Management Of Acute Lower Gastrointestinal Bleeding

Management Of Acute Lower Gastrointestinal Bleeding
Standard of Care Rounds
Presentation by:Mark J. Russo, MD
Advisor: Tracey D. Arnell, MD


OUTLINE

* Resuscitation
* Clinical Presentation
* Diagnostic Evaluation and Non-Surgical Treatment
* Surgical Management

RESUSCITATION

* Indications for transfusion
o Profuse bleeding
o Persistent hemodynamic instability despite crystalloid resuscitation
o Symptomatic anemia (CP, SOB, orthostasis with Hgb < 10)
o AMI or unstable angina with Hgb < 10
o transfused group
+ rebleeding 9 pts
+ longer clotting times in the transfused group.
o control group
+ rebleeding 1 pt
o significantly (P<0.001) more bleeding in the transfusion group
o no difference in mortality (2 vs 1)
o 300 severely anemic, postop pts who refused blood transfusion
* Canadian Critical Care Trials Group
o restrictive strategy (Hgb 7.0-9.0)
+ age < 55yo
+ less critically ill (APACHE scores < 20)
o liberal strategy (Hgb 10.0-12.0)
+ ischemic cardiac disease

Clinical presentation
Localization
Bleeding scan
Tagged rbc scan
Advantages
Disadvantages
Colonoscopy
Angiography
Vasopressin infusion
Embolization
Superselective embolization
Capsule endoscopy
Provocative bleeding study
Indications for surgery
Surgical management
Conclusions

Management Of Acute Lower Gastrointestinal Bleeding.ppt

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UGI Bleed

UGI Bleed
125 slides Presentation by:
Obie M. Powell, M.D.
Joseph A. Iocono, M.D.
Department of Surgery
University of Kentucky

Case study:
History
Characterization of Symptoms
Temporal Sequence
Alleviating / Exacerbating Factors
PMH
Family/Social History
What is your Differential Diagnosis?

Differential Diagnosis

* Esophageal varices
* Gastric varices
* Erosive gastritis
* Mallory Weiss tear
* Reflux esophagitis
* Gastric malignancy
* Vascular malformations
* Nose bleed
* Aorto-enteric fistula
* Gastric ulcer
* Duodenal ulcer

Physical Exam
Laboratory studies:
What is necessary?

* Type and Cross
* CBC: Do you expect anemia?
* CMP: evaluate for hepatic dysfunction and renal compromise
* Coags: active hemorrhage can cause coagulopathy and requires aggressive replacement
* ABG: probe for acidosis

Laboratory Values Discussion
Endoscopy
Surgery for Bleeding Ulcers
Operative Indications
Operative Technique
Gastrointestinal Bleeding
Discussion
Upper Gastrointestinal Bleeding
Lower Gastrointestinal Bleeding
Rectal and Anal Bleeding


Upper GastroIntestinal Bleed.ppt

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Gastro Intestinal Bleeding

Gastro Intestinal Bleeding
Presentation by:David A. Gremse, MD, FAAP, FACG
Professor and Chair of Pediatrics
University of Nevada School of Medicine

Gastrointestinal Bleeding

* Hematemesis- Vomiting of bright red blood
o usually represents bleeding proximal to the ligament of Treitz
* Hematochezia- bright red blood per rectum
o indicates a lower GI source of bleeding
* Blood has a laxative effect so with massive bleeding the stool may be bright red
* Blood streaks on the stool indicates anal outlet bleeding
* Blood mixed with stool indicates bleeding source higher than the rectum
* Blood with mucus indicates an infectious or inflammatory disease
* Currant jelly-like material indicates vascular congestion and hyperemia (intussusception or midgut volvulus)
* Maroon-colored stools indicate voluminous bleeding proximal to the rectosigmoid area
* Melena, passage of black, sticky (tarry) stools suggests upper GI tract bleeding, but can be as distal as the right colon
* Hematemesis suggests a large bleed with possible recurrence, melena alone indicates less voluminous bleeding

Causes of Upper GI Bleeding

* Common
* Nasopharyngeal bleeding
* Erosive Esophagitis
* Peptic ulcer
* Gastritis (H. pylori)
* Mallory-Weiss tear
* Prolapse gastropathy

* Less Common
* Bleeding disorders
* Duplication cyst
* Foreign body
* Tube trauma
* Vascular malformation
* Esophageal varices


Causes of Lower GI Bleeding

* Common
* Anal fissure
* Infectious colitis Salmonella, Shigella, Campylobacter, C.diff
* Inflammatory bowel disease
* Intussusception
* Upper GI source

* Less Common
* Meckel’s diverticulum
* Duplication cyst
* Hirschsprung’s enterocolitis
* Gangrenous intestine
* Vascular malformation

Clinical Findings in PUD Neonatal Period
Clinical Findings in PUD Infants and Toddlers
Clinical Findings in PUD Pre-Schoolers
Clinical Findings in PUD School Age
Pathophysiology of GI Bleeding
Causes and Effects of H+ Ion Backdiffusion
Lowflow states Drugs, EtOH Stress H. pylori Bile Reflux
Mucosal Barrier Break
Parietal Cells
Release of histamine + Vasodilatation
Increased HCl and Pepsin Secretion
Peptic Ulcer Disease Diagnostic Evaluation
Indications for EGD
Case #1 – UGI Bleeding
Esophageal varices
Case #2 – UGI Bleeding
Prolapse Gastropathy
Meckel’s Scan
99mTc- Labeled Red Cell Scan
GI Bleeding - Treatment
Drug Efficacy in Healing Ulcers
ATLS Classification of Shock
Management - Octreotide
GI Bleeding – Summary
Questions

Gastro Intestinal Bleeding.ppt

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