Hemetamesis and Hemetochezia
(Acute GI Hemorrhage)
Dr,Wu ShuMing
GI Dept,RenJi Hospital
SSMU
Five Ways of GI Bleeding
?Hematemesis,vomitting of blood of
altered blood（ coffee grounds） indicates
bleeding proximal to ligament of Treitz
?Melena,Tarry stool,Altered （ black）
blood per rectum （ >60ml）
?Hematochezia,Bright red or maroon
rectal bleeding implies bleeding beyond
Lig.T.*
?FOB+ and Iron deficiency anemia
Factors affect the way to manifest
?Site of bleeding
?Speed of bleeding
?Amount of blood loss
?Flora of enterocolon
,
Differentiating Upper from Low GI
Bleeding
?Hematochezia usually represents a lower GI
source bleeding
?Upper GI lesion may bleed so briskly that
blood doesn`t remain in bowl long enough
to become melena
?Bleeding lesion distal to T Lig.may be
either M.or hematochezia,but never
manifests hematemesis
Common cause of up GI bleeding
Peptic ulcer ；
Gastropathy （ alcohol,aspirin,NSAIDs,
stress）；
GE varices；
Gastric cancer
Less common cause of up GI bleeding
Esophageal or intestinal neoplam
Esophagitis； Malloy-weiss tear,
Hemoptysis,Swallowed blood
Anticoagulant fibrinoloytic therapy,
Telangiectases； aneurysm ； vasculitis； Dieulafoy
ulcer； AV malformation
Connective tissue disease；
Hemabilia（ biliary origin； Crohn`s disease；
amyloidosis,hematological diseases
BENIGN GASTRIC ULCER
The classical presentation of gastric ulcer,
with weight loss and indigestion made worse by
eating,
patients more often describe symptoms that would fit
equally well for duodenal ulcer - investigation
with barium meal or (preferably) endoscopy is,of
course,appropriate for either,Benign ulcers may
occur at any site in the stomach,but are
commonest on the lesser curve away from acid-
secreting epithelium,
Location of benign gastric ulcers in relationship to the distance from the
pylorus,The majority of benign ulcers will be found on the lesser
curvature within 3 cm of the angulus,
Duodenum Ulcer
?The lesion most commonly affecting the
duodenum is ulceration,and it is now
known that both antral infection with
Helicobacter pylori and the presence of
gastric acid are virtual prerequisites for it.,
?A number of cutaneous features (stigmata)
may develop in a patient with cirrhosis,and
these are important as they aid clinical
recognition of chronic liver disease,
Bleeding Survey,Endoscopic Findings in 214 Patients With
Clear Nasogastric Aspirates
FINDING NUMBER OF PATIENTS INCIDENCE (%)
Duodenaal ulcer 64 29.8
Gastric erosions 57 6.5
Gastric ulcer 47 21.9
Esophagitis 23 10.7
Duodenitis 21 9.8
Varices 11 5.1
Mallory-Weiss tear 10 4.7
Neoplasm 8 3.7
Stomal ulcer 7 3.3
Esophageal ulcer 2 0.9
Telangiectasia 0
Other 18 8.4
Clinical manifestation of GI Bleeding
?Abdominal disconfort
Nausea,
?Hemadynamic change,reduction in blood
volume (syncope,light-headedness,
sweating,therst) or shock
?Laboratory changes,HCT,BUN
Hematemesis with other symptoms
?Hematemesis with upper abdominal pain
?Hematemesis with hepatomegly and spleenomegly
?Hematemesis with jaundice
?Hematemesis with Skin & mucosa hemorrhage
?Hematemesis with upper abdominal mass
?Others,NSAIDs,Stress,Burning,Brain operation,
Trauma,Vomiting
Lab.Examination in Localization
& Diagnosis of GI Bleeding
?Endoscopy
?BariumRadiographs
?Angiography
?Radionuclide imaging
Approach to the patient with acute upper
gastrintesttinal hemorrhage
Acute upper Gastrointestinal Hemorrhage
Rapid assessment Monitor hemodynamic status
Fluid resuscitation Gastric lavage(?)
