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GIT Bleeding 1) Define and classify GIT bleeding: Maha AlTuwaijri. Define GIT bleeding: - Gastrointestinal bleeding refers to any bleeding that starts in the gastrointestinal tract that extends from the mouth to the rectum. Classification of GIT bleeding: 1) Upper GI bleeding (UGIB): bleeding derived from a source proximal to the ligament of Treitz. 2) Lower GI bleeding (LGIB): bleeding derived from a source distal to the ligament of Treitz. 2) Causes of upper GI bleeding Afnan AlHazmi 2133788 1- Esophageal causes: 2- Gastric causes: Esophageal varices. Esophagitis. Esophageal cancer. Esophageal ulcers. Mallory-Weiss tear. Gastric ulcer. Gastric cancer. Gastritis. Gastric varices. Gastric antral vascular ectasia. Dieulafoy's lesions. • 3- Duodenal causes: Duodenal ulcer. Vascular malformation, including aorto-enteric fistulae. Fistulae are usually secondary to prior vascular surgery and usually occur at the proximal anastomosis at the third or fourth portion of the duodenum where it is retroperitoneal and near the aorta. Hematobilia, or bleeding from the biliary tree. Hemosuccus pancreaticus, or bleeding from the pancreatic duct. Severe superior mesenteric artery syndrome. Peptic ulcer disease: Peptic ulcers are localized erosions of the mucosal lining of the digestive tract. Ulcers usually occur in the stomach or duodenum. Breakdown of the mucosal lining results in damage to blood vessels, causing bleeding. Gastritis: General inflammation of the stomach lining, which can result in bleeding. Gastritis also results from an inability of the gastric lining to protect itself from the acid it produces. Causes of gastritis include: o NSAIDs or nonsteroidal anti-inflammatory drugs, for example: (ibuprofen) o Steroids o Alcohol o Burns o Trauma Esophageal varices: Swelling of the veins of the esophagus or stomach usually resulting from liver disease. Varices most commonly occur in alcoholic liver cirrhosis. When varices bleed, the bleeding can be massive, catastrophic and occur without warning. Mallory-Weiss tear: A tear in the esophageal or stomach lining, often as a result of vomiting or retching. Mucosal tears also can occur after seizures, forceful coughing or laughing, lifting, straining, or childbirth. Physicians often find tears in people who have recently binged on alcohol. Cancer: • One of the earliest signs of esophageal or stomach cancers may be blood in the vomit or stool. Inflammation: When the mucous membranes break down, they are unable to counteract the harsh effects of stomach acid. NSAIDs, aspirin, alcohol, and cigarette smoking promote gastric ulcer formation. Helicobacter pylori is a type of bacteria that also promotes formation of ulcers. 3-What are the causes of lower GIT bleeding … Aeshah Abdullah 2147789 Etiology of lower gastrointestinal bleeding : Classifications Anatomic Vascular Neoplasms Inflammation others anatomic etiology 1-Diverticulosis: • pressure within the colon causes bulging pockets of tissue (sacs) that push out from the colon walls. A small bulging sac pushing outward from the colon wall is called a diverticulum. • most common near the end of the left colon called the sigmoid colon. • This condition is uncommon before the age of 40 years, but its incidence increases after this age. anatomic etiology factors that can cause diverticular disease as follows: * A diet low in fibre content or high in fat * Increasing age * Constipation * Connective tissue disorders, which can weaken the colon wall. complication: Rectal Bleeding 1st stage 2nd stage Last stage anatomic etiology 2- Meckel's diverticulum: • a true congenital diverticulum, is abulge in the small intestine present at birth . • caused by an incomplete obliteration of the vitelline duct (ie, omphalomesenteric duct) located in the distal ileum. • also contain heterotopic tissue of the stomach (and thus contain parietal cells that secrete HCl), pancreas, or both. • It is the most common malformation of the gastrointestinal tract • The most common presenting symptom is painless rectal bleeding such as melaena-like black offensive stools A memory aid is the rule of 2s: •2% (of the population) •2 feet (proximal to the ileocecal valve) •2 inches (in length) •2 types of common ectopic tissue (gastric and pancreatic) •2 years is the most common age at clinical presentation •2:1 male:female ratio Vascular etiology 1- Gastro enteric angiodysplasia (AD): • defined as pathologically dilated communications between veins and capillaries . • frequently involve the cecum or ascending colon, although they can occur at other places. • Angiodysplasia of the GI tract happens most often in older adults. • cause of gastrointestinal bleeding and anemia. Vascular etiology 2- Ischemic colitis: • IC is also known as mesenteric artery ischemia, mesenteric vascular disease, or colonic ischemia. • Inflammation and injury of the large intestine that results from an interruption of its blood supply . • more common among people with: heart and blood vessel disease, people who have had surgery on their aorta, people who have problems with increased blood clotting. Ischemic colitis affects primarily people who are 60 or older. Neoplasm etiology Colorectal cancer (CRC): • also known as bowel cancer, is the development of cancer from the colon or rectum (parts of the large intestine). • Signs and symptoms may include blood in the stool , a change in bowel movements, weight loss, and feeling tired all the time. • Most colorectal cancers are due to old age and lifestyle factors with only a small number of cases due to underlying genetic disorders . Inflammations etiology 1-ulcerative colitis : • long-term condition that results in inflammation and ulcers of the colon and rectum. • The cause of UC is unknown, Theories involve immune system dysfunction, genetics, changes in the normal gut bacteria, and environmental factors. • The primary symptom of active disease is abdominal pain and diarrhea mixed with blood. Inflammations etiology 2- Crohn’s disease : • Crohn’s Disease is a condition that causes chronic inflammation of the digestive system or gut. • Crohn’s most commonly affects the end of the small bowel (the ileum) and the beginning of the colon, but it may affect any part of the gastrointestinal (GI) tract, from the mouth to the anus. • The primary symptoms is diarrhea with mucus and blood . Others diseases 1- rectal hemorrhoid: • swollen veins located around the anus or in the lower rectum. About 50 % of adults experienced the symptoms of hemorrhoids by the age of 50. • Two types : internal &external • From the symptoms : blood on tissue after having a bowel movement. Others diseases 2- Anorectal varices : • the dilation of collateral submucosal vessels due to backflow in the veins of the rectum. • Typically this occurs due to portal hypertension which shunts venous blood from the portal system through the portosystemic anastomosis present at this site into the systemic venous system. Others diseases 3-Rectal prolapse • is a condition in which the rectum (the last part of the large intestine exits the anus) loses its normal attachments inside the body. • Can occurs on all ages but common in older adults with a long-term history of constipation or a weakness in the pelvic floor muscles. A = Rectal Prolapse B = Hemorrhoids Others diseases 4- Anal fissures •anal fissure is a tear in the lining of the lower rectum (anal canal) Anal fissures are caused : • constipated • repeated diarrhea. • give birth Infection etiology Shigella bacteria Group A Shigella dysenteriae Group B Shigella flexneri Group C Shigella boydii Group D Shigella sonnei Shigellabacteriaare •Shigella organisms are a group of gram-negative They attack the intestinal wall and may cause ulcers that bleed. • Children between the ages of 2 and 4 are most likely to get shigella infection. • Can trans from person to persons • can be passed in contaminated food or by drinking or swimming in contaminated water. • The main sign of shigella infection is diarrhea, which often Blood, mucus, or pus in the stool. References : signs and symptoms of upper GIT bleeding? bayan Al-Abbad Upper Gastrointestinal Bleed 1-Melena or Melenic stools (black, tarry and foul smelling stools or dark-colored stools) Red Hematemesis – * 2-Hematemesis vomiting of fresh blood Coffee Ground Hematemesis – * vomiting of blood altered by stomach acids and enzymes. 