Margaret Denise P.

del Rosario
2308190682

Sec A
July 6, 2015

A. Definition of concepts:
1. Massive GI bleedingCan be divided into Upper GI bleeding or Lower GI bleeding that requires
transfusion of at least 4 units of blood during 24 hours in the hospital or as hypotension with systolic BP
<90mmHg
2. Occult GI bleedingGI bleeding not visible to the physician or patient. It results to a positive occult
blood test or iron deficiency anemia.
3. Obscure Bleedingpersistent or recurrent bleeding from GI tract after negative evaluations with upper
and lower endoscopes
4. Upper GI bleedingBleeding in the esophagus, stomach and first part of the small intestines
5. Lower GI bleedingBleeding in majority of the small intestines. Large intestines or bowels, rectum and
anus
6. Hematemesisvomiting out blood either fresh or coffee ground in nature
7. Melenablack, tarry stools usually from bleeding in the upper GI where acids have reacted to the
blood
8. HematocheziaPassage of fresh blood in the anus with or in stools
9. Anatomic Landmark of Upper GI and Lower GI tract in relation to bleedingLigament of Treitz
10. Hematobiliaupper GI tract bleeding that originates from the biliary tract (Biliary tract hemorrhage)
11. Angiodyplasia vs. Diverticula
Angiodysplasia
Definition: Small vascular malformation of the got
Cause: unexplained GI bleeding and anemia
Lesions: multiple frequently involve the cecum or
ascending colon
Treatment: colonoscopic interventions, angiography
and embolization, medication or surgery

Diverticula
Definition: outpouching of a hollow structure in the
body either true or fals
Cause: high pressure within the colon pushes
against weak spots
Location: end of the descending and sigmoid colons
and first section of the small intestine
Treatment: bipolar probe coagulation, epinephrine
injection and metallic clips

12. Classification of shock and its manifestations

Classification
Hypovolemic

Traumatic

Cardiogenic
- Intrinsic
- Compressive
Septic
- Hyperdynamic (early)
- Hypodynamic (late)
Neurogenic

Hypoadrenal

Manifestation
Anxiety, cold, clammy skin, confusion, decreased or
no urine output, general weakness, pallor,
tachycardia, sweating, unconsciousness
Insomnia, nightmares, startled easily, tachycardia,
fatigue, aches and pains, difficulty concentrating,
edginess and agitation, muscle tension
Tachypnea, shortness of breath, tachycardia, loss of
consciousness, weak pulse, sweating, pallor, cold
hands and feet, decreased urine output
Patches of discolored skin, decreased urine output,
confusion, tachypnea, diffulty of breathing,
palpitations, tachycardia, chills, extreme weakness
and lightheadedness
Warm extremities, decreased urine output, flaccid
paralysis below the injury, loss of spinal reflexes,
sensation, sweating and sphincter tone
Abdominal pain, confusion, dehydration, dizziness,
fatigue, flank pain, headache, high fever, loss of
appetite, loss of consciousness, nausea, low BO,
weakness, tachycardia, tachypnea, excessive
sweating, vomiting

B. Sample cases for GIT bleeding

Case 1
A. The initial assessment based on the above clinical data is: Massive Lower GI bleeding secondary to
Diverticulosis
B. Give 3 differential diagnosis/basis
Differentials
Colon Cancer

Angiodysplasia

Ischemic Colitis

Rule in
Hematochezia
Abdominal Pain
Full abdomen
Pallor
(+) fresh blood on DRE
Above 50 years old
(+) fresh/maroon blood on DRE
Hematochezia
BP 90/60, HR 120/min, RR 23/min
Pallor
Full Abdomen
Hypoactive bowel sounds
(+)tenderness on RLQ and LLQ
(+) fresh/maroon blood on DRE
Hematochezia
BP 90/60, HR 120/min, RR 23/min
Pallor
Full Abdomen
Hypoactive bowel sounds
(+)tenderness on RLQ and LLQ
65 years old

Rule Out
Short duration of symptoms
Rule out through endoscopy and
biopsy

Painless, self-limited
hematochezia
Slow, repeated episodes of
bleeding

Self-limited and recurrent

Short duration of symptoms
(usually presents several weeks
prior to consult)

C. The initial treatment plan/rationale

- Establish the airway and give O2 to stabilize oxygenation and minimize acidosis
- Fluid resuscitation first because of the blood lossadminister colloid or crystalloid
solutions
- Blood transfusion because of class 3 blood loss
D. How would you structure your diagnostic and definitive treatment plan?
Administer all stabilizing treatments first, this should be a priority because the patients condition
may lead to shock. Establish the patients airway, provide O2 and administer colloid and crystalloid
solutions. If there is no improvement after this, administer a blood transfusion and monitor. If the patient
becomes stable then an investigative colonoscopy must be done to localize the bleeding site. If
bleeding is due to diverticulosis, then bipolar probe coagulation, epinephrine injection and metallic clips
may be used. If angiodysplasia then electrocoagulation or argon plasma coagulation. If patient is
unstable after blood transfusion, an exploratory laparotomy must be done a segmental bowel resection
and subtotal colectomy may be performed.

Case 2
A. The initial assessment based on the above clinical data is: Upper Gastrointestinal Bleeding
secondary to Gastric Varices
B. Give 3 differential diagnosis/basis
Disease
Bleeding Peptic ulcer

Hemoilia

Gastrointestinal Cancer

Rule In
Abdominal pain
Full abdomen
Hematemesis
Melena
HR 130/min
RR 25/min
Pallor, weak and thread pulse
Hyperactive bowel sounds
Melena on DRE
Syncope and body weakness
Abdominal pain
Full abdomen
Hematemesis
Melena
HR 130/min
RR 25/min
Pallor, weak and thread pulse
Hyperactive bowel sounds
Melena on DRE
Syncope and body weakness
Abdominal pain
Full abdomen
Hematemesis
Melena
HR 130/min
RR 25/min
Pallor, weak and thread pulse
Hyperactive bowel sounds
Melena on DRE
Syncope and body weakness

Rule out
No history of NSAIDs use
Hypertensive
No history of PUD
Rule out through endoscopy

No jaundice
No history of instrumentation,
gallstone, inflammatory conditions
etc.
Rule out through endoscopy

No history of weight loss

No history of smoking or alcohol
consumption
No mention of H. pylori or Epstein
Barr virus infection
Rule out through endoscopy

C. The initial treatment plan/rationale

- Establish the airway and give O2 to stabilize oxygenation and minimize acidosis
- Fluid resuscitation first because of the blood lossadminister colloid or crystalloid
solutions
- Do an NGT Aspiration to check for fresh blood
D. How would you structure your diagnostic and definitive treatment plan?
Upon stabilization of the patient, an endoscopy must be done. Do rubber band ligation of
varices and epinephrine injections to stop the bleeding. Ocreotide may be given if bleeding persists
for 24 hours, cauterization may also be done using EGD.