UPPER GASTROINTESTINAL
BLEEDING
Case Review
A 38 year-old man present at emergency department
with tarry stools and feeling of light-
headedness. The patient indicates that over the past
24 hours he ahs had several bowel Movements
containing tarry-colored stools and for the past 12
hours has felt light-headed.His past medical and surgical is
unremarkable.The patient complains of
frequent headaches caused by work-related stress
for which he has been self-medicating with 6-8
tablets of ibuprofen a day for the past 2 weeks.He
consumes 2-3 martinis per day and denies tobacco or illicit drug
use.
HISTORY TAKING
Chief complaint
History of presenting illness
Past medical history & past Surgical history
Family history
Social history
Common manifestation
1. Haematemesis
2. Melena
-colour
-frequency
-onset
-amount
-presence of blood clot
Associated Symptoms
Epigastric pain
Dyspepsia
Anaemic
symptoms(dizziness,pallor,tachycardia,syncope)
Dysphagia
Chest pain
Dyspepsia
Dyspnoea
Fatigue
PHYSICAL EXAMINATION
Upper Gastrointestinal Bleeding
Inspection
• look at whole (cachexia, pallor or jaundice)
• Asymmetry or distension.
• bulge (position, size, shape, changes in its shape, and moves with
respiration or increase with coughing)
• patient’s reaction with coughing or moving.
• dilated surface veins.
Palpation
• general light palpation.
• (lightly, systematically, & non tender tender spot)
• (mild just pain
Guarding or tightening severe pain
Sharp exacerbation rebound tenderness)
Palpation for masses.
(presence, position, shape, size, surface, edge, consistence, fluid thrill,
resonance, and pulsatility)
palpation of the normal solid viscera.
liver
Spleen
Kidneys
Percussion
• Over any mass that may be missed on palpation.
• fluid thrill – tap on one side, feel the opposite side with other hand.
• shifting dullness – percuss the dullness in two position to see it moves or
changes (ascites)
• succussion splash – held pt at hips and shake the abdomen from side to
side. If positive, distension with a mixture of fluid and gas.
Auscultation
bowel sounds
• N: low-pitched, every few seconds
• absence: peristalsis has ceased
• paralytic ileus: can hear the heart and
• breath sounds, over 30 sec no bowel
• sound.
• systolic vascular bruits
Differential Diagnosis
Classified into 2 :
I. Variceal bleeding
• Peptic Ulcer
• Gastritis
• Malignancy
II. Non-variceal bleeding
UGIB- VARICEAL BLEEDING
Accounts for 7.8% of UGIB cases in Malaysia.
Majority of the patients have background history of liver
cirrhosis, which causes portal HPT that induce formation of
varices when HVPG >10mmHg
Variceal bleeding occurs when HVPG is more than 12mmHg.
Oesophageal variceal bleeding is more common that gastric
variceal bleeding. However, the severity of bleeding and
mortality are higher in gastric variceal bleeding.
Hepatic venous pressure gradient (HPVG)- difference between the
wedged/occluded hepatic venous pressure and the free hepatic
venous pressure,
UGIB : NON-VARICEAL BLEEDING
1. Peptic Ulcer Disease (PUD)
The commonest cause of non-variceal upper GI bledding
in Malaysia. Occurs most commonly in duodenal bulb and
stomach.
Risk factors include Helicobacter Pylori , increased in older
aged, NSAIDs, smoking and ingestion of steroid and anti-
coagulants.
2. Gastritis
Classified into 4 types ( Acute erosive gastritis, chronic
gastritis, reflux gastritis and hemorrhagic gastritis)
Acute erosive gastritis can cause persistent hemorrhage
result of diffuse loss of mucosal epithelium and small ulcers.
Associated with used of NSAIDs, steroid and intake of
alcohol
3. Malignancy
Accounts for 3.6% of UGIB
Carcinoma and lymphoma of stomach usually bleed at an
advanced ulcerated stage
Risk factors include smoking, increase in age, Helicobacter
Pylori.
Investigation
Forrest classification of upper GI bleed
-a grading system to describe bleeding
lesions in the upper GIT; it is a useful
method in predicting risk of
rebleeding.