self-limited (80%) bleeding (10-20%)
Empiric medical therapy
Urgent endoscopy
recurrent hemorrhage
endoscopy Site not localized Localized
further assessment
enteroscopy,radioisotope
s scan,angiography,
exploratory surgery
Definitive therapy Definitive therapy
Endoscopic view of a Mallory-Weiss tear with active bleeding
(gastric lumen is at top left),B,Endoscopic view of an
organized clot adherent to a Mallory-Weiss tear (gastric lumen
is at bottom left ),
Endoscopic view of a Dieulafoy lesion on the lesser
curvature of the stomach
Endoscopic view of a vascular ectasia (angiodysplasia) in
the duodenum,
Endoscopic view of the gastric antrum with
watermelon stomach,The pylorus is at top center,
Note the linear distribution pattern of the vascular
lesions arranged radially around the pylorus,
Endoscopic views of ulcers with stigmata of recent hemorrhage,A,
Duodenal ulcer with a visible vessel,B,Gastric ulcer with a red spot in
the center of the crater,C,Duodenal ulcer with a red spot in the center
of the crater,D,Purplish clot adherent to a gastric ulcer,
Typical picture of a trivial nonsteroidal anti-inflammatory drug (NSAID)-
induced injury to the gastric mucosa,There are multiple small erosions
with brown-black staining of the center as a result of local bleeding and
petechiae,
Typical round gastric ulcer at the
angulus (incisura) of the stomach,
E S O P H A G U S S T O M A C H
D U O D E N U M
J E J U N U M I L E U M C O L O R E C T U M
E s o p h a g e a l v a r i c e s A V m a l f o r m a t i o n s A n g i o d y s p l a s i a
E s o p h a g i t i s A n g i o d y s p l a s i a A V m a l f o r m a t i o n s
G a s t r i t i s U l c e r s U l c e r a t i v e c o l i t i s
G a s t r i c v a r i c e s A n a s t o m o t i c D i v e r t i c u l o s i s
M a l l o r y - W e i s s t e a r s S i m p l e C a n c e r
P e p t i c u l c e r D i v e r t i c u l a P o l y p s
A V m a l f o r m a t i o n s M e c k e l ' s H e m o r r h o i d s
C a n c e r A c q u i r e d A n a l f i s s u r e
P o l y p s C r o h n ' s d i s e a s e S t o m a l v a r i c e s
L e i o m y o m a V a r i c e s P o s t o p e r a t i v e
S a r c o m a I s c h e m i c u l c e r P o s t p o l y p e c t o m y
B r u n n e r ' s a d e n o m a T u b e r c u l o s i s A n a s t o m o t i c
A n g i o d y s p l a s i a A r t e r i t i s T r a u m a
P a n c r e a t i c r e s t B l i n d l o o p U l c e r s
T r a u m a A n g i o m a S i m p l e
P o s t o p e r a t i v e L e i o m y o m a S t e r c o r a l
R e t a i n e d u l c e r C a n c e r T y p h o i d
R e s i d u a l g a s t r i t i s S a r c o m a A m e b i c
A n a s t o m o t i c u l c e r P o l y p s
U r e m i c u l c e r
S t o m a l v a r i c e s
L y m p h o i d h y p e r p l a s i a
T r a u m a
Causes of Low GI Bleeding
Differentiating Upper from Low GI
Bleeding
?Hematochezia usually represents a lower GI
source bleeding
?Upper GI lesion may bleed so briskly that
blood doesn`t remain in bowl long enough
to become melena
?Bleeding lesion distal to T,Lig,may be
either M.or hematochezia,but never
manifests hematemesis
Hematochezia with other symptoms
?Abdominal pain
?Fever
?Tenesmus
?Systemic Hemorrhage
?Dermal sign
?Abdominal mass
Lab,Examination For detecting
Low GI Bleeeding
?Anoscopy & sigmoidoscopy
?Barium Edema (BE)
?Angiography
