2012-9-27 Physical examination Lab exam s When GI bleeding is suspected, rapid assessment of the ■ Blood is sent to th carried out gauge the urgency of the ment of the vital signs is the best way given without delay if needed well as the depletion and absorbed blood proteins. Fecal occult blood is useful for the diagnosis Endoscopy Angiography triage patient for hospital stay or home Angiography is an important tool in the diagnosis of GI bleeding when endoscopy fails to identify the Give the most accurate diagnosis of the Assess the risk of recurrent bleeding. The potential to achieve immediate control with several atment modalities hemodynamic instability GI bleeding of obscure origIn DIAGNOSIS APPROACH tree of bleed opy in about 5% of patients. using hemobilia. nested either by presence of iron-deficteney anemia control the bleeding whe .through endoscopy or other diagnostic2012-9-27 2 www.zshospital.com Physical examination  When GI bleeding is suspected, rapid assessment of the patient is carried out gauge the urgency of the situation. – Is bleeding acute or chronic? – Is the patient hemodynamically stable or unstable?  Carefully assessment of the vital signs is the best way to judge a patient’s stability. – The blood pressure and heart rate reflect the amount and rapidity of blood loss, as well as the extent of cardiac and vascular compensation. – Postural hypotension: the blood pressure is maintained on recumbency but falls more than 15 to 20 mmHg when the patient sits up.  Bowel sounds are also very important for judging whether the bleeding has ceased or not. www.zshospital.com Lab Exam  Blood is sent to the laboratory for complete blood count, routine chemistries, and clotting studies.  Blood for typing and crossmatching is sent to the blood bank so that the transfusions can be given without delay if needed.  A rise in the BUN after major upper GI bleeding episodes results from volume depletion and absorbed blood proteins.  Fecal occult blood is useful for the diagnosis of occult bleeding. www.zshospital.com Hong Shi, Department of Gastroenterology & Hepatology, Zhongshan Hospital 复 旦 大 学 附 属 中 山 医 院 消 化 科 Endoscopy  Endoscopic examination is the best tool to triage patient for hospital stay or home.  Functions – Give the most accurate diagnosis of the source of bleeding. – Assess the risk of recurrent bleeding. – Offer endoscopic therapy when a source of bleeding is found (endoscopic hemostasis).  Endoscopic examination should be made available to the patient within 24 hours or when the patient is stabilized from his hemodynamic instability. www.zshospital.com Hong Shi, Department of Gastroenterology & Hepatology, Zhongshan Hospital 复 旦 大 学 附 属 中 山 医 院 消 化 科 Angiography  Angiography is an important tool in the diagnosis of GI bleeding when endoscopy fails to identify the source.  Advantages – Accurate localizaion of rapidly bleeding lesions – The potential to achieve immediate control with several treatment modalities. www.zshospital.com Hong Shi, Department of Gastroenterology & Hepatology, Zhongshan Hospital 复 旦 大 学 附 属 中 山 医 院 消 化 科 GI bleeding of obscure origin  The source of bleeding remains unidentified after gastroscopy and colonoscopy in about 5% of patients.  The most common causes include angiodysplasia, small bowel neoplasms, Meckel’s diverticulum, ectopic varices and conditions causing hemobilia.  Capsule endoscopy is better tolerated by the patients.  Double balloon enteroscopy offers an opportunity to control the bleeding when a source is found. www.zshospital.com Hong Shi, Department of Gastroenterology & Hepatology, Zhongshan Hospital 复 旦 大 学 附 属 中 山 医 院 消 化 科 DIAGNOSIS APPROACH  Recognition of hemorrhage – In most cases, the doctors recognize hemorrhage through history taking and physical examination. – Occult bleeding is manifested either by a positive finding of a test for fecal occult blood or by the presence of iron-deficiency anemia.  Assessment of severity  Differentiation of upper from lower GI hemorrage – The approximate site of bleeding can usually be predicted by the manner of presentation. – When the location of bleeding is in question, a nasogastric tube may be placed.  Etiology -through endoscopy or other diagnostic tests