Bleeding from the GutClinical approach

• Severity

Vital signs

Haematocrit

Beware ongoing losses• Acute onset or chronic blood loss

Fe deficiency• Stigmata of disease

Failure to thrive and grow

Purpura

Liver and spleen

Site of bleeding

• Haematemesis

Fresh blood

swallowed, rapid haemorrhage

Altered - “coffee ground”

gastric acid

Site of bleeding

• Bleeding per rectum

Fresh blood not mixed with stool

low rectum and anus

Fresh blood with mucus - dysentery

colon and rectum

Jellied dark blood

intussusception

Melaena - tarry black

bleeding from higher up

Bleeding from the gut

• Bleeding tendency

Vitamin K deficiency

Hepatic failure

Disseminated intravascular coagulation

septicaemia, necrotising enterocolitis

Thrombocytopaeniahaemolytic uraemic syndrome

Vasculitis - Henoch Schonlein purpura

Bleeding from the Gut

• Swallowed blood

Maternal blood swallowed intrapartum

Apt test

Nose bleed

Mouth and pharynx• Oesophagus

Varices (portal hypertension)

Oesophagitis (peptic or other)

Mallory-Weiss tear

Bleeding from the Gut

• Stomach

Gastritis and erosions

Ulcer (peptic, stress)

• Small gut

Meckel diverticulum

Ulcers (peptic and inflammatory)

Intussusception

Volvulus

Polyps

Bleeding from the Gut• Large gut

Dysentery (amoebic, bacterial)

Intussusception

Polyps

Ulcerative colitis

• Rectum and anus

Varices

Polyps

Trauma

Anal fissure

Bleeding from the gutManagement

• Resuscitation as required

• Stop the bleeding

mostly spontaneous

vitamin K

blood component therapy

emergency endoscopic approach

Bleeding from the GutManagement

• Identify the site of haemorrhage

History

Character of blood

Upper gut: endoscopy

Lower gut:contrast studies

isotope scan “Meckel scan”

endoscopy• Identify and manage aetiology• Follow-up for recurrence

Dysentery

• Mucosal invasion or toxin mediated inflammation with necrosis

bacteria - shigella, Esch.coli, others

Entamoeba histolytica, trichiuris• Fever, abdominal pain, extraintestinal features• Sometimes onset in “gastro-like” fashion• Major complications