3-Dyspepsia 4-Heartburn or epigastric pain 5-Abdominal pain Dysphagia – difficulty in swallowing6- 7-Jaundice if bleeding is related to liver diseases 8-Weight loss Syncope and/or Presyncope910-Pallor sign and symptoms of lower gastrointestinal bleeding Amna al-ahmed lower gastrointestinal bleeding young patient may present with fever, dehydration, • abdominal cramps, and hematochezia elderly patients presenting with abdominal pain, rectal • bleeding, and diarrhea may have ischemic colitis The presentation of LGIB can also vary depending on the etiology. Diverticulosis • Diverticulosis presents as painless bright red hematochezia in patients over 50 years of age. Bleeding stops spontaneously patients may be hypotensive and display signs of shock. hematochezia - passage of stools containing blood Angiodysplasia • Patients present with painless bleeding most commonly above the age of 70 years. patients may present with Hemoccult-positive stools, iron-deficiency anemia, and syncop Hemoccult-positive stools Diverticulosis Colon carcinoma• right-sided bleeding: iron-deficiency anemia , syncope , melena. left-sided colonic cancers: bright red blood per rectum Inflammatory bowel disease• Most commonly ulcerative colitis presents with diarrhea with occult blood or recurrent hematochezia Abdominal pain, tenesmus and urgency are often present Anorectal disease Hemorrhoids• present as painless bleeding mixed with stool or dripping into the toilet bowl. There is painful small bleeding in case of anal fissure. Ischemic colitis is seen in elderly especially those who have atherosclerosis presenting as bloody diarrhea with mild abdominal cramps Enumerate the complications of GIT bleeding Amal Alharthi 1) Anemia • Prolonged bleeding detectable in a microscopic study can lead to the loss of iron in the individual. Red blood cells contain a protein called hemoglobin. It is required to carry oxygen to the tissues of the body. A lack of hemoglobin and a lack of red blood cells can occur during constant GI bleeding, causing anemia. • Symptoms of anemia include chest pain, dizziness, fatigue, weakness, headaches, shortness of breath and lack of mental clarity. 2) Hypovolemia • Due to a severe loss of blood and fluid in acute GI bleeding, the heart finds it difficult to pump enough blood to the body, which is referred to as hypovelemia. It is a life-threatening condition since it can cause the body's organs to stop working. • Symptoms of this condition include cool, clammy skin; confusion; agitation; decreased urine output; weakness; pale skin; quick breathing; and loss of consciousness. 3) Shock • Acute and massive bleeding from the gastrointestinal tract can lead to a lack of blood flow to the body. This can damage the different organs of the body, causing organ failure. shock is an emergency condition and if it is not treated immediately, it can worsen quickly, causing irreversible damage to the organs or even death. • Symptoms of shock include an extremely low blood pressure, bluish lips and fingernails, chest pain, confusion, dizziness, anxiety, pale skin, decreased or no urine output, racing but weak pulse rate, shallow breathing, and unconsciousness. 4) Dehydration and Chest Pain • dehydration is another complication of gastrointestinal bleeding. The individual may also develop pain in the chest, especially if there is a heart condition present . Dyspnea and chest pain in the setting of GI bleeding are ominous signs of decreased oxygen-carrying capacity, and myocardial ischemia must be ruled out. • 5) Hypotension 6) puncture site hematoma • The bleeding is typically from arterial puncture above the inguinal ligament or inadequate hemostasis after the procedure but may also occur spontaneously from the anticoagulation used for PCI. Whatever its cause, the diagnosis of retroperitoneal hematoma is initially made on clinical grounds. Symptoms, signs, and laboratory abnormalities that should raise suspicion of retroperitoneal bleed include hypotension, back or flank pain. • References • http://www.medscape.org/viewarticle/565528_2 • Gastrointestinal Bleeding: A Practical Approach to Diagnosis and Management • http://www.livestrong.com/article/190741-complications-of-gi-bleeding/ Give an account in diagnostic tools of GIT Bleeding. By: basmah Al afari 2141556 Upper endoscopy. . An upper endoscopy is a procedure used to visually examine your upper digestive system with a tiny camera on the end of a long, flexible tube. Colonoscopy. • A procedure whereby a physician inserts a viewing tube (colonoscope) into the rectum for the purpose of inspecting the colon. Capsule endoscopy • Capsule endoscopy is a procedure that uses a tiny wireless camera to take pictures of your digestive tract. A capsule endoscopy camera sits inside a vitamin-size capsule you swallow. As the capsule travels through your digestive tract. • Balloon-assisted enteroscopy • Balloon assisted or "deep" enteroscopy is a procedure which allows advancement of a long endoscope into the small intestine for both diagnostic and therapeutic purposes. Reference…. • www.mayoclinic.com continue to diagnostic tools of GIT Bleeding. Fatimah Al Nassir ID:2145435 