?Radionuclide scanning
A,Linear ulcers of Crohn's colitis,B,Mucosa
surrounding the ulcers is nodular (cobblestoning),
Shigella colitis,Patchy areas of erythema,
spontaneous bleeding,and loss of the normal
vascular pattern are evident
Salmonella colitis,Diffuse erythema,spontaneous bleeding,
and loss of the vascular pattern with formation of
telangiectasis are present,
Tuberculosis,Linear ulceration runs circumferentially along
the interhaustral septum with tiny satellite ulcerations,This
must be distinguished from the longitudinal linear ulcerations
seen in inflammatory bowel disease,
Pseudomembranous (antibiotic-associated) colitis,
Numerous elevated yellowish plaques are present on
the mucosal surface,
Amebiasis,Discrete punched-out ulcers are present
in the right colon,
Severe acute ulcerative colitis,No vascular pattern is
discernible,A severe degree of spontaneous bleeding is
present
Large colonic ulcer in a patient
with ischemic colitis,
Advantage colon carcinoma
Barium enema appearance of an ischemic stricture
with features of carcinoma,asymmetry,mucosal
destruction,and shouldering,
Summary of Acute GI Bleeding
?Upper GI source bleeding--Hemetemesis
?Major upper GI bleding-- Hemetemesis &
hemetochezia
?The more distant from the rectum,the more
likely that melena occurs
?The colon lesion--FOB+ or hemetochezia
?The small bowl lesion-- melena or
hemetochezia
The questions should be posed
?Prior bleeding episode?
?Family history of GI diseases
?Dose the patient have the illness of ulcer?
Cirrhosis?cancer?blleding disorder?
?Alcohol? NSAIDs?
?Any precedes symptoms or signs?
(Acute GI Hemorrhage)
Dr,Wu ShuMing
GI Dept,RenJi Hospital
SSMU
Five Ways of GI Bleeding
?Hematemesis,vomitting of blood of
altered blood（ coffee grounds） indicates
bleeding proximal to ligament of Treitz
?Melena,Tarry stool,Altered （ black）
blood per rectum （ >60ml）
?Hematochezia,Bright red or maroon
rectal bleeding implies bleeding beyond
Lig.T.*
?FOB+ and Iron deficiency anemia
Factors affect the way to manifest
?Site of bleeding
?Speed of bleeding
?Amount of blood loss
?Flora of enterocolon
,
Differentiating Upper from Low GI
Bleeding
?Hematochezia usually represents a lower GI
source bleeding
?Upper GI lesion may bleed so briskly that
blood doesn`t remain in bowl long enough
to become melena
?Bleeding lesion distal to T Lig.may be
either M.or hematochezia,but never
manifests hematemesis
Common cause of up GI bleeding
Peptic ulcer ；
Gastropathy （ alcohol,aspirin,NSAIDs,
stress）；
GE varices；
Gastric cancer
Less common cause of up GI bleeding
Esophageal or intestinal neoplam
Esophagitis； Malloy-weiss tear,
Hemoptysis,Swallowed blood
Anticoagulant fibrinoloytic therapy,
Telangiectases； aneurysm ； vasculitis； Dieulafoy
ulcer； AV malformation
Connective tissue disease；
Hemabilia（ biliary origin； Crohn`s disease；
amyloidosis,hematological diseases
BENIGN GASTRIC ULCER
The classical presentation of gastric ulcer,
with weight loss and indigestion made worse by
eating,
patients more often describe symptoms that would fit
equally well for duodenal ulcer - investigation
with barium meal or (preferably) endoscopy is,of
course,appropriate for either,Benign ulcers may
occur at any site in the stomach,but are
commonest on the lesser curve away from acid-
secreting epithelium,
