gibleeding-

8/11/2019 gibleeding-

http://slidepdf.com/reader/full/gibleeding- 1/29

GASTROINTESTINALGASTROINTESTINAL

BLEEDINGBLEEDINGDavid A. Gremse, MD, FAAP, FACGDavid A. Gremse, MD, FAAP, FACG

Professor and Chair of Pediari!sProfessor and Chair of Pediari!s

"niversi# of Nevada S!hoo$ of"niversi# of Nevada S!hoo$ ofMedi!ineMedi!ine



Gasroinesina$ B$eedin%Gasroinesina$ B$eedin%

&emaemesis' (omiin% of )ri%h red&emaemesis' (omiin% of )ri%h red)$ood)$ood

*s*a$$# re+resens )$eedin%*s*a$$# re+resens )$eedin%+roima$ o he $i%amen of Trei-+roima$ o he $i%amen of Trei-

&emao!he-ia' )ri%h red )$ood +er&emao!he-ia' )ri%h red )$ood +er

re!*mre!*m indi!aes a $oer GI so*r!e ofindi!aes a $oer GI so*r!e of

)$eedin%)$eedin% B$ood has a $aaive e/e! so ihB$ood has a $aaive e/e! so ih

massive )$eedin% he soo$ ma# )emassive )$eedin% he soo$ ma# )e




B$ood srea0s on he soo$ indi!aes ana$B$ood srea0s on he soo$ indi!aes ana$o*$e )$eedin%o*$e )$eedin%

B$ood mied ih soo$ indi!aes )$eedin%B$ood mied ih soo$ indi!aes )$eedin%so*r!e hi%her han he re!*mso*r!e hi%her han he re!*m B$ood ih m*!*s indi!aes an infe!io*sB$ood ih m*!*s indi!aes an infe!io*s

or in1ammaor# diseaseor in1ammaor# disease

C*rran 2e$$#'$i0e maeria$ indi!aesC*rran 2e$$#'$i0e maeria$ indi!aesvas!*$ar !on%esion and h#+eremiavas!*$ar !on%esion and h#+eremia3in*ss*s!e+ion or mid%* vo$v*$*s43in*ss*s!e+ion or mid%* vo$v*$*s4




Maroon'!o$ored soo$s indi!aeMaroon'!o$ored soo$s indi!ae

vo$*mino*s )$eedin% +roima$ o hevo$*mino*s )$eedin% +roima$ o he

re!osi%moid areare!osi%moid area Me$ena, +assa%e of )$a!0, si!0#Me$ena, +assa%e of )$a!0, si!0#

3arr#4 soo$s s*%%ess *++er GI ra!3arr#4 soo$s s*%%ess *++er GI ra!

)$eedin%, )* !an )e as disa$ as he)$eedin%, )* !an )e as disa$ as heri%h !o$onri%h !o$on

&emaemesis s*%%ess a $ar%e )$eed&emaemesis s*%%ess a $ar%e )$eed

ih +ossi)$e re!*rren!e, me$enaih +ossi)$e re!*rren!e, me$ena



Ca*ses of "++er GI B$eedin%Ca*ses of "++er GI B$eedin%

CommonCommon

Naso+har#n%ea$Naso+har#n%ea$

)$eedin%)$eedin% Erosive Eso+ha%iisErosive Eso+ha%iis

Pe+i! *$!erPe+i! *$!er

Gasriis 3&. +#$ori4Gasriis 3&. +#$ori4 Ma$$or#'5eiss earMa$$or#'5eiss ear

Pro$a+sePro$a+se

%asro+ah#%asro+ah#

Less CommonLess Common

B$eedin% disordersB$eedin% disorders

D*+$i!aion !#sD*+$i!aion !#s Forei%n )od#Forei%n )od#

T*)e ra*ma T*)e ra*ma

(as!*$ar(as!*$arma$formaionma$formaion

Eso+ha%ea$ vari!esEso+ha%ea$ vari!es



Ca*ses of Loer GI B$eedin%Ca*ses of Loer GI B$eedin%

CommonCommon

Ana$ 6ss*reAna$ 6ss*re

Infe!io*s !o$iisInfe!io*s !o$iisSa$mone$$a,Sa$mone$$a,

Shi%e$$a,Shi%e$$a,

Cam+#$o)a!er,Cam+#$o)a!er,

C.di/ C.di/

In1ammaor#In1ammaor#

)oe$ disease)oe$ disease

In*ss*s!e+ionIn*ss*s!e+ion

Less CommonLess Common

Me!0e$7sMe!0e$7s

diveri!*$*mdiveri!*$*m D*+$i!aion !#sD*+$i!aion !#s

&irs!hs+r*n%7s&irs!hs+r*n%7s

enero!o$iisenero!o$iis Gan%reno*sGan%reno*s

inesineinesine

(as!*$ar(as!*$ar

ma$formaionma$formaion



C$ini!a$ Findin%s in P"DC$ini!a$ Findin%s in P"D

Neonaa$ PeriodNeonaa$ Period Gasri! *$!ers are more !ommonGasri! *$!ers are more !ommon

