Upper Gastrointestinal Bleeding (UGIB) Quiz

Gastrointestinal Bleeding

Upper Gastrointestinal Bleeding (UGIB)

• Defined as blood loss originating from a site in the GIT proximal to the ligament of Treitz
• Etiology:
  • Peptic ulcer (commonest cause, with duodenal ulcer bleeding four times more common than gastric ulcer)
  • Varices
  • Gastritis (acute mucosal erosions)
  • Gastric neoplasms (carcinoma of the stomach, adenoma, angioma, lymphoma, etc.)
  • Stress ulcer
  • Mallory-Weiss tears (longitudinal mucosal tears extending across the esophagogastric junction)
  • Others (esophagitis, vascular malformations, systemic diseases leading to bleeding and coagulation abnormalities)

Signs and Symptoms of UGIB

• Hematemesis (vomiting of blood, which may be a coffee ground material, fresh blood, or blood clots)
• Melena (passage of black tar-like stool due to mixing with altered blood)
• Hematochezia (passage of liquid blood or blood clots per rectum)

Work-up and Management of UGIB

• Initial evaluation: assessment of clinical features, identification of patients who need immediate intervention, and suspicion of the possible site of bleeding and cause
• History: inquiries about scoiodemagraphic variables, PUD history, ingestion of drugs implicated as causes of GI bleeding, liver diseases, co-morbid diseases, and symptoms of bleeding diathesis
• Urgent examination: signs suggestive of seriously depleted blood volume and probably continuing blood loss
• Management:
  • Resuscitation: restoration of blood volume with rapid crystalloid infusion, blood transfusion, and monitoring response to resuscitation measures
  • Alleviating anxiety and pain
  • Placing nasogastric tube to monitor rate of bleeding and for saline lavage
  • Diagnostic evaluation: esophago-gastro-duodenoscopy, other studies performed based on endoscopy findings and availability of facilities
  • Further management: depending on the underlying cause, including medical therapy, endoscopic therapy, and surgical therapy

Lower Gastrointestinal Bleeding (LGIB)

Types of LGIB

• Small intestinal bleeding
• Colorectal bleeding
• Anorectal bleeding

Causes of Colorectal Bleeding

• Neoplasms and polyps
• Diverticulosis/diverticulitis
• Vascular malformations
• Inflammatory causes (intestinal tuberculosis, inflammatory bowel diseases)

Clinical Evaluation of LGIB

• History: note the presence of hematochezia, chronic bleeding, and symptoms related to causes of UGIB
• Physical examination: assessment of hemodynamic status, clinical diagnosis of the possible underlying cause and site of bleeding, and signs of chronic blood loss

Management of LGIB

• Resuscitation: initiation while assessing the patient and monitoring progress closely
• Diagnostic evaluation: further clinical assessment and investigations performed after the patient is hemodynamically stable
• Specific treatment: depending on the underlying cause, including medical therapy, operative therapy, or endoscopic therapy

Colorectal Tumors

Clinical Features of Colorectal Carcinoma

• Nonspecific symptoms: anemia, loss of appetite, weight loss, generalized body weakness
• Local effects of the tumor: palpable lump, features of appendiceal mass, change in bowel habit, passage of mucus, tenesmus, sense of incomplete defecation
• Investigation: stool examination, sigmoidoscopy, colonoscopy, barium enema, biopsy under endoscopic guide
• Management: depending on mode of presentation, stage of the disease, site of the primary lesion, and presence or absence of multiple lesions

Anorectal Abscesses

Clinical Features

• Pain (usually severe), fever, constitutional symptoms, features of proctitis, and constipation
• Physical findings: lump visible and palpable at the anal margin/anal canal or ischiorectal fossa, tenderness, and rectal tender mass

Management

• Abscess drainage as soon as diagnosed, followed by irrigation, packing with saline-soaked gauze, and Sitz bath twice daily till wound healing
• Antibiotics used together with surgical treatment, especially in immunocompromised patients

Perianal Fistulas (Fistula in Ano)

Definition

• A track lined by granulation tissue, connecting the anal canal or rectum internally with the skin around the anus externally

