11.gi bleeding.ppt [read-only] -...
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GASTROINTESTINAL
BLEEDING
ATAN BAAS SINUHAJI
Sub Division of Pediatrics Gastroentero-Hepatology
Department of Child Health, School of Medicine
University of Sumatera Utara/ Adam Malik Hospital
MEDAN
1
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GI Bleeding
Acute
2
Stable
4 important points
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GI bleeding
Blood ?
Gut
1
3
Gut
Out In
Upper or lower
Spesific site
2
3
4
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Materials
Heme protein
4
Hydrogen peroxidase
Colorless guaiac Blue quinone
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Tabel 1. Substances that interfere with Guaiac test
for fecal occult blood
False - Positive results
- Meat (rare or well-done)
- Horseradish
False -Negative results
-Vitamin C
- Storage of specimen > d
5
- Horseradish
- Turnips
- Ferrous sulfate (stool pH <6,0)- Tomatoes
- Fresh red cherries
- Storage of specimen > 4 d- Outdated reagent or card
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GI BleedingGI Bleeding
Gut
6
Out In
Ingestion Non ingestion Upper Lower
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Non ingestion
- Blood disorders : leukemia,ITP, etc
7
- Blood disorders : leukemia,ITP, etc
- Systemic : sepsis
- Rupture aortic aneurysma with enteric fistula
- Hemorrhagic Disease of the Newborn
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Ingestion
Newborn
Swallowed maternal blood
Infants & young children
- Nipples
8
Swallowed maternal blood
APT Downey Test
- Nipples
- Epistaxis
- Oropharyngeal bleeding
- Blood tinged sputum
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Newborn
Hb F Hb A Hb A2
9
50-90%
Alkali resistent
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Manifestation of GI Bleeding
Blood per os Blood per anum
10
Hematemesis
Upper GIT
Occult Overt
Melena Hematochezia
Upper GIT
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Hematochesia
With diarrhoea Without diarrhoea Without stools
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Dysentry
syndrome
Blood strike
Anorectal area
•Anal fissure
•Polyps
Currant jelly
stools
Intussusception
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GI Bleeding
Causes
12
Non lesion GIT Lesion GIT
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Lesion GIT
Upper Lower
13
Mucosal
lesionVariceal
bleedingSurgical
Non
surgical
•Emergency
•ElectiveInflammation
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Clinical presentationClinical presentation
•Hematemesis
•Melena
•Hematochezia
•Hystory & physical examination
•Laboratory evaluation
14
Stable
Nasogastric tube
Blood (+) Blood (-)
Upper GIT bleeding Lower GIT bleeding
•Contrast radiography
•Endoscopy
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Gastric aspiration
The site of bleeding •The amount of bleeding
•The bleeding stop ?
15
Not totally exclude
upper GIT bleeding
•Competent pyloric
•No reflux
•Bleeding stopped
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Clinical presentation
•Hystory and physical examination
•Laboratory evaluation
Stable
Nasogastric tube
Blood (+) Blood (-)
16
Upper GIT bleeding Lower GIT bleeding
Plain abdominal X-ray
(erect & supine)
Obstruction No obstruction
Barium enema
Surgery
•Stool examination / culture
•Meckel’s scan
•Double contrast barium enema
•Colonoscopy
Figure 2. A diagnostic approach
of lower bleeding GIT
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Treatment
A General measures
BControl of upper
17
Treatment BControl of upper
GIT bleeding
CControl of lower
GIT bleeding
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A General measures
1. To restore iv volume
& O2 carrying
capacity
2. To increased
hematocrit
•NaCl 0,9%
•Lactate Ringer
Blood/product
18
A General measureshematocrit
3. Underlying
coagulopathies
•Vit K 1 mg/year
(max 10 mg)
•Fresh Frozen Plasma
•Platelets
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BControl of upper
Gastric lavage with ice saline
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BControl of upper
GIT bleeding
Specific
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Specific treatment of upper GIT bleeding
Mucosal lesion Variceal bleeding
20
Acid neutralizing /
supressor agent
•Vasoactive agent
•Balloon tamponade
•Sclerosing
•Surgery
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Gastric lavage with ice saline
•Standart treatment
•Clearing of fresh blood and clots
21
•Clearing of fresh blood and clots
Adverse effect:
Hypothermia and electrolytes
abnormalities in infant
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Gastric lavage with ice saline
� The recommended volume:
� 50 mL (infants)
� 100-200 mL (older children)
� Rapidly infused to stomach� Rapidly infused to stomach
� Allow to stay for 2-3 minutes and gently aspirated out
� The tube left in place to monitoring any
subsequent hemorrhage
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Mucosal lesion
- Self limiting (spontaneously / ice saline)
- Acid neutralizing / supressor agent
23
Do not stop active bleeding
Antacid 1 mL/kg/dose (max 30 mL/dose)•Every 1-2 hours � gastric pH ≥5
•Thereafter: 1-3 hours after meal & at bed time
6 weeks
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Variceal bleeding
Stop spontaneously
Vasoactive agent
(vasopressin & octreotide)
24
(vasopressin & octreotide)
Splanchnic arterial
blood flow ↓↓
Portal pressure ↓↓
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Variceal bleeding
Radical/surgical consultation
ICU
Resuscitation
25
Endoscopy to visualize varices
Vasoactive agent
Sengstaken – Blackmore tube
Sclerosing therapy Emergency therapy
Figure 3. An approach to the management of variceal bleeding
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VASOPRESSIN
� Bolus dose: 0,3 U/kg (max 20 U/kg) dilluted in
2 mL/kg 5% Dextrose � 20 minutes
� Continous infusion: 0,2-0,4 U/1,73m2/min,if necessarynecessary
� The bleeding cases: the infant is maintained
at the initial dose for 12 hours and then
gradually tapered � 24-36 hours
� Side effect: hypertension, myocardial
ischemic, arrhythmias, water retention and
venous thrombosis26
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OCTREOTIDE
� Bolus dose: 1 μg/kg
� Continued infusion: 1 μg/kg/h with titration
of both bolus and constant infusion up to 5μg/kg/h μg/kg/h
� The bleeding cases: doses should be tapered
by 50% for 12 hours, can be discontinued
when dose is 25% initial dose
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Balloon tamponade
Sengstaken-Blackmore tube
Indication:
•Massive life threatening bleeding
•Continued bleeding despite 4-6 hours
28
•Continued bleeding despite 4-6 hoursof i.v. vasopressin
Complication:
•Ulceration
•Airway obstruction
•Aspiration
•Esophageal rupture
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C Control of lower GIT bleeding
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•Severe lower GIT bleeding is uncommon
•Definitive treatment: depend on the cause
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B � Ongoing bleeding
L � Low systolic blood pressure
E � Elevated prothrombine time
30
E � Elevated prothrombine time
E � Erratic in mental status
D � Comorbid disease (other thanbleeding) requiring admission
to ICU
Figure 4, Predictors of outcome
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CONCLUSION
GI Bleeding
Not unusual
Life threatening problem
31
Life threatening problem
Stable
Bleeding source
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Thank Thank Thank Thank
YouYouYouYou
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