han d*odena$ *$!ers in neonaeshan d*odena$ *$!ers in neonaes

S+onaneo*s Perforaion is a moreS+onaneo*s Perforaion is a more!ommon +resenaion han )$eedin%!ommon +resenaion han )$eedin%

Fre8*en$# asso!iaed ih9Fre8*en$# asso!iaed ih9

&#+oia, Se+sis, RDS, CNS disorder&#+oia, Se+sis, RDS, CNS disorder




Infans and Todd$ersInfans and Todd$ers Presenin% s#m+oms9Presenin% s#m+oms9

(omiin%(omiin% Poor feedin%Poor feedin% Irria)i$i# d*rin% and afer eain%Irria)i$i# d*rin% and afer eain% A)domina$ disenionA)domina$ disenion &emaemesis, me$ena&emaemesis, me$ena

Common$# asso!iaed ihCommon$# asso!iaed ih*nder$#in% disease in his a%e %ro*+*nder$#in% disease in his a%e %ro*+




Pre'S!hoo$ersPre'S!hoo$ers Peri*m)i$i!a$ or %enera$i-edPeri*m)i$i!a$ or %enera$i-ed

a)domina$ +aina)domina$ +ain

(omiin% afer eain%(omiin% afer eain% No!*rna$ or ear$# mornin% +ainNo!*rna$ or ear$# mornin% +ain

Gasri! *$!ers are as !ommon asGasri! *$!ers are as !ommon as

d*odena$ *$!ersd*odena$ *$!ers

Primar# *$!ers are as !ommon asPrimar# *$!ers are as !ommon as

se!ondar# *$!ersse!ondar# *$!ers




S!hoo$ A%eS!hoo$ A%e Ma$e9 Fema$e raio is :9;Ma$e9 Fema$e raio is :9;

B*rnin% e+i%asri! +ainB*rnin% e+i%asri! +ain

No!*rna$ +ainNo!*rna$ +ain

Me$ena, hemaemesis, fe!a$ o!!*$Me$ena, hemaemesis, fe!a$ o!!*$

)$ood)$ood

Primar# *$!ers are more !ommonPrimar# *$!ers are more !ommon

han se!ondar# *$!ershan se!ondar# *$!ers



Paho+h#sio$o%# of GIPaho+h#sio$o%# of GI

B$eedin%B$eedin% M*!osa$ $esionsM*!osa$ $esions

A!id'+e+i! disease, dr*%'ind*!edA!id'+e+i! disease, dr*%'ind*!ed

3NSAIDs4, Infe!io*s 3&. +#$ori4,3NSAIDs4, Infe!io*s 3&. +#$ori4,in1ammaor# )oe$ d-in1ammaor# )oe$ d-

Pora$ h#+erensionPora$ h#+erension

Eso+ha%ea$ vari!es, h#+erensiveEso+ha%ea$ vari!es, h#+erensive%asro+ah#%asro+ah#

Coa%*$o+ah# ' &emo+hi$ia, he+ai!Coa%*$o+ah# ' &emo+hi$ia, he+ai!

!oa%*$o+ah#, C&F <he+ai!!oa%*$o+ah#, C&F <he+ai!



Ca*ses and E/e!s of &Ca*ses and E/e!s of &== Ion Ba!0di/*sionIon Ba!0di/*sion

Lowflow states Drugs, EtOH Stress H. pylori Bile Reflux

Mucosal Barrier Break

Parietal Cells

Release of ista!i"e # $aso%ilatatio"

&"crease% HCl a"% Pepsi" Secretio"

H#



Pe+i! "$!er DiseasePe+i! "$!er Disease

Dia%nosi! Eva$*aionDia%nosi! Eva$*aion &isor# 3medi!aions, fami$# hisor#4&isor# 3medi!aions, fami$# hisor#4

