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Hemetamesis and Hemetochezia (Acute GI Hemorrhage)

Hemetamesis and Hemetochezia (Acute GI Hemorrhage). Dr. Wu ShuMing GI Dept. RenJi Hospital. Five Ways of GI Bleeding. Hematemesis ： vomitting of blood of altered blood （ coffee grounds ） indicates bleeding proximal to ligament of Treitz

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Hemetamesis and Hemetochezia (Acute GI Hemorrhage)

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  1. Hemetamesis and Hemetochezia(Acute GI Hemorrhage) Dr. Wu ShuMing GI Dept. RenJi Hospital

  2. Five Ways of GI Bleeding • Hematemesis：vomitting of blood of altered blood（coffee grounds） indicates bleeding proximal to ligament of Treitz • Melena：Tarry stool. Altered （black） blood per rectum （>60ml） • Hematochezia： Bright red or maroon rectal ,bleeding implies bleeding beyond Lig.T.* • FOB+ and Iron deficiency anemia

  3. Factors affect the way to manifest • Site of bleeding • Speed of bleeding • Amount of blood loss • Flora of enterocolon .

  4. Differentiating Upper from Low GI Bleeding • Hematochezia usually represents a lower GI source bleeding • Upper GI lesion may bleed so briskly that blood doesn`t remain in bowl long enough to become melena • Bleeding lesion distal to T Lig.may be either M.or hematochezia, but never manifests hematemesis

  5. Common cause of up GI bleeding Peptic ulcer ； Gastropathy （alcohol， aspirin， NSAIDs， stress）； GE varices； Gastric cancer

  6. Less common cause of up GI bleeding Esophageal or intestinal neoplam Esophagitis； Malloy-weiss tear， Hemoptysis: Swallowed blood Anticoagulant fibrinoloytic therapy: Telangiectases； aneurysm ；vasculitis；Dieulafoy ulcer； AV malformation Connective tissue disease； Hemabilia（biliary origin；Crohn`s disease；amyloidosis , hematological diseases

  7. BENIGN GASTRIC ULCER The classical presentation of gastric ulcer : with weight loss and indigestion made worse by eating, patients more often describe symptoms that would fit equally well for duodenal ulcer - investigation with barium meal or (preferably) endoscopy is, of course, appropriate for either. Benign ulcers may occur at any site in the stomach, but are commonest on the lesser curve away from acid-secreting epithelium.

  8. Duodenum Ulcer • The lesion most commonly affecting the duodenum is ulceration, and it is now known that both antral infection with Helicobacter pylori and the presence of gastric acid are virtual prerequisites for it..

  9. GE Varices • A number of cutaneous features (stigmata) may develop in a patient with cirrhosis, and these are important as they aid clinical recognition of chronic liver disease.

  10. Clinical manifestation of GI Bleeding • Abdominal discomfort Nausea, • Hemadynamic change: reduction in blood volume (syncope,light-headedness, sweating,therst) or shock • Laboratory changes: HCT, BUN

  11. Hematemesis with other symptoms • Hematemesis with upper abdominal pain • Hematemesis with hepatomegly and spleenomegly • Hematemesis with jaundice • Hematemesis with Skin & mucosa hemorrhage • Hematemesis with upper abdominal mass • Others: NSAIDs, Stress, Burning, Brain operation, Trauma, Vomiting

  12. Lab.Examination in Localization & Diagnosis of GI Bleeding • Endoscopy • Barium Radiographs • Angiography • Radionuclide imaging

  13. Approach to the patient with acute upper gastrintesttinal hemorrhage Acute upper Gastrointestinal Hemorrhage Rapid assessment Monitor hemodynamic status Fluid resuscitation Gastric lavage(?) self-limited (80%) bleeding (10-20%) Empiric medical therapy Urgent endoscopy recurrent hemorrhage endoscopy Site not localized Localized further assessment enteroscopy, radioisotope s scan, angiography, exploratory surgery Definitive therapyDefinitive therapy

  14. Summary of Acute GI Bleeding • Upper GI source bleeding--Hemetemesis • Major upper GI bleding-- Hemetemesis & hemetochezia • The more distant from the rectum, the more likely that melaena occurs • The colon lesion--FOB+ or hemetochezia • The small bowl lesion-- melena or hemetochezia

  15. The questions should be posed • Prior bleeding episode? • Family history of GI diseases • Dose the patient have the illness of ulcer? Cirrhosis?cancer?bleeding disorder? • Alcohol? NSAIDs? • Any precedes symptoms or signs?

