Protocol for principles of history taking and analysis of GIT bleeding

Objectives: by the end of the session the student will be able to:
• Perform history taking of case of upper and lower GIT bleeding simulated by role of three.
Materials:
• History taking will be conducted on peers “role of three”

Plan of training:
• A brief introduction explaining the objectives of the training.
• Demonstration of the principles and technique of history taking
• Dividing the students into groups (15 students each) with a tutor, then each 3 students will
play a rotating role a “patient”, “doctor” and “observer” to perform the history taking through
the provided scenario. The tutor will observe and guide students performing the activity.
• Round table discussion and feedback of the training.

Case scenario:
Will be submitted to the students during the session
 PROCEDURE

GENERAL ADVICES IN HISTORY TAKING AND COMMUNICATION SKILLS:

When you are dealing with patients, always consider your:
A: attitude – how would I feel in this patient’s situation?
B: behavior – always treat patients with kindness and respect
C: compassion – recognize the human story that accompanies each illness
D: dialogue – listen to and acknowledge the patient.
Confidentiality:
o Never tell anyone about a patients’ information unless it is directly related to their case.
Personal appearance:
Your appearance (clothes, hair, make-up) has a great impact on the patients’ opinion of you and
their willingness to interact with you.
• Your name badge should be clearly visible
• Neutralize any extreme in fashion that you may have.
• Ensure you have a good standard of personal hygiene.
• Many people believe men should be clean and tidy.
• Men should usually wear a shirt. If a tie is worn, it should be tucked into the shirt when
examining patients.
• Shoes should be polished and clean.
• Clean surgical scrubs may be worn if appropriate.
Setting:
• The room should be quiet, private, and free from disturbances.
• There should be enough seating for everyone and chairs should be comfortable enough for
an extended conversation.
• Arrange the seats to face yours, with no intervening screens or unnecessary furniture.
Attitude:
• You should always stand when a patient enters a room and take your seat at the same time as
him (as well as you should also stand as they leave).
• Good greeting of the patient and call the patient by his name. It is important to show more
respect to older patients by adding Mr. or Mrs. to their names.
• Introduce yourself to the patient. It advised to title yourself as “Dr” as patients prefer-and
expect-a certain level of formality and to avoid any misunderstanding of your role.
• It is appropriate to shake hands (if allowed), as physical contact always seems friendly and
warms a person to you.
 Clinical approach to gastrointestinal (GI) bleeding

 GI bleeding is a common clinical condition with a mortality rate up to 10%

 It is divided into upper & lower GI bleeding according to the site of bleeding (above or below
ligament of Treitz between 3rd & 4th parts of duodenum respectively as well as the
duodenojejunal junction)

 It is presented clinically either as:

- Hematemesis: vomiting of fresh, clotted or coffee-ground blood due to bleeding from a

source above ligament of Treitz

- Melena: passage of dark black (tarry), offensive & sticky stool that is difficult to flush
due to bleeding from a source above level of ileocecal valve

- Hematochezia: passage of bright red (maroon) blood per rectum due to bleeding from a
source distal to ileocecal valve (most commonly distal to hepatic flexure)

- Fecal occult blood: passage of less than 20 ml blood/day with stool without overt
bleeding. Suspected by presence of iron deficiency anemia & confirmed by fecal occult
blood test.

- Lightheadedness, syncope, angina or dyspnea: may precede the overt bleeding

especially in elderly & cardiac patients

 Obscure GI bleeding: persistent or recurrent bleeding without an obvious source even by routine
endoscopy. It may be overt or occult. Small intestinal lesions (vascular ectasia, ulcers, and tumors)
are the commonest causes.

 Causes of GI bleeding:

▪ Esophageal: erosive esophagitis, varices, ulcers, GERD, Mallory-Weiss syndrome,

carcinoma

▪ Gastric: peptic ulcer, carcinoma

▪ Intestinal: ulcers, angiodysplasia, adenocarcinoma

▪ Colonic: diverticulosis, cancer, IBD, dysentery

▪ Anal/rectal: piles, fissures, malignancy

▪ General: thrombocytopenia, hemophilia, anticoagulant overdose

 Peptic ulcers & esophageal varices are the commonest causes of upper GI bleeding

 Meckel's diverticulum is the most common source of lower GI bleeding in children

 Piles & anal fissures are the commonest causes of lower GI bleeding in adults. However, if they
absent, diverticulosis is the commonest cause of colonic bleeding followed by malignancy and
IBD.
❖ History:
A- Personal history

 Name: Write the full patient’s name. Know it to be familiar with your patient.
▪ Age
o Children: Meckel's diverticulitis, intussusception, rectal polyps
o Young adults: piles, fissure, IBD
o Old age: malignancy
▪ Sex
o Cancer colon is more common in males
o IBD is more common in females
▪ Residence
o Diverticular disease is common in urban areas
o Parasitic dysentery is more in rural areas
▪ Occupation
o Farmers may suffer from bilharzial colitis and 2ry pile
o Medical staffs are prone to peptic ulcer & hepatic cirrhosis with variceal bleeding
▪ Habits
o Cigarette smoking is a risk factor for GI malignancy & peptic ulcer. Smoking index &
pack/year detect the severity of smoking
o Alcohol intake is a risk factor for cirrhosis & peptic ulcer (what? & how much?)

