Hemetamesis and Hemetochezia(Acute GI Hemorrhage)

Dr. Wu ShuMing

GI Dept. RenJi Hospital

Five Ways of GI Bleeding

Hematemesis ： vomitting of blood of altered blood （ coffee grounds ） indicates bleeding proximal to ligament of Treitz

Melena ： Tarry stool. Altered （ black ） blood per rectum （ >60ml ）

Hematochezia ： Bright red or maroon rectal ,bleeding implies bleeding beyond Lig.T.*

FOB+ and Iron deficiency anemia

Factors affect the way to manifest

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

.

Differentiating Upper from Low GI Bleeding

Hematochezia usually represents a lower GI source bleeding

Upper GI lesion may bleed so briskly that blood doesn`t remain in bowl long enough to become melena

Bleeding lesion distal to T Lig.may be either M.or hematochezia, but never manifests hematemesis

Common cause of up GI bleeding

Peptic ulcer ；Gastropathy （ alcohol ， aspirin ， NSAI

Ds ， stress ）；GE varices ； Gastric cancer

Less common cause of up GI bleeding

Esophageal or intestinal neoplam

Esophagitis ； Malloy-weiss tear ，Hemoptysis: Swallowed blood

Anticoagulant fibrinoloytic therapy:

Telangiectases ； aneurysm ； vasculitis ； Dieulafoy ulcer ； AV malformation

Connective tissue disease ；Hemabilia （ biliary origin ； Crohn`s disease ； amylo

idosis , hematological diseases

BENIGN GASTRIC ULCER

The classical presentation of gastric ulcer :with weight loss and indigestion made worse by eati

ng, 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.

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..

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.

Clinical manifestation of GI Bleeding

Abdominal discomfort

Nausea, Hemadynamic change: reduction in blood v

olume (syncope,light-headedness, sweating,therst) or shock

Laboratory changes: HCT, BUN

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

Lab.Examination in Localization & Diagnosis of GI Bleeding Endoscopy Barium Radiographs Angiography Radionuclide imaging

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

Summary of Acute GI Bleeding

Upper GI source bleeding--Hemetemesis Major upper GI bleding-- Hemetemesis & h

emetochezia The more distant from the rectum, the more

likely that melaena occurs The colon lesion--FOB+ or hemetochezia The small bowl lesion-- melena or hemetoc

hezia

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?

2005 年中国急性上消化道出血诊治指南

中华内科杂志编委会 . 急性非静脉曲张性上消化道出血诊治指南（草案） . 中华内科杂志 2005 ； 44(1): 73-76

口服 PPIs

静脉大剂量 PPIs

内镜检查与治疗

出血征象监测、液体复苏并止血治疗

监护病房

中高危 (Rockall评分≥ 3分 )

上消化道出血病情严重度分级 (Rockall评分

重复内镜治疗经血管造影介入治疗

手术治疗 原发病治疗及随访

成功

成功

失败

失败

失血量的评估 失血量 伴随症状

血压和脉搏化验检查

脉搏 血压 休克指数

＜ 400ml 无自觉症状＜ 100/min 正常

＜ 0.58

≥400ml头晕、心慌、口干 ＝ 1

≥800 ml100 ～ 120

SBP70 ～ 80mmHg

脉压差＜ 30mmHg≥1200ml

晕厥、尿少、烦躁＞ 1

HGB≤70g/L肠源性氮质血

症≥1600ml

≥120体位低血压

SBP≤50 ～70mmHg≥2000ml 气促、无尿、昏迷

急性非静脉曲张性上消化道出血诊治指南 中华内科杂志： 2005.1.