Endoscopic ultrasound. An ultrasound probe attached to an endoscope allows doctors to see all the layers of tissue in the digestive tract. Endoscopic retrograde cholangiopancreatography (ERCP) A scope combined with an X-ray procedure allows doctors to see the ducts of the gallbladder, liver and pancreas. However, this test is rarely needed in the evaluation of GI bleeding. .Angiography A contrast dye is injected into an artery, and a series of Xrays are taken to look for and treat bleeding vessels or other .abnormalities MR Enterography Procedure Or Multiphase CT enterography. preparation for an MRI exam, prior to MR enterography the patient is given two minutes before the exam and 20 bottles of a special liquid to drink (one bottle minutes before the exam). The liquid serves to distend the bowel 10 one bottle and marks the bowel for clear identification during the imaging study. Towards the end of the exam the patient is given a small dose of glucagon followed by an injection of gadolinium (an MRI contrast agent). Glucagon prevents the bowel .from moving for a short time, which improves the quality of the images MR Enterography: Uses a powerful magnetic field, radio waves and a computer to produce detailed pictures of the small intestine which may help your doctor diagnosis inflammatory bowel disease,obstruction and other abnormalities. Reference: http://www.mayoclinic.org/diseases-conditions/gastrointestinal20035736bleeding/care-at-mayo-clinic/tests-diagnosis/con- Treatment of lower and upper GIT JEHAN ALMUTAIRI 2134424 The goal of medical therapy in (UGIB) is to correct shock & coagulation abnormalities & to stabilize the patient. Bed rest. • IV access ( if patient need blood transfusion- normal • saline…etc.) Sedation ; Inj. Diazepam to control restlessness & • anxiety. Oxygen therapy. • Stop aspirin & other NSAIDs. • Therapeutic endoscopy. Under direct vision • cauterization in peptic ulcer. Sclerotherapy; • sclerosing & banding for varicose. Medications 1-Proton pump inhibitor ; omeprazole 40mg\BD for 5days.reduced rebleeding of patient with peptic ulcer. 2-Octreotide (sandostatin) ; IV 100maicrogram. Reduce bleeding by decrease splanchnic blood flow & portal pressure in bleeding varicose.*not very effective for bleeding peptic ulcer 3-Vasopressor=vasoconstrictions. IV dec. splanchnic blood flow & dec. portal pressure.(reserved for patient with esophageal varical bleeding). Surgery Sever bleeding or • rebleeding that can’t be controlled by treatments. Slow continuous bleeding • for more than 48 hours. Lower GI Therapeutic endoscopy. Endoscopic • electrocoagulation of angiodysplasia ; if bleeding continuous.(coagulation of bleeding ). colonoscopy is • performed also. Intervention Intra-arterial vasopressor or embolization in the bleeding site • localized by angiography. Intra-arterial vasopressor may stop bleeding in 90% cases with active • bleeding. Esp. in angiodysplasia or diverticulum. Embolization = angiography- site of bleeding-artificial agent= BLOCK • blood vessels that fragile , bleed & malformation. Surgery Continuous bleeding • unresponsive to the above measure require surgical resection. Prognosis of GIT bleeding RAGHAD MALLISHO ID : 2136192 Death in those with a GI • bleed is more commonly due to other illnesses, than the bleeding itself. such as cancer or cirrhosis Re-Bleeding because of upper • GI is more common than lower GI Risk of bleeding is more • common in males, and increases with age. Age older than 60 years is an independent marker for a poor outcome in upper gastrointestinal bleeding . The mortality rate ranging from 12-25 % in this group of patients. 3.3% for those aged 21-31 years 10% for those aged 41-50 years • In those with esophageal varices, bleeding occurs in about 5–15% a year and if they have bled once, there is a higher risk of further bleeding within six weeks The benefits versus risks restarting blood thinners such as aspirin or warfarin and antiinflammatories such as NSAIDs need to be carefully considered. If aspirin is needed for cardiovascular disease prevention, it is reasonable to restart it within seven days in combination with a PPI for those with nonvariceal upper GI bleeding The following up risk factors are associated with • an increase mortality, recurrent bleeding, the need for endoscopic hemostasis, or surgery: Age older than 60 years Severe comorbidity Hypotension Sever coagulopathy Red blood cell transfusion greater than 6 units Inpatient at time of bleeding Reference WWW.Medscape.com WWW.Wikipedia.org