The risk of upper gi bleeding for plain, entericcoated, or buff. Features upper gi bleed lower gi bleedsite above ligament below ligament of treitz of treitzpresentation hemetemesis or hematochezia malenanasogastric blood clear fluidaspirationbowel sounds hyperactive normalbun creatinine increased normalratio. Diagnosis and management of upper gastrointestinal. Assessment of upper gastrointestinal bleeding approach. Murphy is a 45 year old advertising executive who presents to the emergency room complaining of the passage of black stools x 3 days and an associated lightheadedness.
In 1 small casecontrol study in patients with a history of ugib. Gi bleeds are classified into upper or lower in regards to the location of the bleeding. Management of acute upper gi bleeding bja education. The cumulative incidence of recurrent ulcer bleeding. The key issues associated with nsaidinduced ulcers, gi injury and related. As with nausea and vomiting histories the character of the vomit and preceding events can help with getting to a diagnosis here and dont forget about risk factors such as alcohol intake.
Gastrointestinal bleeding is categorized as either upper or lower bleeding, with the ligament of treitz serving as an anatomical landmark to differentiate between the two. Upper gastrointestinal bleeding remains the most common reason for emergency hospital admission with a gastrointestinal problem. The reported incidence of acute upper gastrointestinal bleeding ugib in the united kingdom varies over the range 84172100 000 year. Discuss history questions which will help focus your assessment.
Gastrointestinal bleeding knowledge for medical students. Assess medication and psychosocial history for agents that promote gastrotoxicity. History findings include weakness, dizziness, syncope associated with hematemesis coffee ground vomitus, and melena black stools with a rotten odor. To be able to obtain a history that is targeted to the presenting complaint takes practice, as well as knowledge of possible differential diagnoses. Taking a thorough history can often identify the likely cause of the bleed before endoscopic confirmation. History taking in medicine and surgery third edition jonathan m. Similar to the situation with antiplatelet agents, observational studies in patients who develop upper gastrointestinal bleeding while taking warfarin indicate that those who restart warfarin have markedly lower rates of death and thromboembolic events. You will need to elicit information about any complaints of gastrointestinal disease or disorders. This guide structures the history in parallel with the structure of the gi system, beginning at the mouth and working downwards. Iron deficiency anemia low blood count associated with a low iron level in the blood in someone who has had no visible bleeding. Occasionally, a brisk upper gi bleeding ugib manifests as hematochezia red or maroon stools. Gastrointestinal bleeding with the new oral anticoagulants defining the issues and the management strategies jay desai 1. Acute upper gi bleeding accounts for 8 per cent of emergency hospital admissions higham et al, 2002. Upper gastrointestinal gi bleeding vomiting blood or blood found in the stool that originated from the upper part of the gi tract.
It aims to identify which diagnostic and therapeutic steps are useful so hospitals can develop a structure in which clinical teams can deliver an optimum service for people who develop this condition. Over time you will stop using this approach and only ask a smaller more focused subset of these questions. This means that people with acute upper gastrointestinal bleeding who are already taking lowdose aspirin to prevent further vascular events should be advised to continue taking aspirin if their bleeding has stabilised so that the benefit of taking aspirin can be maintained. In consequence, upper gastrointestinal bleeding still causes approximately 5000 deaths per annum in the uk.
Pathophysiology bleeding along the lining of the gastrointestinal tract is hard to recognize because it is not something you can see immediately, or necessarily get imaging or laboratory test work to discover the cause of bleeding right away. Upper gastrointestinal bleeding associated with the use of. This guideline covers how upper gastrointestinal bleeding can be effectively managed in adults and young people aged 16 years and older. Constipation history bleeding on defecation bright red on tissue paper constipation history diverticular haemorrhage sudden painless rectal bleeding elderly. If gi bleeding occurs while taking apixaban 5 mg, consider switching to apixaban, 2. Over the past decade, hospitalizations due to upper gi complications have decreased, whereas the number of lower gi complications has increased. The barium will make your upper gi tract more visible on an xray. The management of acute upper gastrointestinal bleeding. Upper gi bleed is an acute condition requiring immediate active intervention for resuscitation. Gastrointestinal complications of dual antiplatelet therapy. When there is significant blood loss over a short time, symptoms may include vomiting red blood, vomiting black blood, bloody stool, or. The absence of nausea and vomiting in the setting of melaena or haematochezia thought to be of upper gi origin suggests a bleeding source distal to the pylorus.
