Causes are usually anatomically divided into their location in the upper gastrointestinal tract. People are usually stratified into having either variceal or non-variceal sources of upper gastrointestinal hemorrhage, as the two have different treatment algorithms and prognosis. The diagnosis of upper gastrointestinal bleeding is assumed when hematemesis is documented. In the absence of these findings, consider a nasogastric aspirate to determine the source of bleeding. If the aspirate is negative, the source of a gastrointestinal bleed is likely lower.
The accuracy of the aspirate is improved by using the Gastroccult test.
The nasogastric aspirate can help determine the location of bleeding and thus direct initial diagnostic and treatment plans. Determining whether blood is in gastric contents, either vomited or aspirated specimens, is difficult.
Slide tests are based on orthotolidine Hematest reagent tablets and Bili-Labstix or guaiac Hemoccult and Gastroccult. Rosenthal found orthotolidine-based tests more sensitive than specific; the Hemoccult test's sensitivity reduced by the acidic environment; and the Gastroccult test be the most accurate . Cuellar found the following results:. Holman used simulated gastric specimens and found the Hemoccult test to have significant problems with non-specificity and false-positive results, whereas the Gastroccult test was very accurate.
Among these patients there were no deaths or interventions needed and the patients were able to be effectively treated in an outpatient setting. The predictive values cited are based on the prevalences of upper gastrointestinal bleeding in the corresponding studies. A clinical calculator can be used to generate predictive values for other prevalences. The initial focus is on resuscitation beginning with airway management and fluid resuscitation using either intravenous fluids and or blood.
Based on evidence from people with other health problems crystalloid and colloids are believed to be equivalent for peptic ulcer bleeding. For initial fluid replacement colloids or albumin is preferred in people with cirrhosis. If large amounts of pack red blood cells are used additional platelets and fresh frozen plasma should be administered to prevent coagulopathies.
The benefits versus risks of placing a nasogastric tube in those with upper gastrointestingal bleeding are not determined. Parenteral Iron is increasingly used in these cases to improve patient outcomes and void blood usage. From Wikipedia, the free encyclopedia. Upper gastrointestinal bleeding Other names Upper gastrointestinal hemorrhage, gastrorrhagia, upper GI bleed, UGI bleed Endoscopic image of a posterior wall duodenal ulcer with a clean base, which is a common cause of upper gastrointestinal hemorrhage.
Specialty Gastroenterology Upper gastrointestinal bleeding is gastrointestinal bleeding in the upper gastrointestinal tract , commonly defined as bleeding arising from the esophagus , stomach , or duodenum. Academic Emergency Medicine. Global Family Doctor. N Engl J Med. Modern trends in diagnosis and therapy". Cardiovascular Surgery London, England. The American Surgeon. Am J Emerg Med. The value of a nasogastric aspirate".
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Archives of Internal Medicine. Clin Pharm. January Colitis: Several colitis can present with acute LGIB, including inflammatory bowel disease, infectious disease and ischemic colitis. Features in the history, clinical presentation, biochemical data and endoscopic assessment with biopsy typically lead to the definitive diagnosis. Ischemic colitis: Ischemic colitis is caused by sudden, often temporary, reduction in mesenteric blood flow secondary to hypoperfusion, vasospasm, or occlusion of the mesenteric vasculature.
A recent review of patients with ischemic colitis reported involvement of the sigmoid colon in Mesenteric occlusion related to cardiac thromboembolism has been reported in up to one-third of patients with ischemic colitis whereas hypercoagulable states, vasculitis, and medications are less common risk factors.
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The clinical presentation of ischemic colitis is characterized by the sudden onset of cramping abdominal pain, followed by hematochezia or bloody diarrhea within 24 hours. Typical endoscopic findings are submucosal hemorrhage and ulcerations in the colon with a characteristic segmental distribution abrupt transition between abnormal and normal mucosa.
None of these endoscopic findings are pathognomonic of ischemic colitis, however, and infectious and inflammatory colitis should remain in the differential diagnosis. Anyway endoscopy in this setting has just a diagnostic role. Although GI bleeding is a common manifestation of inflammatory bowel disease, acute severe hematochezia is infrequent.
Patients taking aspirin or non steroidal anti-inflammatory drugs may induce exacerbations of IBD and contribute to the morbidity of the patients taking them. The patients with Ulcerative colitis UC had pancolitis. The median time to recurrence hemorrhage has been reported to be 3 days, which might represent the minimum safe duration of hospitalization, although some patients may have recurrence more than 1 week after the initial episode.
Because of the diffuse nature of the bleeding associated with these diseases, endoscopic treatment of bleeding is rarely appropriate and therefore these lesions are not amenable for endoscopic treatments. NSAIDs possibly damage the normal large intestine, which presents as ulceration, colitis and stricture.