  16. 2005年中国急性上消化道出血诊治指南 上消化道出血病情严重度分级(Rockall评分 中高危(Rockall评分≥3分) 监护病房 出血征象监测、液体复苏并止血治疗 内镜检查与治疗 静脉大剂量PPIs 成功 口服PPIs 失败 重复内镜治疗经血管造影介入治疗 成功 失败 手术治疗 原发病治疗及随访 中华内科杂志编委会. 急性非静脉曲张性上消化道出血诊治指南（草案）. 中华内科杂志2005；44(1): 73-76

  17. 急性非静脉曲张性上消化道出血诊治指南 中华内科杂志：2005.1. Palmar KR. Guideline Gut 2002 失血量的评估

  18. 出血严重程度评估 急性非静脉曲张性上消化道出血诊治指南 中华内科杂志：2005.1. Palmar KR. Guideline Gut 2002

  19. 急性上消化道出血患者Rockall再出血和死亡危险性评估系统急性上消化道出血患者Rockall再出血和死亡危险性评估系统 高危：≥5， 中危：3～4， 低危：0～2

  20. Endoscopic view of a Mallory-Weiss tear with active bleeding (gastric lumen is at top left). B, Endoscopic view of an organized clot adherent to a Mallory-Weiss tear (gastric lumen is at bottom left ).

  21. Endoscopic view of a Dieulafoy lesion on the lesser curvature of the stomach

  22. Endoscopic view of a vascular ectasia (angiodysplasia) in the duodenum.

  23. Endoscopic view of the gastric antrum with watermelon stomach. The pylorus is at top center. Note the linear distribution pattern of the vascular lesions arranged radially around the pylorus.

  24. Endoscopic views of ulcers with stigmata of recent hemorrhage. A, Duodenal ulcer with a visible vessel. B, Gastric ulcer with a red spot in the center of the crater. C, Duodenal ulcer with a red spot in the center of the crater. D, Purplish clot adherent to a gastric ulcer.

  25. Typical picture of a trivial nonsteroidal anti-inflammatory drug (NSAID)-induced injury to the gastric mucosa. There are multiple small erosions with brown-black staining of the center as a result of local bleeding and petechiae.

  26. Typical round gastric ulcer at the angulus (incisura) of the stomach.

  27. Causes of Low GI Bleeding

  28. Differentiating Upper from Low GI Bleeding • Hematochezia usually represents a lower GI source bleeding • Upper GI lesion may bleed so briskly that blood doesn`t remain in bowl long enough to become melena • Bleeding lesion distal to T. Lig. may be either M.or hematochezia, but never manifests hematemesis

  29. Hematochezia with other symptoms • Abdominal pain • Fever • Tenesmus • Systemic Hemorrhage • Dermal sign • Abdominal mass

  30. Lab. Examination For detecting Low GI Bleeeding • Anoscopy & sigmoidoscopy • Barium Edema (BE) • Angiography • Radionuclide scanning

  31. A, Linear ulcers of Crohn's colitis. B, Mucosa surrounding the ulcers is nodular (cobblestoning).

  32. Shigella colitis. Patchy areas of erythema, spontaneous bleeding, and loss of the normal vascular pattern are evident

  33. Salmonella colitis. Diffuse erythema, spontaneous bleeding, and loss of the vascular pattern with formation of telangiectasis are present.

  34. Tuberculosis. Linear ulceration runs circumferentially along the interhaustral septum with tiny satellite ulcerations. This must be distinguished from the longitudinal linear ulcerations seen in inflammatory bowel disease.

  35. Pseudomembranous (antibiotic-associated) colitis. Numerous elevated yellowish plaques are present on the mucosal surface.

  36. Amebiasis. Discrete punched-out ulcers are present in the right colon.

  37. Severe acute ulcerative colitis. No vascular pattern is discernible. A severe degree of spontaneous bleeding is present

  38. Large colonic ulcer in a patient with ischemic colitis.

  39. Advantage colon carcinoma

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