GASTROINTESTINAL

BLEEDING
DR.IWAN KRISTIAN
DEPT.OF.SURGERY
DR.SOETOMO HOSPITAL/ FACULTY
OFMEDICINE, AIRLANGGA UNIVERSITY

Introduction
GI bleeding : 1-2 % of all hospitalization in USA
( 300.000 / year )
Overall mortality : 5 12 %
Upper GI bleeding : 10 %
Lower GI bleeding : < 5 %

Upper GI bleeding : 100 cases / 100.000 population

Acid peptic disease 50 -75 %
60 yrs : 35 45 %

Lower GI bleeding : 20-27 / 100.000 population

24 % of all GI bleeding
Male > female
Chung and Kim. Acute Gastrointestinal bleeding.2003

SEVERITY of bleeding
Major bleeding
Acute blood loss causing hemodynamics of hypovolemia
Sudden passage of large amounts of bloody ,maroon,burgundy
or melenic stool in the absence of hemodynamic compromise.
Hmt < 8 g% from base line or < 30 %.
Tranfusion 4 -6 unit / 24 hours.

Non major bleeding

A chemical test for blood in stool
The passage of hemodinamically insignificant amounts of either
gross blood per rectum or melena

Boley and Kaleya :Schackelfords Surgery of the

alimentary tract ,6 th ed

 Occult GI bleeding :
The most common form of GI bleeding
Chronic or intermittent loss of small amount
of blood of which the patients is unaware.
Manifestation : test + or iron deficiency
anemia

Obscure GI bleeding :
Bleeding that persist or recurs without any
obvious source after endoscopic evaluation
Rockey.Current diagnosis & treatment in
gastroenterology , 2 nd ed.2003

classification
Upper GI bleeding : between upper
oesophagus to lig.Treitz
GE variceal bleeding
Non variceal bleeding

Lower GI bleeding : below lig.Treitz

Small bowel bleeding
Colonic bleeding

Sign and symptom

Bleeding
Hematemesis : vomiting fresh blood
Melanemesis : vomiting coffee-ground
Melena : passage of black stool per rectum
Hematochezia : passage of altered non
black/maroon blood per rectum
Rectal bleeding : passage of fresh blood per
rectum

Sign And Symptom

Systemic effect :

Shock or hypotension
Pallor
Dizziness
Weakness
Anemia

Basic element of the

management of GI
bleeding

Causes of acute upper

GI bleeding

Management of GI
bleeding
Prompt patient resuscitation and stabilization

Check vital sign.

Insert 2 large caliber peripheral catheter if needed
Volume replacement
Pass a large bore NGT
Perform rectal examination
Take history
Insert ETT if needed

Management contd
Assessment of onset &severity of bleeding
serial exam : vital sign, Hmt,ECG

Determination of bleeding site, after the patient

stabilized to guide the diagnostic work up.
Determination of the cause of bleeding
Medical history
Physical examination

Management contd
Control of active bleeding

Medical : PPI
Endoscopy : injection ,banding,clipping
Angiography and embolization
surgery

Upper GI bleeding
management

Lower GI bleeding

Aetology of lower GI
bleeding
Actual bleeding sites
in patients with
hematosechia

Colon : 74 %
UGI : 11 %
Small bowel : 9 %
No sites found : 6 %

Freqency of colonic bleeding

sites in patients with severe
hematosechia

Colonic diverticulosis : 42 %
Colorectal malignancy : 9%
Ischemic colitis : 9 %
Acute colitis, unknown cause : 9 %
Hemorrhoids : 5 %
Post polypectomy : 4 %
Colonic angiodysplasia : 3 %
Crohs disease : 2 %
Other : 10 %
Unkown : 11 %

Longstreth GF .am J Gastroenterol 1997,92-419

Messmann H,Atlas of colonoscopy.2006

LOWER GI bleeding :
management

Endoscopic clipping

Third degree of hemorrhoid

LEFT LATERAL

LITHOTOMY

KNEE CHEST POSITION

Lower GI bleeding :
surgical management