Acute upper gastrointestinal bleeding Haematemesis : is the vomiting of blood from a lesion proximal to the distal duodenum.

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GASTROINTESTINAL BLEEDING

• Acute upper gastrointestinal bleeding
  Haematemesis is the vomiting of blood from a
  lesion proximal to the distal duodenum.
• Melaena is the passage of black tarry stools the
  black colour is due to blood altered by bacteria
  - 50 mL or more is required to produce this.
• Melaena can occur with bleeding from any lesion
  from areas proximal to and including the caecum.
• Following a massive bleed from the upper GI
  tract, unaltered blood (owing to rapid transit)
  can appear per rectum, but this is rare.
• The colour of the blood appearing per rectum is
  dependent not only on the site of bleeding but
  also on the time of transit through the gut.
• The causes for upper GI hemorrhage include the
  following
• Esophageal causes
• Esophageal varices
• Esophagitis
• Esophageal cancer
• Esophageal ulcers
• Gastric causes
• Gastric ulcer
• Gastric cancer
• Gastritis
• Gastric varices
• Gastric antral vascular ectasia.
• Duodenal causes

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• Management of acute gastrointestinal bleeding
• Rapid history and examination.
• Monitor the pulse and blood pressure half-hourly.
  
• Take blood for haemoglobin, urea, electrolytes,
  ,liver functions ,blood grouping and
  crossmatching .
• Establish intravenous access - central line if
  brisk bleed.
• Give blood transfusion/colloid if necessary.
• Stop drugs, e.g. NSAIDs, warfarin
• Indications for blood transfusion are
• (a) SHOCK (pallor, cold nose, systolic PB below
  100 mmHg, pulse gt 100 b.p.m.)
• (b) haemoglobin lt 10 g/dL in patients with recent
  or active bleeding.
• Oxygen therapy for shocked patients.
• Urgent endoscopy in shocked patients/liver
  disease.
• Continue to monitor pulse and BP.
• Re-endoscope for continued bleeding/hypovolaemia.
  
• Surgery if bleeding persists.
• Urgent resuscitation is required in patients with
  large bleeds and the clinical signs of shock.
• Oxygen should be given by face mask and the
  patient should be kept nil by mouth until
  endoscopy has been performed.
• The major principle is to rapidly restore the
  blood volume to normal. This can be best achieved
  by transfusion of whole blood via one or more
  large-bore intravenous cannulae physiological
  saline is given until the blood becomes available
  .

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esophageal varices

• Risk factors
• Age is clearly significant. Below the age of 60
  years mortality from GI bleeding is small, lt
  0.1, but above the age of 80 the mortality is
  greater than 20.
• Patients with recurrent haemorrhage have an
  increased mortality.
• Most re-bleeds (approximately 20 of all cases)
  occur within 48 hours.
• Co-morbidity invariably increases mortality.
• Presence of shock at any time increases
  mortality.

Gasteritis - peptic ulcer

• Lower GIT bleeding
• Acute lower gastrointestinal bleeding
• Massive bleeding from the lower GI tract is rare.
  
• On the other hand, small bleeds from haemorrhoids
  occur very commonly.
• Massive bleeding is usually due to diverticular
  disease or ischaemic colitis.

• The causes of lower gastrointestinal bleeding are
• Coagulopathy - specifically a bleeding diathesis
• Colitis
• ischaemic colitis
• ulcerative colitis
• infectious colitis
• E. coli .
• Shigella
• C. difficile
• Campylobacter jejuni
• Hemorrhoids
• Angiodysplasia
• Neoplasm - cancer
• Diverticular disease - diverticulosis,
  diverticulitis

diverticulosis of the colon

• Most acute lower GI bleeds start spontaneously.
  The few patients that continue bleeding and are
  haemodynamically unstable need resuscitation
  using the same principles as for upper GI
  bleeding . Surgery is rarely required.
• A diagnosis is made using the history, and the
  following investigations as appropriate rectal
  examination (e.g. carcinoma)
• proctoscopy (e.g. anorectal disease, particularly
  haemorrhoids)
• sigmoidoscopy (e.g. inflammatory bowel disease)
• barium enema - ischaemic colitis
• colonoscopy - for any mucosal lesion and removal
  of polyps
• angiography - vascular abnormality (e.g.
  angiodysplasia )
• Isolated episodes of rectal bleeding in the young
  (lt 45 years) only require rectal examination and
  sigmoidoscopy. Colorectal cancer is rare in this
  age group without a strong family history.
  Individual lesions are treated as appropriate.

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• Chronic gastrointestinal bleeding
• Patients with chronic bleeding usually present
  with iron-deficiency anaemia .
• Chronic blood loss producing iron deficiency
  anaemia in all men and all women after the
  menopause is always due to bleeding from the
  gastrointestinal tract, often from a right-sided
  colonic neoplasm which must be excluded. Occult
  blood tests are necessary .
• Measurement of faecal occult blood
• It is only of value in premenopausal women - if
  a history of menorrhagia is uncertain and the
  cause of iron deficiency is unclear
• mass population screening for large bowel
  malignancy.
• Advantages cheap and easy to perform.
• Disadvantages high false-positive rate, leading
  to unnecessary investigations
• Diagnosis
• Chronic blood loss can occur with any lesion of
  the gastrointestinal tract that produces acute
  bleeding .
• It is, however, usual for oesophageal varices to
  bleed severely and rarely to present as chronic
  blood loss.
• It should be remembered that, world-wide,
  hookworm is the most common cause of chronic
  gastrointestinal blood loss.
• History and examination may indicate the most
  likely site of the bleeding, but if no clue is
  available it is usual to investigate both the
  upper and lower gastrointestinal tract
  endoscopically at the same session ('top and
  tail').
• For practical reasons an upper gastrointestinal
  endoscopy is performed first as this takes only
  minutes, followed by colonoscopy when any lesion
  can be removed or biopsied.
• A barium enema is performed only if colonoscopy
  is unavailable. A small bowel follow-through is
  the next investigation, but the diagnostic yield
  is very low