Gastrointestinal Hemorrhage

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Gastrointestinal Hemorrhage ????? ???????????? ??
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????????(the ligament of Treitz)??,??????????????
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• Supper Gastrointestinal Hemorrhage
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Etiology

• Upper gastrointestinal bleeding is most
  commonly caused by peptic ulceration,
  gastroesophageal varices, acute erosive and
  hemorrhagic gastritis, and gastric cancer

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Etiology
Esophageal Diseases Duodenal and Gastric
Diseases Portal Hypertension-Related
Causes Hemobilia Hemosuccus Pancreaticus Systemic
Diseases

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Esophageal Diseases

1. Esophagitis
2. Esophageal ulceration
3. Tumor of the esophagus
4. Esophagus diverticulitis
5. Esophagus injury physical (Mallory-Weiss Tear)
   chemical (strong acid or alkali) radioactive

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Duodenal and Gastric Diseases

• Gastric Ulcer Acute erosive and hemorrhagic
  gastritis Gastric cancer Gastric polyp
  Zollinger-Ellison Syndrome MALToma
  Neurofibromatosis Gastric vascular abnormity
  (Vascular Ectasia, Arteriovenous Malformations,
  Dieulafoy's Lesion) Prolapse of gastric mucosa
  Gastritis after operation stoma ulcer
• Duodenal Ulcers Duodenal diverticulitis
  Acute erosive duodenitis Crohns disease
  Duodenal tuberculosis

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Portal Hypertension-Related Causes

1. Esophageal varices
2. Gastric varices
3. Portal hypertensive gastropathy

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Hemobilia

• Including trauma, gallstones, cholecystic
  carcinoma, cholangiocarcinoma, ascariasis of
  biliary tract, liver cancer, liver abscess,
  hepatic hemangioma

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Hemosuccus Pancreaticus

• Pancreatic cancer
• Erosion of a pseudocyst into the splenic or
  peripancreatic artery or formation of an arterial
  aneurysm in the course of chronic pancreatitis

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Systemic Diseases

• Vascular Diseases
• hypersusceptible purpura
• hereditary hemorrhagic telangiectasia
• Hematic Diseases
• haemophilia thrombocytopenic
  purpura
• Uremia
• Connective Tissue Diseases
• polyarteritis nodosa systemic lupus
  erythematosus
• Stress-related gastric mucosal injury

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Clinical Presentation

• Hematemesis
• Melena
• Hematochezia
• Symptoms of blood loss
• Anemia and Change of hemogram
• Elevation in the BUN level

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Hematemesis

Be defined as the vomiting of blood and
indicates an upper gastrointestinal site of
bleeding blood may be either fresh, bright red,
or it may be old and take on the appearance of
coffee grounds bright red blood often from
varices or arterial lesion Patients with coffee
ground emesis are not usually bleeding actively
but have had a recent or even remote bleeding
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Melena

Be defined as passage of black, tarry, and
foul-smelling stool Character of melena is due
to degradation of blood to hematin or other
hemochromes by bacteria Instillation of 50 to
100 mL of blood into the stomach is required to
produce melena consistently, tests for fecal
occult blood become positive when about 5 mL is
lost per day
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Hematochezia

Refers to passage of bright red blood from the
rectum that may or may not be mixed with
stool It is happen when patients have gastro-
intestinal lesions that bleed massively
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Symptoms of blood loss

• Including lightheadedness tachycardia
  angina pectoris postural hypotension (the blood
  pressure is maintained on recumbency but falls
  more than 15 to 20 mmHg when the patient sits up)
  or even shock (pale to ashen, dyspnea, sweating
  and distressed, syncope)

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Anemia and Change of hemogram
Patients who bleed small amounts of blood over
long periods of time develop iron deficiency
anemia, a low mean corpuscular volume (MCV),
hypochromic, microcytic red blood cell and
detection of occult blood in the stool with
standard fecal occult blood tests If blood loss
is acute, hematocrit value may not reflect blood
loss accurately and the MCV, hemoglobin
concentration is normal, Because equilibration
with extra-vascular fluid and subsequent
hemodilution requires several hours

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Elevation in the BUN level

The blood urea nitrogen (BUN) level may be
mildly elevated in patients with upper GI
bleeding Due to breakdown of blood proteins to
urea by intestinal bacteria and its absorption,
as well as from a mild reduction in glomerular
filtration rate BUN less than 14.3 mmol/L
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Clinical Localization of Bleeding

• Hematemesis is from an upper gastrointestinal
  source of bleeding
• Melena is usually the result of upper
  gastrointestinal bleeding and should not be
  confused with components of the diet (such as red
  meat and vegetables containing peroxidases) or
  the dark-green character of ingested iron or the
  black, nonfoul-smelling stool caused by ingestion
  of bismuth (such as bismuth subsalicylate)

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• Hematochezia is usually the result of lower
  gastrointestinal bleeding but approximately 10
  of the patients with rapid bleeding from an
  upper source present with hematochezia
• The nasogastric lavage has been used
  extensively to help differentiate upper from
  lower gastrointestinal bleeding, but now, the use
  is discouraged
• Other clues to an upper gastrointestinal
  source of bleeding include hyperactive bowel
  sounds and an elevation in the BUN level out of
  proportion to creatinine

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Algorithm for management of upper
gastrointestinal bleeding
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• Lower digestive Hemorrhage
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Definition

Lower digestive hemorrhage refers to bleeding
(hemorrhage) that arises in the digestive tract
below the ligament of Treitz
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Radionuclide imaging

• Radionuclide imaging (such as Tagged Red Blood
  Cell Scintigraphy) is mainly adopted in patients
  with lower gastrointestinal bleeding
• Advantages (1) sensitivity to low rates of
  bleeding (0.1 to 0.5 mL/min) (2) safety (3) it
  is noninvasive (5) low cost
• Disadvantages include its lack of therapeutic
  capability and doubt about its accuracy

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Angiography

• Angiography is adopted when bleeding is so
  massive that endoscopy cannot be safely or
  satisfactorily performed and surgery is
  contraindicated

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Clinical features which predict recurrent
bleeding and increased mortality
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????(background)

• ????
• 1998.04-2000.07 ?????????
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• 1993.09-1996.07 ??????(????????) ?????
• 1986.09-1991.02 ????????
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• 2000.03-2002.04 ??????St.-Josef-Hospital?
  ?????????
• 2006.10-2007.6 ????????? ??????
• 2007.7-2007.11 ?????????????????? ?????????
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• 1991.07-1993.07 ???????? ????
• 1996.07-1998.01 ???????? ????
• 2002.04-2005.07 ??????????????? (?????)
• 2005.07?? ??????????????? (?????)
• 
  ????????????????? ???????
• 2007.12 ????????????????

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