GASTROGASTRO

INTESTINAL BLEEDINGINTESTINAL BLEEDING

AN APPROACH TO AN APPROACH TO

DIAGNOSISDIAGNOSIS

Gatot Sugiharto, dr. SpPDGatot Sugiharto, dr. SpPD

Internal Medicine Dept. Faculty of MedicineInternal Medicine Dept. Faculty of Medicine

Wijaya Kusuma UniversityWijaya Kusuma University2014 2014

DEFINITIONSDEFINITIONS

PATHOPHYSIOLOGY OF GI PATHOPHYSIOLOGY OF GI BLEEDINGBLEEDING

SOURCES OF GI BLEEDINGSOURCES OF GI BLEEDING

UPPER VS LOWERUPPER GI BLEED LOWER GI BLEED

UPPER VS LOWER

UPPER GI BLEED LOWER GI BLEED

UPPER GI BLEEDUPPER GI BLEED

• RISK FACTORS• NSAID USE

• H. PYLORI INFECTION

• INCREASED AGE

• UPPER GI BLEEDING ACCOUNTS FOR APPROXIMATELY 350,000 HOSPITALIZATIONS PER YEAR.

ETIOLOGY OF UPPER BLEEDSETIOLOGY OF UPPER BLEEDS

CAUSES OF UPPER GI BLEEDCAUSES OF UPPER GI BLEED(1)(1)

CAUSES OF UPPER GI BLEED CAUSES OF UPPER GI BLEED (2)(2)

CAUSES OF UPPER GI BLEED CAUSES OF UPPER GI BLEED (3)(3)

CAUSES OF LOWER GI BLEEDING CAUSES OF LOWER GI BLEEDING (1)(1)

CAUSES OF LOWER GI BLEEDING CAUSES OF LOWER GI BLEEDING (2)(2)

PHYSICAL EXAMPHYSICAL EXAM

LAB WORK UPLAB WORK UP• CBCCBC

• SERIAL HGBSERIAL HGB

• PLATELETS PLATELETS

• BASIC PANELBASIC PANEL• LFT, RFTLFT, RFT

• BLOOD TYPE AND CROSSMATCHBLOOD TYPE AND CROSSMATCH

• COAGULATION STUDIESCOAGULATION STUDIES

• STOOL WBCS TO EVALUATE INFECTIOUSSTOOL WBCS TO EVALUATE INFECTIOUS

• IMAGING STUDIES?IMAGING STUDIES?

HOW TO LOCATE OF BLEEDINGHOW TO LOCATE OF BLEEDING

EVIDENCE OF UPPER GI BLEEDEVIDENCE OF UPPER GI BLEED

• HEMATEMESIS (50%)HEMATEMESIS (50%)

• NGT WITH POSITIVE BLOOD ON ASPIRATENGT WITH POSITIVE BLOOD ON ASPIRATE

• HEMATOCHEZIA (11%)HEMATOCHEZIA (11%)

• MELENA (BLACK TARRY STOOLS)MELENA (BLACK TARRY STOOLS)

• THIS DEVELOPS WITH APPROXIMATELY 150-200CC OF THIS DEVELOPS WITH APPROXIMATELY 150-200CC OF BLOOD IN THE UPPER GI TRACT. BLOOD IN THE UPPER GI TRACT.

• STOOL TURNS BLACK AFTER 8 HOURS OF SITTING WITHIN STOOL TURNS BLACK AFTER 8 HOURS OF SITTING WITHIN THE GUTTHE GUT..

• HEMATEMESIS (50%)HEMATEMESIS (50%)

• NGT WITH POSITIVE BLOOD ON ASPIRATENGT WITH POSITIVE BLOOD ON ASPIRATE

• HEMATOCHEZIA (11%)HEMATOCHEZIA (11%)

• MELENA (BLACK TARRY STOOLS)MELENA (BLACK TARRY STOOLS)

• THIS DEVELOPS WITH APPROXIMATELY 150-200CC OF THIS DEVELOPS WITH APPROXIMATELY 150-200CC OF BLOOD IN THE UPPER GI TRACT. BLOOD IN THE UPPER GI TRACT.

• STOOL TURNS BLACK AFTER 8 HOURS OF SITTING WITHIN STOOL TURNS BLACK AFTER 8 HOURS OF SITTING WITHIN THE GUTTHE GUT..

COMMON CAUSE OF UPPER GI BLEEDINGDUODENAL ULCER VARICOSE

COMMON CAUSE OF UPPER GI BLEEDING

ANGIODYSPLASIA ESOPHAGITIS

GI MALIGNANCYGI MALIGNANCY

GASTRIC CARCINOMA ESOPHAGEAL TUMOR

SIGN & SYMPTOM OF LOWER GI BLEEDSIGN & SYMPTOM OF LOWER GI BLEED• ACUTE (<3 DAYS) VS CHRONIC (>3 DAYS/SEVERAL DAYS)ACUTE (<3 DAYS) VS CHRONIC (>3 DAYS/SEVERAL DAYS)

• HEMATOCHEZIA VS MELENAHEMATOCHEZIA VS MELENA

• BLOOD IN TOILET, CLEAR NGT ASPIRATEBLOOD IN TOILET, CLEAR NGT ASPIRATE

• NORMAL RENAL FUNCTIONNORMAL RENAL FUNCTION

• USUALLY HEMODYNAMICALLY STABLEUSUALLY HEMODYNAMICALLY STABLE• <200ML : NO EFFECT ON HR**<200ML : NO EFFECT ON HR**

• >800ML: SBP DROPS BY 10MMHG, HR INCREASES BY 10>800ML: SBP DROPS BY 10MMHG, HR INCREASES BY 10

• >1500ML: POSSIBLE SHOCK>1500ML: POSSIBLE SHOCKOROR

• 10% HCT: TACHYCARDIA*10% HCT: TACHYCARDIA*

• 20% HCT: ORTHOSTATIC HYPOTENSION20% HCT: ORTHOSTATIC HYPOTENSION

• 30% HCT: SHOCK30% HCT: SHOCK

• STOPS SPONTANEOUSLY (80 - 85% OF THE TIME)STOPS SPONTANEOUSLY (80 - 85% OF THE TIME)

MELENA VS HEMATOCHEZIAMELENA VS HEMATOCHEZIA

ETIOLOGY OF HEMATOCHEZIAETIOLOGY OF HEMATOCHEZIA

Barnet J and H Messmann H. Nat Rev Gastroenterol Hepatol 6, 637-646 (2009).

COMMON CAUSE OF LOWER GI BLEED

DIVERTICULOSISCOLONIC POLYPS

COMMON CAUSE OF LOWER GI BLEED

HEMMORHOIDECOLON CARCINOMA

MANAGEMENT OF GI BLEED MANAGEMENT OF GI BLEED (1)(1)

MANAGEMENT OF GI BLEED MANAGEMENT OF GI BLEED (2)(2)