Location of benign gastric ulcers in relationship to the distance from the
pylorus,The majority of benign ulcers will be found on the lesser
curvature within 3 cm of the angulus,
Duodenum Ulcer
?The lesion most commonly affecting the
duodenum is ulceration,and it is now
known that both antral infection with
Helicobacter pylori and the presence of
gastric acid are virtual prerequisites for it.,
?A number of cutaneous features (stigmata)
may develop in a patient with cirrhosis,and
these are important as they aid clinical
recognition of chronic liver disease,
Bleeding Survey,Endoscopic Findings in 214 Patients With
Clear Nasogastric Aspirates
FINDING NUMBER OF PATIENTS INCIDENCE (%)
Duodenaal ulcer 64 29.8
Gastric erosions 57 6.5
Gastric ulcer 47 21.9
Esophagitis 23 10.7
Duodenitis 21 9.8
Varices 11 5.1
Mallory-Weiss tear 10 4.7
Neoplasm 8 3.7
Stomal ulcer 7 3.3
Esophageal ulcer 2 0.9
Telangiectasia 0
Other 18 8.4
Clinical manifestation of GI Bleeding
?Abdominal disconfort
Nausea,
?Hemadynamic change,reduction in blood
volume (syncope,light-headedness,
sweating,therst) or shock
?Laboratory changes,HCT,BUN
Hematemesis with other symptoms
?Hematemesis with upper abdominal pain
?Hematemesis with hepatomegly and spleenomegly
?Hematemesis with jaundice
?Hematemesis with Skin & mucosa hemorrhage
?Hematemesis with upper abdominal mass
?Others,NSAIDs,Stress,Burning,Brain operation,
Trauma,Vomiting
Lab.Examination in Localization
& Diagnosis of GI Bleeding
?Endoscopy
?BariumRadiographs
?Angiography
?Radionuclide imaging
Approach to the patient with acute upper
gastrintesttinal hemorrhage
Acute upper Gastrointestinal Hemorrhage
Rapid assessment Monitor hemodynamic status
Fluid resuscitation Gastric lavage(?)
self-limited (80%) bleeding (10-20%)
Empiric medical therapy
Urgent endoscopy
recurrent hemorrhage
endoscopy Site not localized Localized
further assessment
enteroscopy,radioisotope
s scan,angiography,
exploratory surgery
Definitive therapy Definitive therapy
Endoscopic view of a Mallory-Weiss tear with active bleeding
(gastric lumen is at top left),B,Endoscopic view of an
organized clot adherent to a Mallory-Weiss tear (gastric lumen
is at bottom left ),
Endoscopic view of a Dieulafoy lesion on the lesser
curvature of the stomach
Endoscopic view of a vascular ectasia (angiodysplasia) in
the duodenum,
Endoscopic view of the gastric antrum with
watermelon stomach,The pylorus is at top center,
Note the linear distribution pattern of the vascular
lesions arranged radially around the pylorus,
Endoscopic views of ulcers with stigmata of recent hemorrhage,A,
Duodenal ulcer with a visible vessel,B,Gastric ulcer with a red spot in
the center of the crater,C,Duodenal ulcer with a red spot in the center
of the crater,D,Purplish clot adherent to a gastric ulcer,
Typical picture of a trivial nonsteroidal anti-inflammatory drug (NSAID)-
induced injury to the gastric mucosa,There are multiple small erosions
with brown-black staining of the center as a result of local bleeding and
petechiae,
Typical round gastric ulcer at the
angulus (incisura) of the stomach,
E S O P H A G U S S T O M A C H
D U O D E N U M
J E J U N U M I L E U M C O L O R E C T U M
E s o p h a g e a l v a r i c e s A V m a l f o r m a t i o n s A n g i o d y s p l a s i a
E s o p h a g i t i s A n g i o d y s p l a s i a A V m a l f o r m a t i o n s