Causes

• Usually an untreated or inadequately treated anorectal abscess
• Granulomatous infections and inflammatory bowel diseases

Clinical Features

• Seropurulent discharge with perianal irritation
• External opening seen as a small elevated opening on the skin around the anus with a granulation
• Internal opening felt as a nodule on digital rectal examination
• Signs of underlying/associated diseases

Anal Fissure (Fissure in Ano)

Definition

• An elongated tear (ulcer) in the lower anal canal, which lies along the long axis of the canal

Etiology

• Passage of hard fecal mass precipitates and aggravates the condition

Clinical Features

• Pain (commonest feature)
• Characteristic sharp, severe pain starting during defecation and lasting an hour or more, ceasing suddenly to reappear during the next bowel motion
• Constipation: patient tends to be constipated for fear of the pain on defecation### Symptoms of Anal Fissure
• Bright streaks of blood on the stool surface or toilet paper indicate bleeding
• Discharge is common in chronic cases
• Manifestations of underlying diseases and/or complications may also occur

Physical Examination

• Tightly closed anus due to sphincter spasm may be observed
• Sentinel pile (skin tag) may be visible at the anal verge
• Lower end of the fissure can be seen on gentle parting of the buttocks
• Digital examination may not detect the fissure in early cases
• In fully established cases, the fissure may feel like a vertical crack in the anal canal
• Patients with HIV and other viral infections may have big ulcers and fissures

Conservative Management

• Recommended for small, acute, and superficial fissures that may heal spontaneously
• Includes a high fiber diet, high fluid intake, and a mild laxative to encourage soft, bulky stools
• Local anesthetic ointment or suppository may be administered

Surgical Measures

• Needed when conservative management fails, or in cases of chronic fissures with fibrosis, skin tag, or mucous polyp, or recurrent anal fissures
• Procedures include lateral anal sphincterotomy, fissurectomy, and sphincterotomy
• Requires an experienced operator to reduce complications such as hematoma formation, incontinence, and mucosal prolapse
• After-care includes bowel care, daily baths, and stool softening until wound healing occurs

Gastrointestinal Bleeding

Upper Gastrointestinal Bleeding (UGIB)

• Defined as blood loss originating from a site in the GIT proximal to the ligament of Treitz
• Etiology:
  • Peptic ulcer (commonest cause, with duodenal ulcer bleeding four times more common than gastric ulcer)
  • Varices
  • Gastritis (acute mucosal erosions)
  • Gastric neoplasms (carcinoma of the stomach, adenoma, angioma, lymphoma, etc.)
  • Stress ulcer
  • Mallory-Weiss tears (longitudinal mucosal tears extending across the esophagogastric junction)
  • Others (esophagitis, vascular malformations, systemic diseases leading to bleeding and coagulation abnormalities)

Signs and Symptoms of UGIB

• Hematemesis (vomiting of blood, which may be a coffee ground material, fresh blood, or blood clots)
• Melena (passage of black tar-like stool due to mixing with altered blood)
• Hematochezia (passage of liquid blood or blood clots per rectum)

Work-up and Management of UGIB

• Initial evaluation: assessment of clinical features, identification of patients who need immediate intervention, and suspicion of the possible site of bleeding and cause
• History: inquiries about scoiodemagraphic variables, PUD history, ingestion of drugs implicated as causes of GI bleeding, liver diseases, co-morbid diseases, and symptoms of bleeding diathesis
• Urgent examination: signs suggestive of seriously depleted blood volume and probably continuing blood loss
• Management:
  • Resuscitation: restoration of blood volume with rapid crystalloid infusion, blood transfusion, and monitoring response to resuscitation measures
  • Alleviating anxiety and pain
  • Placing nasogastric tube to monitor rate of bleeding and for saline lavage
  • Diagnostic evaluation: esophago-gastro-duodenoscopy, other studies performed based on endoscopy findings and availability of facilities
  • Further management: depending on the underlying cause, including medical therapy, endoscopic therapy, and surgical therapy

Lower Gastrointestinal Bleeding (LGIB)

