Title 9. Upper & Lower GI bleeding.pdf ✅

Upper & Lower GI bleeding ABU SAMN & MEERA Upper GI Bleeding General - Bleeding proximal to the ligament of Treitz. - Causes: • Esophagus: cancer, varices, Mallory Weis syndrome. • Stomach: cancer, ulcers. • Duodenal: ulcers. - Symptoms: • Hematemesis: vomiting blood. • Coffee-ground emesis. • Melena: → Black tarry shinny stool that is foul smelling. • Epigastric discomfort. • Signs of hypovolemia. • Can be hematochezia if a very massive bleeding from an UGI source. - Signs: • Hypovolemia, shock. → Tachycardia, hypotension, LOC. - Investigations: • CBC: anemia. • Blood type, cross match. • PT/PTT. • LFTs. • Upper GI endoscopy: Gold standard. → Diagnostic and therapeutic. • Selective mesenteric angiography. → Used in case of massive bleeding where EGD fails to diagnose the site of bleeding. - Management: • Initial management: → IV fluids, Foley’s catheter. → NG tube. → Water lavage. → Endoscopy. • Surgery: → Only 10% need surgery. → Indication: continuous bleeding after endoscopy, recurrent bleeding, shock. - Risk factors for death following UGI bleeding: • Age >60 years. • Shock. • >5 units of PRBC transfusion. • Concomitant health problems. Peptic Ulcer - The MC cause of upper GI bleeding. - Common: 10% of population. - MC cause: H.pylori. - Types: • 1: lesser curvature. • 2: in stomach and duodenum (2 ulcers). • 3: pyloric canal. • 4: proximal, gastroesophageal junction. • 5: anywhere, associated with NSAIDS. Melena
Upper & Lower GI bleeding ABU SAMN & MEERA - Complications: • Perforation: → MC complication. → Caused by an anterior ulcer. → Presentation: acute onset of upper abdominal pain radiating to the back, rigidity, acute abdomen. → Can cause Valentino's syndrome. → Investigation: upright chest x-ray: air under diaphragm. → Management: NPO, NG tube, IV fluids, IV antibiotics, Graham patch if needed. • Bleeding: → Caused by a posterior ulcer. → Bleeding form gastroduodenal artery. → Presentation: hematemesis (coffee ground), melena, hematochezia, shock signs. → Management: resuscitation, NPO, IV fluids, blood, IV antibiotics, PPI, most cases stop bleeding spontaneously without the need for surgery. • Stenosis: → Causes gastric outlet obstruction. ➢ Succussion splash on physical examination. ➢ https://www.youtube.com/watch?v=IvX_TgiJU5I → Presentation: projectile non-bilious vomiting. → Labs: hypochloremic hypokalemic metabolic alkalosis. → Management: NPO, IV fluids, PPI, pyloric dilation by endoscopy. Gastric Duodenal Common Less More Age >40 <40 More in Males Males Caused by ↓ gastric protection ↑ production of gastric acid MC site Lesser curvature Within 2 cm of the pylorus in the duodenal bulb Response to food Exacerbated Relieved Body weight Thin Obese Malignancy Could be (you should take biopsy) Benign Associated with NSAIDS Genetics Features More severe pain, less relieved by antacids Present earlier Treatment PPIs or H2 blockers, H. pylori treatment - Diagnosis: • Urea breath test. • Upper GI endoscopy. Esophageal Varices - Two thirds of patients with portal hypertension develop esophageal varices. - Two thirds of patients with esophageal varices bleed. - Treatment: sclerotherapy or band ligation via endoscope, TIPS, liver transplant.
Upper & Lower GI bleeding ABU SAMN & MEERA Dumping Syndrome - Delivery of hyperosmotic chyme to the small intestine causes massive fluid shifts into the bowel. - A complication of gastric bypass surgery. - Presentation: postprandial. • Early (immediately): → Epigastric fullness, sweating, light headedness, tachycardia, colic, diarrhea, bloating, vomiting, cramping. → Exacerbated by more food, relieved by lying down. • Late (after 30-40 minutes): → Tremor, faintness, prostration, weakness, sweating, dizziness. → Exacerbated by exercise, relieved by food. → Associated with hypoglycemia. - Treatment: diet changes, ondansetron, acarbose, reconstruction of the pyloric sphincter. Lower GI Bleeding General - Bleeding distal to the ligament of Treitz. - Causes: • Children: Meckel’s diverticulum (MC), intussusception, UC, FAP. • Adults: coagulopathy, AVM, UC, colorectal cancer, diverticulosis, hemorrhoids, anal fissure, drugs. - Amount of bleeding: - Symptoms: • Hematochezia: bright red blood per rectum. • With or without abdominal pain. • Anorexia, fatigue, syncope, shortness of breath, shock. - Signs: same as UGI bleeding. - Investigations: • Same as UGI bleeding but we also do colonoscopy. • Upper GI bleeding should be excluded: → Do UGI endoscopy. → NG tube is placed. - Management: • Same as UGI bleeding but we also do colonoscopy. → Localize the location of bleeding. → Inject epinephrine. • Stop antiplatelet, anticoagulants used. ْل َر ِِّب ا ْر َح ْم ُه َما َك َما َربَّيَانِي َصِغي ًر ا ( ُ ) َوق