G a s t r i t i s U l c e r s U l c e r a t i v e c o l i t i s
G a s t r i c v a r i c e s A n a s t o m o t i c D i v e r t i c u l o s i s
M a l l o r y - W e i s s t e a r s S i m p l e C a n c e r
P e p t i c u l c e r D i v e r t i c u l a P o l y p s
A V m a l f o r m a t i o n s M e c k e l ' s H e m o r r h o i d s
C a n c e r A c q u i r e d A n a l f i s s u r e
P o l y p s C r o h n ' s d i s e a s e S t o m a l v a r i c e s
L e i o m y o m a V a r i c e s P o s t o p e r a t i v e
S a r c o m a I s c h e m i c u l c e r P o s t p o l y p e c t o m y
B r u n n e r ' s a d e n o m a T u b e r c u l o s i s A n a s t o m o t i c
A n g i o d y s p l a s i a A r t e r i t i s T r a u m a
P a n c r e a t i c r e s t B l i n d l o o p U l c e r s
T r a u m a A n g i o m a S i m p l e
P o s t o p e r a t i v e L e i o m y o m a S t e r c o r a l
R e t a i n e d u l c e r C a n c e r T y p h o i d
R e s i d u a l g a s t r i t i s S a r c o m a A m e b i c
A n a s t o m o t i c u l c e r P o l y p s
U r e m i c u l c e r
S t o m a l v a r i c e s
L y m p h o i d h y p e r p l a s i a
T r a u m a
Causes of Low GI Bleeding
Differentiating Upper from Low GI
Bleeding
?Hematochezia usually represents a lower GI
source bleeding
?Upper GI lesion may bleed so briskly that
blood doesn`t remain in bowl long enough
to become melena
?Bleeding lesion distal to T,Lig,may be
either M.or hematochezia,but never
manifests hematemesis
Hematochezia with other symptoms
?Abdominal pain
?Fever
?Tenesmus
?Systemic Hemorrhage
?Dermal sign
?Abdominal mass
Lab,Examination For detecting
Low GI Bleeeding
?Anoscopy & sigmoidoscopy
?Barium Edema (BE)
?Angiography
?Radionuclide scanning
A,Linear ulcers of Crohn's colitis,B,Mucosa
surrounding the ulcers is nodular (cobblestoning),
Shigella colitis,Patchy areas of erythema,
spontaneous bleeding,and loss of the normal
vascular pattern are evident
Salmonella colitis,Diffuse erythema,spontaneous bleeding,
and loss of the vascular pattern with formation of
telangiectasis are present,
Tuberculosis,Linear ulceration runs circumferentially along
the interhaustral septum with tiny satellite ulcerations,This
must be distinguished from the longitudinal linear ulcerations
seen in inflammatory bowel disease,
Pseudomembranous (antibiotic-associated) colitis,
Numerous elevated yellowish plaques are present on
the mucosal surface,
Amebiasis,Discrete punched-out ulcers are present
in the right colon,
Severe acute ulcerative colitis,No vascular pattern is
discernible,A severe degree of spontaneous bleeding is
present
Large colonic ulcer in a patient
with ischemic colitis,
Advantage colon carcinoma
Barium enema appearance of an ischemic stricture
with features of carcinoma,asymmetry,mucosal
destruction,and shouldering,
Summary of Acute GI Bleeding
?Upper GI source bleeding--Hemetemesis
?Major upper GI bleding-- Hemetemesis &
hemetochezia
?The more distant from the rectum,the more
likely that melena occurs
?The colon lesion--FOB+ or hemetochezia
?The small bowl lesion-- melena or
hemetochezia
The questions should be posed
?Prior bleeding episode?
?Family history of GI diseases
?Dose the patient have the illness of ulcer?
Cirrhosis?cancer?blleding disorder?
?Alcohol? NSAIDs?
?Any precedes symptoms or signs?