Ph#si!a$ eam 3in!$*de &emo!!*$4Ph#si!a$ eam 3in!$*de &emo!!*$4

CBC, #+e > s!reen for GI )$eedin%CBC, #+e > s!reen for GI )$eedin%

PT, PTTPT, PTT

H. pyloriH. pylori ani)od#, fasin% %asrinani)od#, fasin% %asrin$eve$$eve$

"++er GI Series"++er GI Series

EGDEGD



Indi!aions for EGDIndi!aions for EGD

&emaemesis, Me$ena, &eme 3=4&emaemesis, Me$ena, &eme 3=4

soo$soo$

Severe +ain, ei%h $ossSevere +ain, ei%h $oss "ne+$ained anemia"ne+$ained anemia

S#m+oms +ersis des+ie ria$ ofS#m+oms +ersis des+ie ria$ of

anise!reor# hera+#anise!reor# hera+#

Eva$*aion of a)norma$ "GI seriesEva$*aion of a)norma$ "GI series

Eva$*aion of sa*s ofEva$*aion of sa*s of

H. pyloriH. pylori



Case ?; @ "GI B$eedin%Case ?; @ "GI B$eedin%

; O5F ih S<P s+$ene!om# #r a%o; O5F ih S<P s+$ene!om# #r a%ofor Evan7s s#ndromefor Evan7s s#ndrome

5ea0ness, +a$$or, me$ana da#s5ea0ness, +a$$or, me$ana da#s Eam @ &R' ;, BP'<, a!h#!ardi!,Eam @ &R' ;, BP'<, a!h#!ardi!,

+a$e, a)domen nonender, nondisended,+a$e, a)domen nonender, nondisended,no he+aome%a$#no he+aome%a$#

La) @ &<&.<;H.;, 5BC, .J +$ae$es,La) @ &<&.<;H.;, 5BC, .J +$ae$es,;;,KKK, PT;:. se!J AST, :J ALT, J;;,KKK, PT;:. se!J AST, :J ALT, J

T.)i$i, K.J a$0 +hos, T.)i$i, K.J a$0 +hos,



Eso+ha%ea$ vari!esEso+ha%ea$ vari!es



Case ? @ "GI B$eedin%Case ? @ "GI B$eedin%

;; O5M +revio*s$# hea$h# ih ; da#;; O5M +revio*s$# hea$h# ih ; da#

h<o fever, vomiin% and diarrheah<o fever, vomiin% and diarrhea

Emesis over +as hr, <)$ood $as Emesis over +as hr, <)$ood $as imesimes

Eam @ &R' , BP';;<, a)domenEam @ &R' , BP';;<, a)domen

nonender, nondisended, nononender, nondisended, no

he+aome%a$#he+aome%a$#

La) @ &<&;:.<:H.;, 5BC, .J +$ae$es,La) @ &<&;:.<:H.;, 5BC, .J +$ae$es,

:,KKK, PT;. se!:,KKK, PT;. se!



Pro$a+se Gasro+ah#Pro$a+se Gasro+ah#



Me!0e$7s S!anMe!0e$7s S!an

HHmHHm T!'Pere!hneae S!an ' in2e!ed I( T!'Pere!hneae S!an ' in2e!ed I(and a!!*m*$aes in %asri! iss*e 'and a!!*m*$aes in %asri! iss*e '

RL *+a0e is dia%nosi! of Me!0e$7sRL *+a0e is dia%nosi! of Me!0e$7sdiveri!*$*mdiveri!*$*m Fa$se 3=4 ' )$eedin% $esions s*!h asFa$se 3=4 ' )$eedin% $esions s*!h as

Crohn7s disease, in*ss*s!e+ion,Crohn7s disease, in*ss*s!e+ion,heman%ioma, P"Dheman%ioma, P"D

Fa$se 3'4 ' Bari*m, )$adderFa$se 3'4 ' Bari*m, )$adderoverdisenion, no %asri! m*!osa inoverdisenion, no %asri! m*!osa in

diveri!*$*mdiveri!*$*m



HHmHHm T!' La)e$ed Red Ce$$ S!an T!' La)e$ed Red Ce$$ S!an

HHmHHm T!'s*$f*r !o$$oid is added o a T!'s*$f*r !o$$oid is added o a

sam+$e of he +aien7s )$ood !e$$ssam+$e of he +aien7s )$ood !e$$s

and re'inf*sed I(' +aien is s!annedand re'inf*sed I(' +aien is s!annedih %amma !ameraih %amma !amera

&a$f'$ife is shor 3. min4 so ha&a$f'$ife is shor 3. min4 so ha

afer ;K min*es on$# ;K is $ef inafer ;K min*es on$# ;K is $ef inhe !ir!*$aionhe !ir!*$aion

