Gastro-intestinal bleeding – This course is designed to understand the concept of community health nursing: nurses’ roles and interventions in family health, school health, occupational health, environmental health, elderly health care, gender issues, disaster management and principles and terminology of epidemiology. The aim of the course is to acquire knowledge and skills in community health nursing.

Gastro-intestinal bleeding

Gastro-Intestinal Bleeding:

Gastrointestinal bleeding (GI bleed), also known as gastrointestinal hemorrhage, is all forms of bleeding in the gastrointestinal tract, from the mouth to the rectum. When there is significant blood loss over a short time, symptoms may include vomiting red blood, vomiting black blood, bloody stool, or black stool.

Important Definition

Presentation of upper GI bleeding:

20% present with melaena
30% haematemesis
50% both haematemesis & melaena

Haematemesis:

Vomiting out of blood (Above ligamentum teris) from stomach through oesophagus & mouth
Indicates an upper GI source of bleeding

Melaena

Passage of loose /semisolid foul-smelling dark, black tarry stool per rectum.
Melaena indicates that blood has been present in the GI tract for at least 14 h.
Melaena is suggestive upper Gl bleeding, small gut bleeding or right sided colonic bleeding.

Difference between Hematemesis and Hemoptysis:

Points	Haematemesis	Haemoptysis
Definition	Vomiting of blood or blood clot.	Coughing out of blood
Colour of blood	Altered	fresh
Taste	Acidic	Alkaline
Contents	Mixed with food materials	Mixed with cough
Other symptoms	Symptom of Gl system	Symptom of respiratory systems
Reaction with litmus paper	Turn to red	Turn to blue

Nice to know:

Basic elements of management of acute upper gastrointestinal bleeding include-

Prompt patient resuscitation and stabilization.
Assessment of the onset and severity of bleeding.
Regional localization of bleeding site.
Determination of the most likely cause of upper gastrointestinal bleeding.
Preparation for emergent upper GI endoscopy.
Control of active bleeding or treatment of lesions at high risk of rebleeding with therapeutic endoscopy.
Minimization of treatment related complications.
Treatment of re-bleeding episodes.

Common Causes of Upper Gastro-Intestinal Bleeding:

Bleeding Peptic ulcer diseases (35-50%)
Gastric erosions (10-20%)
Oesophagitis (10%)
Rupture of varices 2-9% (Oesophageal & gastric) (Liver diseases & Portal vein thrombosis).
Mallory Weiss tear (5%)
Vascular malformation. (5%
Cancer of stomach or oesophagus (2%)
Dieulafoy’s lesion-2%
Aorto-duodenal fistula (0.2%)

The way of presentation of upper gastro-intestinal bleeding:

Haematemesis and/or melaena (Mainly)

Causes of Haematemesis:

Mallory Weiss tear
Irritation or erosion of the lining of the esophagus or stomach
vomiting of ingested blood after hemorrhage in the oral cavity, nose or throat
Vascular malfunctions of the gastrointestinal tract such as bleeding gastric varices or intestinalvarices.
Tumor of the stomach or esophagus.
Radiation poisoning
viral hemorrhagic fevers,
Gastroenteritis
Gastritis
Peptic ulcer
Chronic viral hepatitis
Intestinal Schistosomiasis
History of smoking
latrogenic Injury (invasive procedure such as endoscopy or transesophageal echocardiography)
Zollinger-Ellison Syndrome (severe peptic ulcer)
Atrio-oesophageal fistula

Causes of Melaena:

a. Common:

Diverticular disease
Angiodysplasia
Anal fissure
Haemorrhoids
Inflammatory bowel disease

b. Less common:

Ischemic colitis
Carcinoma
Hook worm
conditions of haematemesis
Ulcerative colitis
Crohns disease etc.

Management of Haematemesis:

Clinical features:

a. Symptoms:

If bleeding is less: no systemic sign
If bleeding is severe:

✔Weakness, faintness

✔Nausea, sweating

✔ Agitated, restless

✔ Disorientation

✔ Vomiting of coffee ground material or bright red blood

b. Signs:

Patient is anxious and pale.
Anemia in severe case
Pulse: weak and rate is high
BP: High

Investigations of haematemesis:

Endoscopy of upper GIT
Ba-meal X-ray
Radionuclide scan with radio labeled red cells
BT, CT and PT
Full blood count

Treatment of haematemesis:

A. In case of bleeding from stomach and duodenum:

a. Conservative treatment:

Bed rest
Sedation (inj. morphine 15 mg IM or IV state)NG suction
Liquid antacid 10-15 ml every hourly
H₂ receptor blocker (IV cemetidine, ranitidine)
IV infusion or blood transfusion
Diet: Ice cold milk

b. Surgical treatment:

Indications:

✔ Massive and continuous bleeding

✔ Recurrence of bleeding one has stopped

✔ Age over 60 years

✔ Previous H/O two/three times bleeding

✔ Continued bleeding

Methods:

In chronic DU bleeding: Suturing of bleeding vessels with vagotomy and gastrojejunostomy/pyloroplasty.

✔ In gastric ulcer bleeding: Partial gastrectomy

✔ In acute gastric erosion: Gastrotomy with occlusion of bleeding vessels with ligation/diathermy, or partial gastrectomy

B. In case of bleeding from oesophageal varices: