Transcript Diagnostic approach to GI bleeding

Diagnosis of
Gastrointestinal Bleeding
Liu Zhenhua
Hematemesis and Hematochezia
The approach to gastrointestinal (GI) bleeding is
tailored to the manner of
appearance
Recognition of hemorrhage
Is bleeding acute or chronic?
Intensive care
Where is the source of bleeding?
What is the causes of bleeding?
Diagnosis
Empiric therapy
Treatment
Recognition of hemorrhage
Is bleeding acute or chronic?
Intensive care
Where is the source of bleeding?
What is the causes of bleeding?
Diagnosis
Empiric therapy
Treatment
( 经验治疗 )
Recognition of hemorrhage
Clinical Manifestations
1 Manner of bleeding presentation
2 Hypovolemia or shock
3 Anemia
Manner of bleeding presentation
Patients manifest blood loss
from the GI tract in five ways:
1) Hematemesis
Bloody vomitus, either fresh and
bright red or older and “coffee ground” (Acidic hematin) in character
Hemoptysis?
Nosebleeding?
Manner of bleeding presentation
2)
Melena

Shiny, black, sticky (tarry stool), foul-
smelling

Degradation of blood

Exogenous stool darkeners
iron
bismuth
Manner of bleeding presentation
3) Hematochezia
bright red or maroon blood from the
rectum
 pure blood
 blood intermixed with formed stool
 bloody diarrhea
Manner of bleeding presentation
4)
Occult
detected only by testing the stool
with a monoclonal antibody for human
hemoglobin
Estimate amount of bleeding from
upper GI tract
5~10 ml/d
50~70 ml/d
250~300 ml in short time
OB
+
Melena
Hematemesis
Manner of bleeding presentation
5) other symptoms of blood loss
dizziness, dyspnea, angina or
even shock
Blood loss
Sympathetic-adrenal medulla system
Catecholamine
Tachycardia
Pulse
Ischemia
of skin
Secretion of
sweat gland
Pale
Cold extremities
Sweating
Visceral vascular
contraction
Oliguria
Rectal temperature
Hypovolemia or shock
Speed and volume of blood loss
Weakness, giddiness, oliguria, cold extremity,
sweating
Vital signs: tachycardia, hypotention
Anemia
pale
fatigability
dizziness
dyspnea
palpitation
angina
Is bleeding acute or chronic?
1) Bleeding speed
Hematemesis of fresh blood generally
indicates a more severe bleeding episode
than melena, which occurs when bleeding is
slow enough to allow time for degradation of
blood
Is bleeding acute or chronic?
2) Blood pressure and heart rate
depend on
 amount of blood loss
 suddenness of blood loss
 extent of cardiac and vascular
compensation
Is bleeding acute or chronic?
postural hypotension
---- early physical finding
tachycardia
---- greater loss, compensate
recumbent hypotension
---- final results
Is bleeding acute or chronic?
Postural hypotension
A postural drop in blood pressure of 10 to
20 mm Hg
Is bleeding acute or chronic?
3) Bowel sound
Active bowel sound usually be presented in
acute bleeding from GI tract
Is bleeding acute or chronic?
4) Hematocrit

bleeding slowly

hypochromic microcytic red blood cells

mean corpuscular volume (MCV) of the cells
may be low
Is bleeding acute or chronic?
If blood loss is acute, the hematocrit
dose not change during the first few hours
after hemorrhage
About 24 to 72 hours later, plasma
volume is larger than normal and the
hematocrit is at its lowest point
Is bleeding acute or chronic?
7
6
5
4
Volume 3
(Liters)
2
45
%
45
%
1
A
B
Hematocrit changes
A Before bleeding
B Immediately after bleeding
C 24~72 hours after bleeding
27
%
C
Emergent and intensive care
Initially
vital signs
• supine and upright
blood pressure
• pulse
If blood loss is significant, intravenous
fluids must be started
Saline or other
balanced electrolyte
solutions are most
rapidly available
 Blood is sent to the lab
complete blood count
clotting studies
routine chemistry studies
 Blood for typing and cross-matching is
sent to the blood bank
Where is the source of bleeding?
Localization
Upper GI bleeding: bleeding from a
source proximal to the ligament of
Treitz.
Lower GI bleeding: bleeding from a
site distal to the ligament of Treitz.
Localization
Treitz:
The ligament of Treitz is an
anatomic
landmark
for
duodenal-jejunal junction
the
Localization
Differentiating features of
upper GI and lower GI bleeding
Manifestation
Nasogastric
aspirate
BUN
Bowel sound
Upper GI
Lower GI
Hematemesis
melena
Hematochezia
Bloody
Elevated
Hyperactive
Clear
Normal
Normal
More proximal lesions produce
hematemesis or melena, whereas more
distal lesions are more likely to produce
hematochezia
If hematochezia is
from
an
upper
GI
source,
it
usually
reflects
a
massive
bleed (i. e. , greater
than 1000 ml).
What is the causes of bleeding?
90% upper GI bleeding is due to four
lesions:
1)
2)
3)
4)
peptic ulcer
hemorrhagic gastritis
esophageal or gastric varices
gastric cancer
peptic ulcer
hemorrhagic gastritis
esophageal varices
gastric cancer
Causes of gastrointestinal bleeding
 Mallory-Weiss tear
Portal-hypertensive gastropathy
Ancylostomiasis
Post-sphincterotomy
Causes of gastrointestinal bleeding
• Colorectal cancer
• Colitis
• Large hemorrhoid
• Rectum tear
• Vascular anomalies
• Hematologic diseases
Diagnostic approach to
gastrointestinal bleeding
1
2
3
4
5
History and physical examination
Endoscopy
Barium radiography
Angiography
Nuclear scintigraphy
Diagnostic approach to GI bleeding
History and physical examination
A history of previously documented
GI tract disease determined by
radiography, endoscopy, or surgical
procedures is very useful.
Diagnostic approach to GI bleeding
A history of epigastric burning pain
promptly relieved by food or antacids or
nocturnal pain suggests peptic ulcer
disease, particularly duodenal ulcer
Diagnostic approach to GI bleeding
Localized epigastric tenderness to
palpation may indicate peptic ulcer disease
or gastritis
Diagnostic approach to GI bleeding
Patients with hepatitis B or
chronic active liver disease may
present with painless hematemesis
from esophageal varices.
Diagnostic approach to GI bleeding
Patients with stigmata of chronic liver
disease
[e.g.,
spider
angioma,
ascites,
gynecomastia] and upper GI bleeding often
bleed from esophageal varices or erosion
Diagnostic approach to GI bleeding
Patients with forceful, retching or multiple
episodes of vomiting of food prior to the onset
of hematemesismay be bleeding from Mallory－
Weiss tears of the gastroesophageal junction.
Diagnostic approach to GI bleeding
Colorectal malignancy is often suggested by
a history of
gradual weight loss
intermittent blood in the stools
altered bowel habits
Diagnostic approach to GI bleeding
Hemorrhoidal bleeding is often
suggested by the presence of bright red
blood surrounding well-formed, normalappearing stools.
Diagnostic approach to GI bleeding
A rectal examination is essential to
document stool color as well as to palpate for
gross ano-rectal mass lesions such as polyps,
cancers, or large hemorrhoids.
Diagnostic approach to GI bleeding
Endoscopy
Endoscopy is the diagnostic
procedure of choice because of
its high accuracy and immediate
therapeutic potential
Endoscopy, however, must be
performed only following adequate
resuscitation
Diagnostic approach to GI bleeding
Barium radiography
Barium radiography is noninvasive
but has significant disadvantages,
particularly in patients who are bleeding
briskly (actively)
Diagnostic approach to GI bleeding
Angiography
Angiography may localize the site of
bleeding
Diagnostic approach to GI bleeding
Angiography
Bleeding must be active because
angiography detects only extravasation of
contrast into the GI tract
Think about：

What is the clinical manifestations of GI tract
bleeding ？

What are the possible causes of GI tract
bleeding?