Introduction upper gastrointestinal bleeding ugib is a poten. The absence of nausea and vomiting in the setting of melena or hematochezia thought to be of upper gi origin suggests a bleeding source distal to the pylorus. Catherine roberson is 81 year old who was brought to emergency by her daughter because of blood with bowel motion. Upper gastrointestinal bleeding is an uncommon but potentially serious, lifethreatening condition in children. Reducing the gastrointestinal risks of lowdose aspirin. Drug treatments in upper gastrointestinal bleeding. Effect of age on the risk of major bleeding events all gi bleeding and ich with lowdose aspirin. In the uk, the incidence is between 47 and 116 per 100,000 of the population and is higher in areas where there is socioeconomic deprivation dallal and palmer, 2002.
Upper gastrointestinal bleeding is defined as blood loss proximal to the ligament. Both upper gastrointestinal bleeding and lower gastrointestinal bleeding have different causes, include ulcers, gastritis, cancer, infection, ibd, hemorrhoids, and anal fissures. After successful completion of this course, you will be able to. Management of upper gastrointestinal bleeding annals of. Data are shown as adjusted irr, crude or adjusted or or hr, plus 95% cis, for the risk of major bleeds with lowdose aspirin vs no aspirin. The risk was significantly increased in patients with a history of peptic ulcer andor upper gastrointestinal bleeding, and in those taking antiplatelet drugs.
Acute upper gastrointestinal bleeding augib continues to be the most common gastrointestinal emergency and accounts for over 9000 deaths a year in the uk. The structural basis of history taking 1 how to present the history. Current evidence suggests that nsaids increase the risk of lower gi bleeding and perforation to a similar extent as that seen in the upper gi tract. Gastrointestinal history taking requires a systematic approach to ensure you dont miss anything important. However, although lgib is statistically less common than upper gi bleeding ugib, it has been suggested that lgib is underreported. Overview acute upper gastrointestinal bleeding in over. Symptoms of upper gi bleeding vomiting bright red blood vomiting dark clots. Evaluation of upper gi bleed approach bmj best practice. Specific attention should be directed at the following. The role of endoscopy in the management of acute nonvariceal upper gi bleeding. Lower gastrointestinal bleeding lgib accounts for approximately 2033% of episodes of gastrointestinal gi hemorrhage, with an annual incidence of about 2027 cases per 100,000 population in western countries. The history and clinical findings are suggestive of an upper gastrointestinal bleed ugib. Learn the signs, treatments, and risk factors of gi bleeding.
A uk audit in 2007 found an overall mortality of 10%. Lower gastrointestinal bleeding clinical presentation. The most common causes are gastritis, duodenal ulcer, esophageal varices, benign gastric ulcer, esophagitis, and malloryweiss tear. Approach to gastrointestinal bleeding samir haffar m.
To prepare for an upper gi series, dont eat, drink, smoke, or chew gum. About 60% of patients with a history of upper gi bleeding are bleeding from the lesion previously identified. Gastrointestinal bleeding gi bleed, also known as gastrointestinal hemorrhage gib, is all forms of bleeding in the gastrointestinal tract, from the mouth to the rectum. Good history taking is crucial in order determine the source of bleeding. Upper gi bleeding is defined as bleeding proximal to the ligament of treitz. Upper gastrointestinal bleeding 370 vaginal bleeding 376 visual loss acute and chronic 384. Discuss the components of a focused gastrointestinal assessment. The purpose of this study was to determine the risk of upper gastrointestinal ugi bleeding in gastric bypass patients taking clopidogrel and to develop a plan of management for these patients. In the next 1015 minutes take focused history and perform focused physical examination. A lady with haematemesis clinical case scenario geeky. The 3 steps to take when you arent sure of the source. Devise a plan to effectively manage acute gi bleeding and optimize treatment responses in the individual patient.
The diagnostic approach includes history, examination, laboratory evaluation, endoscopic procedures, and imaging studies. C 4, 14 early upper endoscopy within 24 hours of presentation is recommended in most patients with upper gastrointestinal bleeding. Mechanisms of aspirininduced gi injury are due to local effects within the gi mucosa that. Blood transfusions generally should be administered to patients with upper gastrointestinal bleeding who have a hemoglobin level of 7 g per dl 70 g per l or less. Diagnosis and management of upper gastrointestinal bleeding.
Design plans for the prevention of upper gi bleed ing caused by commonly associated risk factors. Rectal pr bleeding history taking osce station guide and mark scheme the rectal bleeding pr osce station is a common history station as there are important differentials to exclude such as bowel cancer and upper gi bleeding and it is a common symptom in general practice and the emergency department. Acute upper gastrointestinal bleeding in adults nice. Massive upper gi bleeding, however, can produce bright red blood per rectum if gi transit time is rapid. Management of acute upper gastrointestinal bleeding the bmj.1512 144 388 495 419 136 16 718 847 908 444 170 1241 141 79 1125 753 502 732 197 363 469 522 691 937 1453 253 987 113 193 695 887 816 1469 172