Level of competent : 3B

GI Disorders Lecture in GERIATRI System, FKUH

 Hematemesis
Melena
Hematochezia
Occult bleeding
 Acute Vs Chronic

Upper vs Lower
 100%

required earlier and intensive care,

Symptoms of UGI Bleeding
80% 74%
suddenly life threatening.
Acute GI Present with hematemesis, melena,
bleeding 60%
hematochezia or coffe ground
vomiting
40%
26.00%
20%

0%
Melena Haemetemesis-melena
slow and intermittent, symptoms
Chronic GI
from blood loss or anemia
bleeding
 esophagus lig.Treitz of duodenum
UPPER GI
BLEEDING Variceal & non variceal

Incidence : 40-150 episode/100.000 people/year

mortality 6-10%, 5x more common than LGIB, >

lowest of lig.treitz intestine- colon

LOWER GI
BLEEDING 85% spontaneous recover, 15% hemodynamic
disturbance (proximal terminal ileum)

Incidence : 20-27 episode/100.000 people/year;

mortality 4-10%
5
ETIOLOGY OF GI BLEEDING

6
 Peptic Ulcer disease Aortoenteric fistel
Mallory Weiss Tears
Hemobilia
Dielufoy Lesion Hemosuccus pancreatikus
Vaskular malformation, and
Cameron lesion
Watermelon stomatch (gastric antral
Upper Gastrointestinal Tumors
vascular ectasia)

Peptic ulcers (40-70%) are the most

common cause of UGI bleeding

Saltzman JR. In Current diagnosis & treatment Gastroenterology, Hepatology & Endoscopy. 2009,pp324-342.
 250
LOWER GI TRACT. 190 200
200
Hemorrhoid
Colorectal carsinoma 150 121
Inflammatory Bowel
disease (Ulcerative 100
colitis/Crohns disease) 42
50
Colorectal polyp 8
Diverticular disease 0
Iskemia colitis Hemorroid IBD Colorectal Polip Diverticulosis
Angiodysplasia cancer

Intestinal hemorrhage

8
 Syncope : tachycardia, headache,
drowsy
Shock: hypotension (systolic
blood pressure <100 mm
Hg), rapid pulse (100 beats
/minute), pallor (conjungtiva,
PHYSICAL
HISTORY mucosa membran,nail bed), LABORATORY STUDY
EXAMINATION
coolless of extremities
Vomiting or Precise cause of Initial blood study :
passage of blood bleeding (blood CBC, electrolytes,
from rectum loss & peripheral blood urea nitrogen
Age of patient vasoconstriction, (BUN), creatinine,
Ingestion of gastric sign of CLD) glucose, clotting
mucosal irritants Rectal examination status (platelet
(aspirin, NSAIDs, Postural sign (age, count, PT/APTT)
alcohol) CV status, rate of
Associated medical blood loss)
condition (no=1% &
4=70%)

5/30/2012 9
 UGI LGI

Manifestation Hematemesis Hematokezia

Melena

Nasogastric aspirate Blood Clear

BUN/creatinin ratio Increase Normal

Peristaltic Hyperactive Normal

10
CLINICAL MANIFESTATION

11
POSTURAL SIGNS

Principle : Blood loss loss of intravascular volume

a fall in Cardiac output & blood pressure.

rapid pulse rate

Estimate :

Patient sits from supine position measurement of pulse and blood

pressure

The pulse rate increases > 20 beats/minute and systolic blood

pressure drops 10 mm Hg about 20% of blood loss prediction
(exceeded 1L)

5/30/2012 12
Blood loss < 750 750-1500 1500- > 2000
(ml) 2000
Blood loss (%) < 15 15-30 30-40 > 40

Pulse rate < 100 > 100 > 120 > 140

Blood normal normal decreased

pressure
Pulse pressure Normal or decreased decreased

Respiratory 14-20 20-30 30-40 > 35

rate
Urine output > 30 20-30 30-40 > 34
(ml)
Mental status Slightly Mildly anxious Anxious & Confused &
anxious confused lethargic
Fluid crystalloid crystalloid Crystalloid & Crystalloid &
replacement blood blood
Lau JY, Chung SCS. In Clinical Gastroenterology & Hepatology, 2005,p123.
MANAGEMENT

14
 blood drawn
>1 iv cath
1. for laboratory
A large-bore iv catheter inserted
promptly into a peripheral vein
Immediate venous access
(jugular,subclavia
infusion or femoral)
Shock, continue bleeding,
normal saline angina pectoris, hematocrite
hypotonic sodium < 20%
2.
solution
Infusion of
transfusion (PRC)
fluids & blood
electrolyte solution
clotting factor
High risk patients : older age, coexisting
cardiac illnesses, hepatic cirrhosis
packed red cells (PRC)until Ht > 30%
Young healthy patients
4. : whole blood until
3.
Ht > 20%
Monitoring of urine
Central venous pressure
output
catheter
 Adverse
Benefits
effects
Document the be passed in all patients
Should Patient discomfort
presence of blood
Predisposition to GE
Monitor the rate of reflux & pulmonary
bleeding aspiration

Aspirate is
1. DIAGNOSTIC
clear Irritation of
NG tube esophageal & gastric
Removed Identify recurrence of
mucosa, creating
bleeding after initial
mucosal artifact &
control
2. THERAPEUTIC Clears with Fresh blood
Large mount of existing
aggravating old blood
lavage lesion
Retained material

Lavage & decompress

the stomatch
Remove gastric acid Facilitates subsequent
endoscopy
Hemostasis
 Team of physician

Gastroenterologist Radiologist Surgeon

 Endoscopy Radionuclide scan

Barium contrast
Selective angography
radiography

Identifies the source of the bleeding after restoring stability patient hemodynamic
 Acid inhibiting drugs
Fasting Histamin-2 antagonist < Proton pump inhibitory
Non-fasting : (omeprazole, pantoprazole, esomeprazole)
Offending
few-often Emergency
80mg surgery
iv followed : Persistent
80mg/hour or recurrent
continous infusion
agent/ulcerog
severe bleeding
up to 72hours or iv/12hours
Less stimulating enic drugs
acid/pepsin Oral 1-2 weeks
Hypotension or shock
Continued bleed w/ transfusion 6 units
blood & no diagnosis in initial endoscopy
Severe active bleeding cant controlled by
Others :
endoscopy or angiography
Cytoprotective agent (sucralfate, rebamipide,
teprenone)
Endoscopic treatment
Hemostatic (tranexamic acid,
carbamazochrome) Surgery
Vasoactive drugs (vasopressin, somatostatin)
Antibiotics
High risk/poor prognosis

Age > 60 years old

Shock
Hb < 9 dl
Comorbid disease : cardiovascular,
pulmonary, liver, renal
23
 Admit pts with h/o recent brisk bleeding &
orthostatic changes
Admit pts with less sever blood loss who
have comorbid conditions aggravated by
anemia
Profound anemia with no evidence of blood
loss
Refer pts who are candidate for endoscopy
or colonscopy when source of bleeding is
elusive