B- COMPLAINT
• In the patient's own words + its duration & in a chronological order if there are many
complaints.
Complaint may be (the definition of the type of bleeding)
o Passage of fresh bleeding per rectum
o Passage of dark black offensive stool
o Easily fatigue, palpitation, syncope, dyspnea, angina chest pain.

C- PRESENT HISTORY
o Full analysis of the main complaint/s:
o Review of other symptoms of GIT
o Symptomatic review of other possibly affected systems (respiratory, cardiac,
neurology. etc)

❖ Analysis of complaint:

1) Onset, course: acute onset, with regressive, progressive or recurrent course according to the
nature of the disease & effectiveness of treatment
2) Duration
 Hematemesis: occurs within less than 6 hours of onset of bleeding
 Melena: occurs within 8-14 hours of onset of bleeding
  Hematochezia: most commonly due to a colonic source. However, if upper GI bleeding
is very massive, it may cause a shorter transit time within the gut causing hematochezia
(within less than 8 hours) & in this case the patient is most commonly having
hemodynamic instability and severe anemia.
3) Aggravating factors: NSAIDs, repeated vomiting in Mallory-Weiss syndrome,
anticoagulants
4) Relieving factors: drug & endoscopic therapy
5) Amount of bleeding:
 Drops: in piles, fissures
 Small: in coffee-ground hematemesis (usually ulcers & erosions)
 Melena: more than 60-80 ml
 Occult blood: less than 20 ml
 Massive with blood clots: in variceal bleeding, hematochezia secondary to upper GI
bleeding & vascular ectasia (e.g: Dieulafoy’s lesions)
Massive bleeding in children is caused by
o Meckel's diverticulum
Massive bleeding in adults is caused by
o Diverticulosis coli
o Ulcerative colitis
o Angiodysplasia
o Ischemic colitis
o Massive bleeding from upper GIT

6) Color of blood:
 Coffee-ground: in mild hematemesis due to formation of acid hematin in stomach
 Fresh blood: in hematochezia & severe hematemesis
 Dark black (tarry digested blood): melena

7) Character of bleeding:
 Hematemesis: preceded by vomiting, blood may contain food particles & followed by
melena
 Melena: preceded by hematemesis, offensive, sticky & difficult to flush
 Hematochezia:
o Piles, fissures: fresh blood after defecation, mostly painful
o Left-colon & rectal causes: blood streaks on well-formed stool
o Diverticulosis: Fresh blood without defecation, mostly painless
o IBD: bloody diarrhea
o Dysentery: blood with mucous & tenesmus
8) Content of bleeding:
 Hematemesis: may contain food particles
 Hematochezia: may pass with well-formed stool
 Tenesmus: blood passes with mucus

❖ Associated GIT symptoms:

a) Upper GI symptoms:
 - Halitosis, anorexia, polyphagia, odynophagia, dysphagia
- Vomiting, heart burn, regurgitation, water brush, hiccough
b) Lower GI symptoms:
- Flatulence, distension, audible borborygmi
- Constipation: with cancer colon
- Diarrhea: with IBD, colonic polyposis, carcinoid syndrome
- Tenesmus: with parasitic dysentery
c) Abdominal pain: epigastric, flank, suprapubic, radiated to back
d) Hepatological symptoms:
- Jaundice, abdominal swelling, LL swelling
e) Genitourinary symptoms:
- Erectile dysfunction & decreased libido: in cirrhosis
- Dysuria, polyuria, frequency

❖ Symptoms of other systems affection:

a) History of abdominal trauma

b) General constitutional symptoms: fever, headache, malaise, myalgia, arthralgia
c) Cardiac symptoms: syncope, dyspnea, angina chest pain, cyanosis
d) Pulmonary symptoms: cough, hemoptysis, expectoration, wheeze
e) Neurological symptoms: weakness, hyposthesia, hypo-hyperreflexia, hypo-hypertonia
(stress ulcers in stroke patients)

D- PAST HISTORY
o Diseases: of Bilharziasis, hepatitis, bleeding tendency, hypertension, IBD
o Operations: hemorrhoidectomy
o Drugs: NSAIDs, steroids, anticoagulants

E- FAMILY HISTORY
 History of parents’ consanguinity (in pediatric age group patients)
 History of similar condition in the family members.
 History of familial illnesses in first degree relatives e.g. colonic polyposis, cancer colon.