulcer AV malformation
• Connective tissue disease
• Hemabilia(biliary originCrohns
  diseaseamyloidosis , hematological diseases

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BENIGN GASTRIC ULCER

• The classical presentation of gastric ulcer
• with weight loss and indigestion made worse by
  eating,
• patients more often describe symptoms that would
  fit equally well for duodenal ulcer -
  investigation with barium meal or (preferably)
  endoscopy is, of course, appropriate for either.
  Benign ulcers may occur at any site in the
  stomach, but are commonest on the lesser curve
  away from acid-secreting epithelium.

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Duodenum Ulcer

• The lesion most commonly affecting the duodenum
  is ulceration, and it is now known that both
  antral infection with Helicobacter pylori and the
  presence of gastric acid are virtual
  prerequisites for it..

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GE Varices

• A number of cutaneous features (stigmata) may
  develop in a patient with cirrhosis, and these
  are important as they aid clinical recognition of
  chronic liver disease.

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Clinical manifestation of GI Bleeding

• Abdominal discomfort
• Nausea,
• Hemadynamic change reduction in blood volume
  (syncope,light-headedness, sweating,therst) or
  shock
• Laboratory changes HCT, BUN

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Hematemesis with other symptoms

• Hematemesis with upper abdominal pain
• Hematemesis with hepatomegly and spleenomegly
• Hematemesis with jaundice
• Hematemesis with Skin mucosa hemorrhage
• Hematemesis with upper abdominal mass
• Others NSAIDs, Stress, Burning, Brain operation,
  Trauma, Vomiting

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Lab.Examination in Localization Diagnosis of GI
Bleeding

• Endoscopy
• Barium Radiographs
• Angiography
• Radionuclide imaging

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Approach to the patient with acute upper
gastrintesttinal hemorrhage

• Acute upper Gastrointestinal Hemorrhage
• Rapid assessment Monitor
  hemodynamic status
• Fluid resuscitation
  Gastric lavage(?)
• self-limited (80)
  bleeding (10-20)
• Empiric medical therapy
• Urgent
  endoscopy
• recurrent hemorrhage
• endoscopy Site not localized
  Localized
• further
  assessment
• enteroscopy,
  radioisotope
  
  s
  scan, angiography,
  
• 
  exploratory surgery
• Definitive therapy
  Definitive therapy

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Summary of Acute GI Bleeding

• Upper GI source bleeding--Hemetemesis
• Major upper GI bleding-- Hemetemesis
  hemetochezia
• The more distant from the rectum, the more likely
  that melaena occurs
• The colon lesion--FOB or hemetochezia
• The small bowl lesion-- melena or hemetochezia

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The questions should be posed

• Prior bleeding episode?
• Family history of GI diseases
• Dose the patient have the illness of ulcer?
• Cirrhosis?cancer?bleeding disorder?
• Alcohol? NSAIDs?
• Any precedes symptoms or signs?

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Endoscopic view of a Mallory-Weiss tear with
active bleeding (gastric lumen is at top left).
B, Endoscopic view of an organized clot adherent
to a Mallory-Weiss tear (gastric lumen is at
bottom left ).
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Endoscopic view of a Dieulafoy lesion on the
lesser curvature of the stomach
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Endoscopic view of a vascular ectasia
(angiodysplasia) in the duodenum.
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Endoscopic view of the gastric antrum with
watermelon stomach. The pylorus is at top center.
Note the linear distribution pattern of the
vascular lesions arranged radially around the
pylorus.
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Endoscopic views of ulcers with stigmata of
recent hemorrhage. A, Duodenal ulcer with a
visible vessel. B, Gastric ulcer with a red spot
in the center of the crater. C, Duodenal ulcer
with a red spot in the center of the crater. D,
Purplish clot adherent to a gastric ulcer.
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Typical picture of a trivial nonsteroidal
anti-inflammatory drug (NSAID)-induced injury to
the gastric mucosa. There are multiple small
erosions with brown-black staining of the center
as a result of local bleeding and petechiae.
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Typical round gastric ulcer at the angulus
(incisura) of the stomach.
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Causes of Low GI Bleeding
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Differentiating Upper from Low GI Bleeding

• Hematochezia usually represents a lower GI source
  bleeding
• Upper GI lesion may bleed so briskly that blood
  doesnt remain in bowl long enough to become
  melena
• Bleeding lesion distal to T. Lig. may be either
  M.or hematochezia, but never manifests
  hematemesis

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Hematochezia with other symptoms

• Abdominal pain
• Fever
• Tenesmus
• Systemic Hemorrhage
• Dermal sign
• Abdominal mass

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Lab. Examination For detecting Low GI Bleeeding

• Anoscopy sigmoidoscopy
• Barium Edema (BE)
• Angiography
• Radionuclide scanning

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A, Linear ulcers of Crohn's colitis. B, Mucosa
surrounding the ulcers is nodular (cobblestoning).
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Shigella colitis. Patchy areas of erythema,
spontaneous bleeding, and loss of the normal
vascular pattern are evident
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Salmonella colitis. Diffuse erythema, spontaneous
bleeding, and loss of the vascular pattern with
formation of telangiectasis are present.
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Tuberculosis. Linear ulceration runs
circumferentially along the interhaustral septum
with tiny satellite ulcerations. This must be
distinguished from the longitudinal linear
ulcerations seen in inflammatory bowel disease.
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Pseudomembranous (antibiotic-associated) colitis.
Numerous elevated yellowish plaques are present
on the mucosal surface.
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Amebiasis. Discrete punched-out ulcers are
present in the right colon.
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Severe acute ulcerative colitis. No vascular
pattern is discernible. A severe degree of
spontaneous bleeding is present
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Large colonic ulcer in a patient with ischemic
colitis.
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Advantage colon carcinoma