Palmar KR. Guideline Gut 　 2002

出血严重程度评估

分级 年龄 伴发病

失血量 (ml) 血压 (mmHg)

脉搏( 次 /分 )

血红蛋白(g/L)

症状

轻度＜ 60 无 ＜ 500 基本正常 正常 无变化 头昏

中度＜ 60 无 500~1000 下降 ＞ 100 70 ～

100 晕厥、口渴、少尿

重度＞ 60 有 ＞ 1500 收缩压＜ 80＞ 120 ＜ 70

肢冷、少尿、意识模糊

急性非静脉曲张性上消化道出血诊治指南 中华内科杂志： 2005.1.Palmar KR. Guideline Gut 　 2002

急性上消化道出血患者Rockall 再出血和死亡危险性评估系统

变量 评 分

0 1 2 3年龄( 岁 ) ＜ 60 60 － 79 ≥80

休克无休克（收缩压＞100mmHg ，脉率＜ 100 次／分）

心动过速（脉率＞ 100 次／分，收缩压＞100mmHg ）

低血压（收缩压＜ 100mmHg ），脉率＞ 100 次／分

伴发病 无 心力衰竭、缺血性心脏病及其他重要伴发病

肝衰竭、肾衰竭和癌肿播散

内镜诊断 Mallory-Weiss 撕裂，无病变 溃疡等其他病变 上消化道恶性疾病

内镜下出血征象 无或有黑斑

上消化道血液潴留、黏附血凝块，血管显露或喷血

高危：≥ 5， 中危： 3～ 4， 低危： 0～ 2

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 ).

Endoscopic view of a Dieulafoy lesion on the lesser curvature of the stomach

Endoscopic view of a vascular ectasia (angiodysplasia) in the duodenum.

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.

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.

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 pete

chiae.

Typical round gastric ulcer at the angulus (incisura) of the stomach.

ESOPHAGUS STOMACHDUODENUM

JEJUNUM ILEUM COLORECTUM

Esophageal varices AV malformations AngiodysplasiaEsophagitis Angiodysplasia AV malformationsGastritis Ulcers Ulcerative colitisGastric varices Anastomotic DiverticulosisMallory-Weiss tears Simple CancerPeptic ulcer Diverticula PolypsAV malformations Meckel's HemorrhoidsCancer Acquired Anal fissurePolyps Crohn's disease Stomal varicesLeiomyoma Varices PostoperativeSarcoma Ischemic ulcer PostpolypectomyBrunner's adenoma Tuberculosis AnastomoticAngiodysplasia Arteritis TraumaPancreatic rest Blind loop UlcersTrauma Angioma SimplePostoperative Leiomyoma StercoralRetained ulcer Cancer TyphoidResidual gastritis Sarcoma AmebicAnastomotic ulcer Polyps

Uremic ulcer Stomal varices Lymphoid hyperplasia Trauma

Causes of Low GI Bleeding

Differentiating Upper from Low GI Bleeding

Hematochezia usually represents a lower GI source bleeding

Upper GI lesion may bleed so briskly that blood doesn`t remain in bowl long enough to become melena

Bleeding lesion distal to T. Lig. may be either M.or hematochezia, but never manifests hematemesis

Hematochezia with other symptoms

Abdominal pain Fever Tenesmus Systemic Hemorrhage Dermal sign Abdominal mass

Lab. Examination For detecting Low GI Bleeeding

Anoscopy & sigmoidoscopy Barium Edema (BE) Angiography Radionuclide scanning

A, Linear ulcers of Crohn's colitis. B, Mucosa surrounding the ulcers is nodular (cobblestoning).

Shigella colitis. Patchy areas of erythema, spontaneous bleeding, and loss of the normal vascular pattern are evident

Salmonella colitis. Diffuse erythema, spontaneous bleeding, and loss of the vascular pattern with formation of telangiectasi

s are present.

Tuberculosis. Linear ulceration runs circumferentially along the interhaustral septum with tiny satellite ulcerations. This must be distinguished from the longitudinal linear ulcerations s

een in inflammatory bowel disease.

Pseudomembranous (antibiotic-associated) colitis. Numerous elevated yellowish plaques are present on th

e mucosal surface.

Amebiasis. Discrete punched-out ulcers are present i

n the right colon.

Severe acute ulcerative colitis. No vascular pattern is discernible. A severe degree of spontaneous bleeding is present

Large colonic ulcer in a patient with ischemic colitis.

Advantage colon carcinoma