The clinical evaluation of gastroin...

The clinical evaluation of gastrointestinal bleeding be pendents on the hemodynamic status of the patient and the suspected source of the bleeding. Patients presenting with upper gastrointestinal or massive lower gastrointestinal bleeding, postural hypotension, or hemodynamic instability require inpatient stabilization and evaluation. The diagnostic tool of choice for all cases of upper gastrointestinal bleeding is esophagogastroduodenoscopy; for acute lower gastrointestinal bleeding, it is colonoscopy, or arteriography if the bleeding is too brisk. When bleeding cannot be identified and controll intraoperative enteroscopy or arteriography may help localize the bleeding source, facilitating segmental resection of the bowel. If no upper gastrointestinal or large bowel source of bleeding is identified, the small bowel can be investigated using a barium-contrast upper gastrointestinal series with small bowel follow-through enteroclysis, push enteroscopy technetium-99m-tagged r line cell scan, arteriography, or a Meckel's scan. These touchstones may be used alone or in combination.

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Although gastrointestinal bleeding is greatest in quantity commonly a result of benign anal pathology, life-threatening hemorrhage, cancers, and polyp must be considered in making the diagnosis. (1) Acute, massive upper gastrointestinal bleeding has an incidence of 40 to 150 episodes by means of 100,000 persons annually, with a mortality rate of 6 to 10 percent (2-4) Acute, massive lower gastrointestinal bleeding has an incidence of 20 to 27 episodes through 100,000 persons annually, with a mortality rate of 4 to 10 percent (56) Mortality rates increase in patients with advancing age and increasing number of associated underlying comorbidities, specifically renal and hepatic dysfunction, heart disease, and malignancies. (2-47)

Gastrointestinal bleeding can existing in several forms, depending forward the rate of blood loss: microscopic vital fluid loss presents as iron-deficiency anemia or hemoccult-positive stools; hematemesis is vomiting of blooming blood; "coffee-ground" emesis is vomiting of altered black blood; melena is black tarry stools; hemochezia is the passing of r posterity via the rectum (usually from the lower gastro-intestinal tract, if it were not that sometimes from a briskly bleeding upper gastrointestinal source). (8)

mostly cases of gastrointestinal bleeding unfold spontaneously, regardless of the amount of life-current lost. (9-11) The stability of the patient and the rate of bleeding dictate the order in which various diagnostic conducts should be conducted. The goal is to identify and, if necessary, treat the source of bleeding, while maintaining hemodynamic stability. (610)

Evaluation

The evaluation of the upper or lower gastro-intestinal tract for sources of gastrointestinal bleeding hangs on whether the bleeding is acute massive hemorrhage or chronic intermittent bleeding (1012) (Tables 1 (2-46791012-21) and 2 (7132223) Hospitalization is required in patients who are hemo-dynamically unstable or somewhat old and those who have comorbidities. These patients usually are admitted in an intensive care setting, based onward risk stratification criteria (Table 3) (24) Patients with minimal or intermittent bleeding who are stratified as cheap risk can be evaluated in an outpatient setting. (513)

Acute Massive Rectal Bleeding

Acute massive rectal bleeding repeatedly arises from an upper gastrointestinal source (2101625) (Table 1 (2-46791012-21) When there is evidence or clinical suspicion of an upper gastrointestinal source of bleeding, the diagnostic work-up begins with an esophagogastroduodenoscopy (EGD) which is the diagnostic tool of choice for evaluation of lesions above the ligament of Treitz. (6910162627) Table 4 (34102128-30) describes the history and clinical findings associated with gastrointestinal sources of rectal bleeding. If the patient is not experiencing hematemesis and endoscopy is not immediately available, a nasogastric tube may be placed for gastric lavage while awaiting endoscopy. (1012) If no vital current is returned and bile is identified, an upper gastrointestinal source is long less likely, and the work-up can focus onward the large bowel. (6,9,10,12,13)

Colonoscopy is individual of two diagnostic tools of choice used to evaluate acute lower gastrointestinal bleeding (610121326) (Table 1 (2-46791012-21) Several studies have demonstrated that colonoscopy identifies definitive bleeding sites in more than 70 percent of patients. (261012163132) Colonoscopy may be performed forcibly or electively, depending on the patient's hemodynamic status and risk-stratification criteria.

If bleeding stops or hemodynamic stability is achieved, colonic preparation may introduce colonoscopy to increase visibility and diagnostic yield. (31) Advantages of colonoscopy include direct visualization; access for tissue biopsy; and the ability to treat bleeding lesions primarily with heat probe, epinephrine injection, laser therapy, band ligation, or hemoclipping. (121416) As an initial diagnostic ordeal colonoscopy has a higher yield and a lower complication rate than arteriography. (61213) When used to evaluate sub- massive lower gastrointestinal bleeding, colonoscopy is highly effective; however, in cases of massive hemorrhage it may be limited by the agency of poor visibility. (6,12)