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

Test your knowledge on Upper Gastrointestinal Bleeding, its definition, symptoms, and management. Learn about the mortality and morbidity rates, especially in the elderly.