Massive lower gastrointestinal bleeding after rejection of pancreatic transplants
Short-term therapy can be just as significant and colitis can occur even after a few days of NSAID use[68,69]. NSAIDs given in both the oral and parenteral forms have been found to cause colonic ulcerations. Colonic perforation, as an adverse effect of NSAIDs, has been reported in sporadic cases in the literature[71,72]. Several studies found that NSAIDs can cause diverticular bleeding and perforation, flare-up of inflammatory bowel disease, and play a role as an etiologic factor in lymphocytic colitis.
Inflammatory bowel diseases, malignancy and infectious colitis must be ruled out before establishing the diagnosis of NSAID-induced colopathy.
NSAIDs have numerous deleterious effects on the colon. NSAID- induced colopathy is not a rare condition.
Discontinuation of the offending drug is mandatory. In some case reports, steroids have been used in the treatment of NSAID colonic stricture which failed to resolve after discontinuation of the offending drug. Infectious colitis: Massive lower gastrointestinal bleeding due to intestinal TB was once an uncommon complication of TB, but recent reports indicate an increased incidence especially in developing Countries. In HIV patients, lower gastrointestinal bleeding may occur due to opportunistic infections, such as cytomegalovirus CMV.
Taken together, the co-infection of CMV colitis and intestinal TB appears to contribute to the massive hemorrhage as reported in the case report. Surgical resection is usually not indicated for intestinal TB, however, mortality is high when intestinal TB is complicated with bleeding.
Previous reports indicate that surgery remains the definitive management for the treatment of patients with massive gastrointestinal bleeding due to intestinal TB[78,79]. Indeed, timely resection dramatically improved the condition of patients. Therefore, early surgical intervention is recommended for lower gastrointestinal bleeding with intestinal TB.
Infective colitis can be a cause of massive lower gastrointestinal bleeding requiring acute surgical intervention.
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Causative organisms include Entamoeba and Histoplasma species. However, concurrent colonic infection with both these organisms is very rare. Occasionally there is a focal bleeding from the tumor Figure 4 that can be temporized with coagulation therapy but bleeding is generally slow and diffuse. Recently hemospray has emerged as a new hemostatic technique for this gastrointestinal bleeding. The available data demonstrated the potential for hemostatic spray as a definitive or bridge therapy particularly in oozing lesion while in brisk arterial bleeding the efficacy is unknown. Several single case reports and small series have described the efficacy of Hemostatic spray in acute bleeding in various GI conditions eg Mallory Weiss; Dieulafoy lesion, gastric antral vascular ectasia, post-polypectomy, radition proctopathy and tumor bleeding.
Dieulafoy lesions: A bleeding Diulafoy lesion Figure 6 is caused by an exposed artery arising with a minute mucosal defect and, unless actively bleeding, may be difficult to detect. When seen the endoscopic treatment are identical at those of the upper GI tract such as thermal method, clipping and band ligation for eradication.
Upper gastrointestinal bleeding
The terms acute hemorrhagic rectal ulcer AHRU was first used by Soenho et al and was estabilished as disease entity in Japan by Hirooka et al It has been described as a bleeding lesion that frequently occur in elderly patients who have severe underlying disorders and characterized by the presence of either irregular or nearly round ulcer formation at lower part of the rectum presented as abrupt fresh rectal bleeding as initial symptom.
Patients often have major medical comorbidities of end stage renal disease on hemodialysis, respiratory failure requiring mechanical ventilation, decompensated cirrhosis, critically ill or malignancy. Although there are some reports about the importance of comorbidities in the outcome of LGIB, there is no information about their influence on colorectal anastomosis bleeding.
The median time from primary surgery to LGIB was 6. It is extremely rare to occur as much as 10 days after surgery.
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In case of postoperative bleeding it is well known that nonoperative treatment is usually successful in almost all cases. The Cochrane group analyzed data regarding the colorectal anastomosis technique and its complication rate. The conclusion was that there is no scientific evidence to demonstrate any increased risk of hemorrhage of the stapled over hand-sewn technique.
The presence of clot in the suture of the anastomosis may be responsible for the persistence of bleeding and therefore its removal could expose the vessel permiting the definitive treatment. The management of patients with ileocolic anastomosis is the most challenging situation.
The utility of endoscopy has been suggested and efficacy and safety of sclerotherapy, clips or electrocoagulation to stop bleeding has been investigated[85,86,88,89]. However the use of angiographic localization and control of bleeding could be a safe alternative. Surgery should be considered in patients with hemodynamic instability despite aggressive resuscitation and in case of endoscopic or angiographic failure.