UPPER GI BLEEDS

Bleeding from a gastrointestinal source proximal to the ligament of Treitz which occurs at the duodeno-jejunal flexture.

Definition

Haematemesis or Malaena Abdo pain, hypotension (fatigue etc), purpura,

liver pathology stigmata (spleno-hepato- megaly, spider naevi, jaundice, hepatic flap

DDx

Rx – Upper Bleeds

Resuscitate/ABC - hypovolemia:  Rapid history and examination, note age. Monitor pulse and BP every 30 mins Take blood for haemoglobin, urea, electrolytes

and grouping; Establish IV access Give blood transfusion/colloid if necessary Indications: 1. If in shock: BP<100, pulse

>100bpm 2.haemoglobin<10g/dL Oxygen therapy for shocked patients

Correct any clotting abnormalities – Vit K? Warfarin?

Vasopressin PPI Urgent Endoscopy

– adrenaline/banding (arrests bleeding)

LOWER GI BLEEDS

Definition

The loss of blood from the GI tract distal to the ligament of Trietz.

This is the anatomical marker for the junction between the duodenum and the jejunum.

Causes

Causes of lower GI haemorrhage in adults Percentage of pts

Diverticular disease-Diverticulosis/diverticulitis of small intestine-Diverticulosis/diverticulitis of colon

60%

IBD-Crohn's disease of small bowel, colon, or both-Ulcerative colitis -Noninfectious gastroenteritis and colitis

13%

Benign anorectal diseases-Hemorrhoids -Anal fissures -Anal fistulas

11%

Neoplasia-Malignant neoplasia of small intestine-Malignant neoplasia of colon, rectum, and anus

9%

Coagulopathy 4%

Arteriovenous malformations (AVM) 3%

TOTAL 100%

Meckel diverticulum, intussusception, polyposis syndromes, and IBD are the common causes of GI bleeding in children and adolescents 

Signs and Symptoms

Maroon/red stained stools (hematochezia) or bright red blood from the rectum.

Malaena may also occur but it points more towards upper GI bleeds.

Hypotension; tachycardia Pallour, weakness, fainting and other signs

of anaemia (if chronic) Perform History and ask about IBD, weight

loss, FHx of Ca, stomach pain, bleeding disorders, last period.

Rx – Lower Bleeds

Resuscitation and initial assessment – same as in upper GIT bleeding

Localization of the bleeding site – using investigations such as rectal examination, proctoscopy, sigmoidoscopy, colonoscopy, etc)

Therapeutic intervention to stop bleeding at the site.

Rx Anaemia

H. Pylori and PUD

95 % DU assoc. With H. Pylori; 80% GU; 4:1

Risks: Smoking, NSAIDs, aspirin, steroids, increased acid secretion, increased gastric emptying, stress???, AGE (x>80)

Gram –ve, burrows into mucoid lining; Dx:13C Urea breath test

Serological tests – IgG antibodies – 80% sensitive & specificEndoscopy: Rapid urease test gastric biopsies added to urea soln. with phenol red. If present ph inc.↑ & causes colour change

Culture biopsies cultured on special medium with antibiotic sensitivities.

Rx