Gastrointestinal bleeding

The basic things you should be

knowing about
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Presentation
Upper gi bleeding :
Above the ligament of treitz or above the
duodenojejunal flexure
Manifested in the form of hematemesis or malena
Lower gi bleeding
Below the ligament of treitz
Manifested in the form of hematochezia
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Ligament of treitz
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Common causes of upper gi bleeding
Peptic ulcer
Bleeding oesophageal varices
Gastroduodenal erosions
Erosive oesophagitis
Mallory Weiss tear
Malignancy
Vascular ectasias
No cause found
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Vomiting due to GI bleeding or due to
some other causes ?
It is important to differentiate whether the
bleeding is due to GI bleeding or some other
causes like hemoptysis or epistaxis.
Ask if the patient had bleeding from the nose
before vomiting of blood.
Ask for cough preceding the vomiting of
blood.
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How to differentiate the different
causes of gi bleeding
Peptic ulcer
The patient gives a history of burning or gnawing
abdominal pain which is worsened by intake of
food or which awakens the patient at night.
There is history of nausea,belching and
unintentional weight loss
Bleeding oesophageal varices
May present with other signs of decompensated
cirrhosis such as ascites , hepatic encephalopathy
, jaundice
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Erosive oesophagitis :
There may be history of burning sensation in the
chest overlying oesophagus
There may be h/o dysphagia ( difficulty in
swallowing )
Mallory Weiss tear
Typical h/o retching before vomiting
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Management of upper gi bleeding
The first and foremost thing is resuscitation
Fluid resuscitation by ringer lactate or normal saline through a wide
bore cannula (16 G)
Insertion of nasogastric tube to
decompress the stomach
Aspirate the blood to know the probable site of bleeding
Insertion of Foley's catheter to monitor the urine output
Send the blood for hemoglobin , hematocrit ,Rh typing , blood
grouping and cross matching
If the hemoglobin or hematocrit comes out to be very low prepare for
blood transfusion with packed RBC.
In the mean time we can access the blood loss which can be done
as follows
15-20 % = no symptoms
20-40 % = tachycardia and hypotension
>40 % = shock


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Management continued
Send for LFT (liver function test) in patients who are
suspected to have cirrhosis

Start the patient on PPI
Pantoprazole 80 mg bolus followed by 8mg/hr for 48-72
hours
Do an endoscopy to locate the site of bleeding
If the bleeding is from a peptic ulcer and is profusely
bleeding
Sclerotherapy with adrenaline (1:10000) can be given
endoscopically
Use a hemostat clip to stop the bleeding endoscopically
If the ulcer is due to H.pylori then start the patient on anti
H.pylori triple therapy regimen .

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Management continued.
If the bleeding is due to bleeding varices then :
rubber band ligation of the varices can be done
Sclerotherapy can also be done
Octreotide 50 g iv bolus followed by 50 g/h can
be given
if above measures fail to control the bleeding then
TIPS ( Transjugular Intrahepatic Portosystemic
Shunting ) should be considered
In cases where the endoscopic procedure is not
available compression of varices with Sengstaken
Blackmore tube can be done although it is not a
primary choice of procedure.

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Case
A 4o years old gentleman with significant
alcohol intake history was brought to the
emergency dept. with H/o vomiting of blood.
What are the common causes of
hematemesis? How will you manage this
patient ?
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