1.Haematemesis(must be differentiated from haemoptysis)
2.Anaemia(occult blood loss)
3.Malena
4.Bleeding Per Rectal.
1.Haematemesis:
e.g, a 50 year-old male presents with haematemesis to the emergency department. What to do?
1.Assessment of and resuscitation-ABC.
2.Cause---->history and examination.
3.Upper GI endoscopy.
Causes of upper GI bleeding:
Ulcers:(60%)
-oesophageal
-gastric
-duodenal
Erosions:(26%)
-oesophageal
-gastric
-duodenal
-Mallory-Weiss tear (4%)
-Oesophageal varice(4%)
-Tumour
-Vascular lesions, e.g. Dieulafoy disease(gastric arterial malformation), rupturing of aortic aneurysm.
-Others (5%)
Esophageal Varices:
Management:
-Step 1----banding(endoscopy)<--lower risk of esophageal ulcers.
----sclerotherapy(endoscopy guided)
-using ethanol amine oleate or butyl cyanoacrylate.
-Step2----balloon tamponade(maximum 12-24 hours<---because it may pressure necrosis if prolonged)---->so after successful management--->banding and sclerotherapy and the patient is discharged.
-Step 3----create anastomosis between portal-systemic shunt:
1.Either by, transjugular intrahepatic porto-systemic shunt(TIPS)-by radiologist, not by surgeons.
2. or, open shunt shuts(surgery)--->increased mortality and morbidity.
Meidcal management:
-Acute phase-?
-follow up.
Peptic Ulcers.
-history of:
-use of NSAIDs.
-dysphagia
-diagnosed with peptic ulcer disease
Management----> i.v. proton pump inhibitor, e.g. omeprazole.
1. endoscopy.
-injection of dilute adrenalin
-heater/probe/argon laser
-glue
-clips.
but if bleeding continues
-laparotomy.
Upper GI Tumour
-Gasterectomy.
Mallory Weiss Syndrome
-conservative management.
Ruptured Aortic Aneurysm:
possible at high risk sites like:
in thoracic region- near oesophagus.
in abdominal region- ner duodenum.
Management
-repair with laparotomy/open.
2.Melaena
-Severe case:
- ABC assessments required.
Causes:
-Upper GIT:
-Oesophageal varices
-GI tumours
-Peptic ulcers
-Mallory Weiss syndrome(a longitudinal tear below gastro-esophageal junction induced by repetitive and strenuous vomiting)
-Small Intestine:
-typhoid
-tuberculosis
-Meckel's Diverticulum(a small bulge in SI at birth)
-Tumours
-Large Intestine:
-Malignancies of colon and rectum.
E.g. A Case involving right colon malignancy:
In history,
-pain in the right iliac fossa
-Loss of appetite and weight
-change in bowel habit
-Obstruction(constipation)
-colic pain in central abdomen
-full abdomen distension.
Investigation:
-Endoscopy(upper GI)
-Colonoscopy(large bowel)
Small Intestine:
-Enteroscopy(not available here)
-Contrast CT)Crohn's disease)
Treatment:
-Upper GI:
-Read above, the previous section.
-Tumours:
-resection
3.Occult Blood Losses/Anaemia
Signs:
-easily fatiguilability
-SOB on exertion.
case, e.g.
-A 40 year old woman presents with easily fatiguilability and she gets shortness of breathing on exertion.
Causes:
-same as the causes of melaena but it has a slow progression.
Differential Diagnoses:
-cardiac failure/IHD
-lung problems like asthmas, COPD, etc.
Shortness Of Breath:
At Rest:
-hypoxia
-hypercapnia
-Acidosis
On Exertion:
-Hypoxia.
Hypoxia Type:
1.Hypoxic Hypoxia- commonest.
-respiratory causes.
-decreased ability of oxygen or
-inability of oxygen to diffuse across the lungs.
2.Anaemic/Hypemic Hypoxia
-Anaemic causes.
-decreased oxygen carrying capacity of blood
3.Stagnant/Stasis Hypoxia
-cardiac causes.
-decreased cardiac output
-high venous pooling due to high G force.
4.Histotoxic Hypoxia
-occurs when cells can not take up oxygen from the blood.
-alcohol and cyanide poisoning can cause this.
Stages Of Hypoxia:
1.Indifferent- may not know that there's a problem.
2.Compensatory- denial is common.
3.Disturbances- obvious symptoms begins; tingling, numbness, etc.
4.Critical- loss of consciousness.
Prevention:
1.Early recognition of the symptoms.
2.Proper use of oxygen equipments
3.Good maintenance of the oxygen equipment
4.Preflight all oxygen equipment
5.Strict adherence to oxygen requirements(required above 12,500 feet)
Causes of Anaemia:
-Decreased production of normal RBCs:
-Decreased dietary intake of iron.
-Bone marrow problems.
-Increased Destruction:
-in the Spleen
-infiltration.
-Blood Loss:
-menorrhagia
-Per Rectal Bleeding.
Investigations:
-Full Boold Count.
-WBC
-Blood picture/film
*all these investigations confirms the iron deficiency in the patient.
-Upper GI endoscopy
-Colonoscopy
-Enteroscopy
*These are done if there's history of Gastro-Intestinal blood loss and it shows the site of Blood loss.
-Gynaecological examination for Gynaecological bleeding.
4.Bleeding PR.
-History and examintaion
Causes:
1.Haemorrhoids
2.Polyps
3.Malignancies
4.IBD
5.Fissures
6.Diverticulosis(a condition when pouches/diverticula develop in the colon)
