Gastrointestinal Bleeding

Gastrointestinal Bleeding PCOM Internal Medicine Residents 2004

GI Bleeding • Initial Evaluation • Approach to the Patient • Sources • Upper GI Bleeds • Lower GI Bleeds • Etiology • Management • Admission Orders

Initial Evaluation • History and Physical points to Source/Etiology • History of Present Illness • Attention to PMHx, Social Hx, Medications

History • Hematemesis (coffee grounds vs. bright red) • Hematochezia • Melena - dark, tarry stool • Pain symptoms • Medications – NSAIDs, steroids, ASA, Plavix, Coumadin, Lovenox, Heparin, Iron • PMHx - arthritis, ulcer disease, EtOH

Good Thorough Physical Exam Including: • HR, BP, tilt test, RR, O2 saturation • General appearance, Mental status • Neck veins, oral mucosa • Skin temperature and color • Abdominal exam • Rectal • Stigma of Cirrhosis • NG Tube findings (upper vs. lower g.i. source) • Urine output

Approach to the patient • Labs • CBC • Serial HgB • Platelets • BMP • BUN, Cr • Type and Crossmatch • Coagulation studies • Imaging studies?

Sources of GI Bleeding • Upper GI Tract • Proximal to the Ligament of Treitz • 70% of GI Bleeds • Lower GI Tract • Distal to the Ligament of Treitz • 30% of GI Bleeds

Localization of Bleeding • History • NG Tube • EGD • Colonoscopy • Tagged RBC Scan • Angiography

Upper GI Bleed • 50% present with hematemesis • NGT with positive blood on aspirate • 11% of brisk bleeds have hematochezia • Melena (black tarry stools)—this develops with apporximately 150-200cc of blood in the upper GI tract. • Stool turns black after 8 hours of sitting within the gut.

Upper GI Bleed • Risk Factors • NSAID use • H. pylori infection • Increased age • Upper GI Bleeding accounts for approximately 350,000 hospitalizations per year.

Upper GI Bleed • Etiology of Upper Bleeds • Duodenal Ulcer-30% • Gastric Ulcer-20% • Varices-10% • Gastritis and duodenitis-5-10% • Esophagitis-5% • Mallory Weiss Tear-3% • GI Malignancy-1% • Dieulafoy Lesion • AV Malformation-angiodysplasia

Duodenal Ulcer

Varices

Esophagitis

GI Malignancy • Esophageal Tumor

GI Malignancy • Gastric Carcinoma

Angiodysplasia

Lower GI Bleed • Hematochezia • Blood in Toilet • Clear NGT aspirate • Normal Renal Function • Usually Hemodynamically stable Only 1/3 of patients with lower GI bleeds have positive orthostatics (tilt test).

Lower GI Bleed • Etiology of Lower Bleeds • Diverticular-20% • AVM-10% • Malignancy-2-26% • Inflammatory Bowel Disease-10% • Ischemic Colitis • Acute Infectious Colitis • Radiation Colitis/Proctitis • Aortoenteric Fistula

Diverticulosis

Diverticulitis-NOT A CAUSE OF GI BLEEDING

Colonic Polyps

Malignancy • Colon Carcinoma

Hemmorrhoids

Management of GI Bleed • Oxygen • IV Access-central line or two large bore peripheral IV sites • Isotonic saline for volume resuscitation • Start transfusing blood products if the patient remains unstable despite fluid boluses. • Airway Protection • Altered Mental Status and increased risk of aspiration with massive upper GI bleed.

Management of GI Bleed • ICU admit indications • Significant bleeding with hemodynamic instability • Transfusion • Brisk Bleed, transfusing should be based on hemodynamic status, not lab value of Hgb. • Cardiopulmonary symptoms-cardiac ischemia or shortness of breath, decreased pulse ox • 1 unit PRBC increases Hgb by 1mg/dL and increase Hct by 3% • FFP for INR greater than 1.5 • Platelets for platelet count less than 50K

Basic Admission Orders • Admit to ICU/intermediate care/telemetry s/o … • Dx: Upper/Lower G.I. Bleed • Condition: • VS: • Allergies: • Activity: Bedrest • Nursing: Is/Os, ? Foley • Diet: NPO

Basic Admission Orders (Cont.) • IVF: NSS @ ?cc/h • Medications: I.V. Protonix, convert medications to i.v., hold anti-hypertensives • Labs: serial H/H, type and cross, coags, Chem 7, LFTs • Consults: g.i., surgery?

References • Harrison’s Principles of Internal Medicine 14th edition • Gastrointestinal Atlas.com endoscopy photos

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Gastrointestinal Bleeding