Gastrointestinal bleeding

Transcription

1 Gastrointestinal bleeding..is the reason in 2 % of all admissions to hospital cases/year in the US. The incidence of urgent upper GI bleeding: 145/ inhabitant/year in Hungary ( Nagy Gy. MBA Suppl 2002/3) Average mortality rate: 8% FORMS: Haemathemesis: red or black( coffee ground appearance);melaena (the stool is black and tarry and always diarrhoea as blood is osmotically laxative); Hematochesia

2 Site of GI bleeding 85-95% from upper tract 2% from small intestine 5-18% large intestine

3 Clinical signs depend on the site and severity of the bleeding Localisation Reasons Proximal source Distal source Ulcer, erosion, varicies, Mallory Weiss, tumour, IBD, ischaemic vascular lesions, angiodysplasia, altered hemostasis

4 DIAGNOSTIC APPROACH History Physical examination Laboratory parameters Endoscopy Isotope scan Angiography X-Ray studies: no more

5 TAKING HISTORY Onset of complains (sudden or chronic) Pain location and characteristics Weight loss, weekness, changing bowel habit Characteristics of the stool and vomit Abdominal cramps Drug, alkohol abuse, diet Fever comorbidity

6 PHYSICAL EXAMINATION-1 Examination of the oropharyngs, nasal cavity: to exclude swallowed blood Presence of blood in the bowel causes hypermotility (on auscultation) Palpation of defence ( ileus,intestinal infarct) Rectal digital examination

7 PHYSICAL EXAMINATION-2. skin: jaundice, pale,cold, vet Anxiety, restlessness, lightheadidnes Systolic BP< 100 mmhg, puls rate > 100: visual distrubances, collaps while changing position: postural hypotension 10-20/min difference in pulse rate or mmhg in BP between supine and sitting position = blood loss more than 20% of total blood volume (or 1-2 units of whole blood) Blood loss <500 ml rarely associated with systemic signs More intensive bleeding (40% of total volume) results in decreased venous return to the heart, decreased cardiac output, increased peripheral vasoconstriction, shock with tachycardia and hypotension.

8 LABORATORY FINDINGS Hemoccult test: for screening, for early diagnosis of tumours casuing chr. occult bleeding. PCV starts to decline after 6 hrs of onset because of hemodilution, so the PCV is not sensitive indicator of acute blood loss, since it may take h to completely equilibrate with the vascular compartments. Leukocytosis, thrombocytosis BUN > 40 mg/dl in acute an severe bleeding (Nitrogen overload due to brakedown of blood proteins to urea by intestinal bacteria) BUN/kreatinin ratio>100 in upper GI bleeding BUN/kreatinin ratio <50 in lower GI bleeding Hypovolaemic shock caused by massive GI bleeding will be the consequence of centrilobular hepatic necrosis leading to elevation of hepatic enzymes SGOT and SGPT and myocardial infarction in elderly

9 Signs of upper GI bleeding Vomiting of blood or coffee-ground material (blood that has been in the stomach for at least several minutes) Blood per nasogastric tube Melaena: as little as 100 ml of blood can produce melaena Maroon-colored stools meaning brisky bleeding of upper GI source

10 Bleeding from the small intestine Rare, painless, hard to localize Only tool for diagnosis: angiography+ct, izotope (technetium pertechnecate)scan and lately: capsullar endoscopy Origin: angiodysplasia (in 40%), Meckel divericula, bening tumors

11 Bleeding from the lower GI tract Fresh blood and clots. Reason: rectal varicies, hemmorhoids, tumour: polyps or carcinoma, fissures, diverticulosis (in 50% of elderly cases), angiodysplasia Slower rates of bleeding, more proximal in the colon, can present with maroon-colored or currant jelly stools

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13 DIAGNOSTIC PROCEDURES Gastroscopy: for identification of the site and reason of bleeding: timing the best within hours after the bleeding episode. Urgent endoscopy for variceal hemorrhage! Colonoscopy Mesenteric angiography Capsullar enteroscopy CT - MR enterography radioisotop scan The bleeding source remains obscure in 52 % even after upper and lower endoscopic examination had been performed!

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16 angiography This is an extravasation

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18 Emergency quidelines: patients with active or severe bleeding should be managed in intesive care unit (ICU) When patient first seen in shock: prior taking history: vital signs should be noted, blood sent for typing and large bore (14-18 gauge) iv.line (catheter) placed for early fluid supply. Urine output should also be monitored and airways should be protected PCV<25, BTT GI bleeding in 85% usually stop within the first hours spontaneously. Surgical consultation and intervention is needed in approx. 10% of the cases.

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20 TREATMENT GUIDELINES-1 Maintain intravascular volume and hemodynamic stability Stop bleeding: local measures: nasogastric lavage with cold tap water, sclerotherapy of varicies, electrocoagulation for ulcers and angiodysplasia, systemic: H2 blocker, protonpump INH, antacids to maintain gastric ph near 7.0 Surgical intervention indicated in cases where 24 h of adequate measures the blood loss is more than 6 units, and the bleeding returns

21 TREATMENT GUIDELINES-2 Blood replacement: packed red cells should be given to maintain PCV at 30%, central venous pressure at 8-15 cm water, and systolic BP at greater than 100 mm Hg. Each unit of blood should raise the PCV 3% if the patient is not still bleeding

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25 Thalidomide for the treatment of chronic gastrointestinal bleeding from angiodysplasias: a case series. Eur J Gastroenterol Hepatol BACKGROUND: Mucosal angiodysplasias, either inherited or acquired, can cause gastrointestinal bleeding, sometimes refractory to treatment and requiring ongoing transfusion. Thalidomide was started with 50 mg/day and then increased incrementally by 50 mg every week up to 200 mg/day, if tolerated, and continued for 6 months. Patients who continued mg/day of thalidomide for 6 months did not require any transfusions during the 6 months of medication. During 6-months posttreatment of these three patients, one maintained response without any transfusion for 2 months, then required 1 U of blood every 4 weeks, one patient required 2 U of blood every 3-4 weeks, and one patient died from diabetes complications. CONCLUSION: Thalidomide should be considered as a therapeutic option in patients who are resistant to conventional therapy, but it has a high discontinuation rate because of its side-effects.