HHmHHm T! a!!*m*$aes a he )$eedin% T! a!!*m*$aes a he )$eedin%

sie and $i%hs *+ on s!an ' !ansie and $i%hs *+ on s!an ' !an



GI B$eedin% ' TreamenGI B$eedin% ' Treamen

ABCs ' +roe! aira# ihABCs ' +roe! aira# ihhemaemesis in an o)*nded +aienhemaemesis in an o)*nded +aien

I( a!!ess ' o $ines 3K.H NS in oneI( a!!ess ' o $ines 3K.H NS in one$ine, PRBC7s no !om+ai)$e ih$ine, PRBC7s no !om+ai)$e ihderose4derose4

Transf*se for &%) <a!ive Transf*se for &%) <a!ive)$eedin%)$eedin% NG $ava%eNG $ava%e Ana!ids 3; m$<0% *+ o :K m$ 8 hr4Ana!ids 3; m$<0% *+ o :K m$ 8 hr4 PPI m 0 $oadin dose hen ;PPI m 0 $oadin dose hen ;



Dr*% E!a!# in &ea$in%Dr*% E!a!# in &ea$in%

"$!ers"$!ers Dr*%Dr*% Re%imenRe%imen "$!ers &ea$ed"$!ers &ea$ed

&RA&RA ee0s ee0s ee0s ee0s

CimeidineCimeidine K m%<0<dK m%<0<d KK HKHK RaniidineRaniidine ' m%<0<d' m%<0<d

FamoidineFamoidine ;' m%<0<d;' m%<0<d

PPIsPPIs

Ome+ra-o$eOme+ra-o$e K.': m%<0<dK.': m%<0<d HH Lanso+ra-o$eLanso+ra-o$e K.' m%<0<dK.' m%<0<d

S*!ra$faeS*!ra$fae K'K m%<0<dK'K m%<0<d



ATLS C$assi6!aion of Sho!0ATLS C$assi6!aion of Sho!0

ClassClass Bloo%Bloo%

LossLossBPBP HR HR CapCap

refillrefill 'euro 'euro

(( )(*+)(*+ 'L'L -p to-p to

(/0+(/0+'L'L 'L'L

00 0 1 0*+0 1 0*+ Decrease%Decrease% 2(*2(* 2 3 sec2 3 sec 4lert4lert

33 3 1 3*+3 1 3*+ Decrease%Decrease% 2(*2(* 2 3 sec2 3 sec LetargicLetargic

55 5 1 5*+5 1 5*+ 'ot 'ot

palpa6le palpa6le2(*2(* 2 3 sec2 3 sec O6tu"%e%O6tu"%e%



Mana%emenMana%emen

C$ass ;, no anemia, no a!iveC$ass ;, no anemia, no a!ive

)$eedin% on $ava%e, ma# )e fo$$oed)$eedin% on $ava%e, ma# )e fo$$oed

*+ as o*+aien*+ as o*+aien C$ass , mi$d anemia, a!ive )$eedin%C$ass , mi$d anemia, a!ive )$eedin%

ma# )e moniored on ardsma# )e moniored on ards

C$ass : or admi o PIC", !enra$C$ass : or admi o PIC", !enra$$ine, areria$ $ine$ine, areria$ $ine

I(F )o$*ses, ransf*sion as neededI(F )o$*ses, ransf*sion as needed



Mana%emenMana%emen

I!ed sa$ine ' ih !oo$in%, )$eedin%I!ed sa$ine ' ih !oo$in%, )$eedin%

ime in!reases o : !onro$, !$oin%ime in!reases o : !onro$, !$oin%

ime in!reases *+ o K, and PT !anime in!reases *+ o K, and PT !anin!rease o !onro$, and !anin!rease o !onro$, and !an

!a*se h#+ohermia!a*se h#+ohermia

NG *)e is *sef*$ o moniorNG *)e is *sef*$ o monior)$eedin%, )* no in reamen)$eedin%, )* no in reamen