Types of LGIB

• Small intestinal bleeding
• Colorectal bleeding
• Anorectal bleeding

Causes of Colorectal Bleeding

• Neoplasms and polyps
• Diverticulosis/diverticulitis
• Vascular malformations
• Inflammatory causes (intestinal tuberculosis, inflammatory bowel diseases)

Clinical Evaluation of LGIB

• History: note the presence of hematochezia, chronic bleeding, and symptoms related to causes of UGIB
• Physical examination: assessment of hemodynamic status, clinical diagnosis of the possible underlying cause and site of bleeding, and signs of chronic blood loss

Management of LGIB

• Resuscitation: initiation while assessing the patient and monitoring progress closely
• Diagnostic evaluation: further clinical assessment and investigations performed after the patient is hemodynamically stable
• Specific treatment: depending on the underlying cause, including medical therapy, operative therapy, or endoscopic therapy

Colorectal Tumors

Clinical Features of Colorectal Carcinoma

• Nonspecific symptoms: anemia, loss of appetite, weight loss, generalized body weakness
• Local effects of the tumor: palpable lump, features of appendiceal mass, change in bowel habit, passage of mucus, tenesmus, sense of incomplete defecation
• Investigation: stool examination, sigmoidoscopy, colonoscopy, barium enema, biopsy under endoscopic guide
• Management: depending on mode of presentation, stage of the disease, site of the primary lesion, and presence or absence of multiple lesions

Anorectal Abscesses

Clinical Features

• Pain (usually severe), fever, constitutional symptoms, features of proctitis, and constipation
• Physical findings: lump visible and palpable at the anal margin/anal canal or ischiorectal fossa, tenderness, and rectal tender mass

Management

• Abscess drainage as soon as diagnosed, followed by irrigation, packing with saline-soaked gauze, and Sitz bath twice daily till wound healing
• Antibiotics used together with surgical treatment, especially in immunocompromised patients

Perianal Fistulas (Fistula in Ano)

Definition

• A track lined by granulation tissue, connecting the anal canal or rectum internally with the skin around the anus externally

Causes

• Usually an untreated or inadequately treated anorectal abscess
• Granulomatous infections and inflammatory bowel diseases

Clinical Features

• Seropurulent discharge with perianal irritation
• External opening seen as a small elevated opening on the skin around the anus with a granulation
• Internal opening felt as a nodule on digital rectal examination
• Signs of underlying/associated diseases

Anal Fissure (Fissure in Ano)

Definition

• An elongated tear (ulcer) in the lower anal canal, which lies along the long axis of the canal

Etiology

• Passage of hard fecal mass precipitates and aggravates the condition

Clinical Features

• Pain (commonest feature)
• Characteristic sharp, severe pain starting during defecation and lasting an hour or more, ceasing suddenly to reappear during the next bowel motion
• Constipation: patient tends to be constipated for fear of the pain on defecation### Symptoms of Anal Fissure
• Bright streaks of blood on the stool surface or toilet paper indicate bleeding
• Discharge is common in chronic cases
• Manifestations of underlying diseases and/or complications may also occur

Physical Examination

• Tightly closed anus due to sphincter spasm may be observed
• Sentinel pile (skin tag) may be visible at the anal verge
• Lower end of the fissure can be seen on gentle parting of the buttocks
• Digital examination may not detect the fissure in early cases
• In fully established cases, the fissure may feel like a vertical crack in the anal canal
• Patients with HIV and other viral infections may have big ulcers and fissures

Conservative Management

• Recommended for small, acute, and superficial fissures that may heal spontaneously
• Includes a high fiber diet, high fluid intake, and a mild laxative to encourage soft, bulky stools
• Local anesthetic ointment or suppository may be administered

Surgical Measures

• Needed when conservative management fails, or in cases of chronic fissures with fibrosis, skin tag, or mucous polyp, or recurrent anal fissures
• Procedures include lateral anal sphincterotomy, fissurectomy, and sphincterotomy
• Requires an experienced operator to reduce complications such as hematoma formation, incontinence, and mucosal prolapse
• After-care includes bowel care, daily baths, and stool softening until wound healing occurs