Ia-spurting
b-oozing
IIa-visible vessel
b-adherent clot
c-haematin on ulcer base
III-lesions without active bleeding
Management For UGIB
• The principles :
1) resuscitation
- for management of shock and replacement of blood loss
- haemostases to stop the bleeding
2) Diagnosis of cause
3) Treatment of condition
General treatment :
Bed rest and vital signs monitoring
Resuscitation for blood loss (establish iv line and infusion of
crystalloid, colloid or blood)
Treat shock
Cathetherize
Establish diagnosis by endoscopy
Control varices with stengstaken tube or injection
Administer iv proton pump inhibitor
Eradication of h. pylori
Non-surgical intervention
Laser coagulation
Local cautery
Adrenaline injection
Gastric hypothermia for gastric erosions
Sclerotherapy for varices treatment
Octreotide infusion for varices
Embolization for treatment of angiomatous malformations
Surgical interventions
1) indications: -
Massive uncontrolled bleeding
Rebleeding, especially if bleeding vessels or clot has been seen at
endoscopy
More than 4 unit bleed in 24 hours unless the cause is varices
2) Operative :
Peptic ulcer : oversewing the ulcer with proton pump inhibition
and eradication of h pylori if appropriate. Partial gastrectomy
may be necessary
Acute erosions : partial gastrectomy if necessary
Esophageal varices : esophageal transection. Portocaval or distal
splenorenal shunting
Carcinoma: partial or total gastrectomy
Lower Gastrointestinal Bleeding
Definition: Bleeding from a gastrointestinal source
distal to ligament of Treitz
Example of case
67 year-old man
6-hour history of bleeding per rectum,
maroon-colored stool with blood clots, light-
headed
Began after urge to defecate and several
voluminous bowel movement
Not associated with abdominal pain
Previous borderline HPT with d/c and hernia
repair 2 years ago
Common Causes of Lower GI Bleed
According to Age
Infants/Toddlers Children/Teenagers Adults/Elderly
Volvulus Anal fissures Upper GI bleed
Intusseception Intussuception Angiodysplasia
Meckel diverticulum Meckel diverticulum Diverticulosis
Hirshsprung disease Polyps Neoplasm/polyps
Inflammatory bowel Anorectal disease
disease
Angiodysplasia Mesentric ischaemia
Hemolytic-uremic Inflammatory bowel
syndrome disease
Clinical presentation of acute GI Location
bleed
Hematemesis Proximal to ligament of Treitz
Melena Upper GI tract to right colon
Hematochezia Entire GI tract (massive, rapid
bleeding), usually lower such as
diverticular disease and
hemorrhoids
Nature of rectal bleeding Possible diagnosis
(a) Painless bleeding
Blood mixed with stool Colon carcinoma
Blood streaked on stool with Rectal carcinoma, colitis
mucous
Blood after defecation Hemorrhoids
Blood alone (massive amount) Diverticular disease
(b) Painful bleeding
-anal fissures,
-if rectal carcinoma spreads below mucocutaneous junction
Associated symptoms
Abdominal pain
Fever
Loss of appetite and loss of weight
Anemic symptoms
Change in bowel habits
Relevant Medical History
-Ulcerative colitis, chrons disease lead to colon cancer
-Family history of malignancy
-Smoking (worsen Chrons), smoking cessation (worsen UC)
Investigation for lower GI bleed
- Protoscope
- Sigmoidoscopy
- Colonoscopy
MANAGEMENT OF LOWER GI
BLEEDING
DEFINITE TREATMENT ACCORDING TO CAUSES.
Diverticular disease-high fibre, laxative,
antispasmodic, surgical resection
Crohn’s disease &Ulcerative colitis-5-
aminosalicylates (reduce
inflammation),antibiotics, immunosupressants eg
aziothioprine, ileal/colon resection
Colon cancer-Chemotherapy, radiotherapy, colon
resection
Hemorrhoids-banding, stapled hemorrhoidopexy
Angiodysplasia-endoscopic obliteration (cautery,
epinephrine injection)