Thera+e*i! endos!o+# Thera+e*i! endos!o+#

3s!$erohera+#4 *sef*$ in vari!ea$3s!$erohera+#4 *sef*$ in vari!ea$



GI B$eedin% @ S*mmar#GI B$eedin% @ S*mmar#

Remem)er #o*r a)C7sRemem)er #o*r a)C7s

I( a!!ess if )$eedin% is si%ni6!anI( a!!ess if )$eedin% is si%ni6!an

P$an dia%nosi! or0'*+ )ased onP$an dia%nosi! or0'*+ )ased on+resenaion+resenaion

Consider non'GI !a*ses of )$ood inConsider non'GI !a*ses of )$ood in

he GI ra! 3e.%., sa$$oed )$ood4he GI ra! 3e.%., sa$$oed )$ood4



*esion ?;*esion ?; An ;'monh'o$d )o# +assed a dar0 red soo$ fo*r ho*rs a%oAn ;'monh'o$d )o# +assed a dar0 red soo$ fo*r ho*rs a%o

and anoher )$ood# soo$ d*rin% +h#si!a$ eaminaion. &eand anoher )$ood# soo$ d*rin% +h#si!a$ eaminaion. &ehas no fever, vomiin%, diarrhea, or !onsi+aion. &is %rohhas no fever, vomiin%, diarrhea, or !onsi+aion. &is %rohand deve$o+men have )een norma$. On +h#si!a$and deve$o+men have )een norma$. On +h#si!a$eaminaion, his +*$se is ;K<min, res+iraor# rae <min,eaminaion, his +*$se is ;K<min, res+iraor# rae <min,and )$ood +ress*re is < mm&%. The a)domen is sofand )$ood +ress*re is < mm&%. The a)domen is sof

and nonender. Re!a$ eaminaion revea$s maroon'!o$oredand nonender. Re!a$ eaminaion revea$s maroon'!o$oredsoo$ ha is %*aia! +osiive. The remainder of he +h#si!a$soo$ ha is %*aia! +osiive. The remainder of he +h#si!a$eaminaion is norma$. Gasri! as+irae is ne%aive foreaminaion is norma$. Gasri! as+irae is ne%aive for)$ood. La)oraor# eva$*aion revea$s hemo%$o)in %<dL,)$ood. La)oraor# eva$*aion revea$s hemo%$o)in %<dL,hemao!ri . Prohrom)in ime, +aria$ hrom)o+$asinhemao!ri . Prohrom)in ime, +aria$ hrom)o+$asinime, and INR ere norma$. Afer inraveno*s 1*idime, and INR ere norma$. Afer inraveno*s 1*idadminisraion and er#hro!#e ransf*sion, hi!h of headminisraion and er#hro!#e ransf*sion, hi!h of he

fo$$oin% is mos $i0e$# o )e dia%nosi!fo$$oin% is mos $i0e$# o )e dia%nosi!

A. Bari*m enemaA. Bari*m enema

B. Me!0e$ radion*!$ide s!anB. Me!0e$ radion*!$ide s!an

C. Com+*eri-ed omo%ra+h# 3CT s!an4 of he a)domenC. Com+*eri-ed omo%ra+h# 3CT s!an4 of he a)domen

D. "++er %asroinesina$ series ih sma$$ )oe$ fo$$oD. "++er %asroinesina$ series ih sma$$ )oe$ fo$$ohro*%hhro*%h



*esion ?*esion ?

A 'ee0'o$d infan has done e$$ sin!e )irh *ni$ )$oodA 'ee0'o$d infan has done e$$ sin!e )irh *ni$ )$oodand m*!*s a++eared in he soo$ for he +as : da#s. &e isand m*!*s a++eared in he soo$ for he +as : da#s. &e isa0in% his *s*a$ fo*r o*n!es of !o'mi$0 form*$a +era0in% his *s*a$ fo*r o*n!es of !o'mi$0 form*$a +erfeedin% iho* vomiin%. &e is more irria)$e d*rin%feedin% iho* vomiin%. &e is more irria)$e d*rin%defe!aion. Ph#si!a$ eaminaion revea$s ha he a)domendefe!aion. Ph#si!a$ eaminaion revea$s ha he a)domenis sof and no disended. The hemo%$o)in is ;K %<dL.is sof and no disended. The hemo%$o)in is ;K %<dL.

5hi!h of he fo$$oin% is he mos $i0e$# e+$anaion for he5hi!h of he fo$$oin% is he mos $i0e$# e+$anaion for he6ndin%s in his infan6ndin%s in his infan

A. &irs!hs+r*n% diseaseA. &irs!hs+r*n% diseaseB. Me!0e$ diveri!*$*mB. Me!0e$ diveri!*$*m

C. Ana$ 6ss*reC. Ana$ 6ss*re

D. Co'mi$0 +roein !o$iisD. Co'mi$0 +roein !o$iis

E. Mid%* vo$v*$*sE. Mid%* vo$v*$*s

gibleeding-

Documents