GASTROINTESTINAL (G.I) BLEEDING

1. GASTROINTESTINAL (G.I) BLEEDING Fadi J. Zaben RN MSN

2. Normal Anatomy: The gastrointestinal tract starts at the mouth, which leads to the esophagus, stomach, small intestine, colon, and finally, the rectum and anus. The GI tract is a long, hollow, muscular tube through which food passes and nutrients are absorbed.

3. Definition: • Gastrointestinal (GI) bleeding refers to any bleeding that starts in the gastrointestinal tract. • GI bleeding is not just a gastroduodenal disorder but may occur anywhere along the alimentary tract. • Bleeding from the GI tract is a common medical problem. • Bleeding is a symptom of an upper or lower GI disorder. • It may be obvious in emesis or stool, or it may be occult (hidden).

4. Types of G.I Bleeding: Bleeding may come from any site along the GI tract, but is often divided into: • Upper GI bleeding: • The upper GI tract includes the esophagus (the tube from the mouth to the stomach), stomach, and first part of the small intestine. • An upper source is characterized by hematemesis and melena. • About half of cases are due to peptic ulcer disease. • Esophagitis and erosive disease is the next most common causes.

5. Continue….. • Lower GI Bleeding: • The lower GI tract includes much of the small intestine, large intestine or bowels, rectum, and anus. • It may be indicated by red blood per rectum, especially in the absence of hematemesis. • The most common cause is hemorrhoids.

6. Incidence: • Upper GI bleed 100/100,000. • Lower GI Bleed 20/100,000. • Both are more common in males and elderly.

7. Etiology: • Trauma anywhere along the GI tract. • Erosions or ulcers. • Rupture of an enlarged vein such as a varicosity (esophageal or gastric varices). • Inflammation, such as esophagitis (caused by acid or bile), gastritis, inflammatory bowel disease (chronic ulcerative colitis, Crohn's disease), and bacterial infection.

8. Continue…… • Alcohol and drugs (aspirin-containing compounds, NSAIDs, anticoagulants, corticosteroids). • Diverticular disease. • Cancers. • Vascular lesions or disorders, such as bowel ischemia, aortoenteric fistula. • Mallory-Weiss tear. • Anal disorders, such as hemorrhoids or fissures.

10. Clinical Manifestations: • Characteristics of Blood: • Bright red: vomited from high in esophagus (hematemesis): from rectum or distal colon (coating stool). • Mixed with dark red: higher up in colon and small intestine: mixed with stool. • Shades of black (coffee ground‌): esophagus, stomach, and duodenum; vomitus from these areas. • Tarry stool (melena): occurs in patient who accumulates excessive blood in the stomach

11. Signs and Symptoms of Bleeding: • Massive bleeding: • Acute, bright red hematemesis or large amount of melena with clots in the stool. • Rapid pulse, drop in BP, hypovolemia, and shock. • Subacute bleeding: • Intermittent melena or coffee-ground emesis. • Hypotension. • Weakness, dizziness. • Chronic bleeding: • Intermittent appearance of blood. • Increased weakness, paleness, or shortness of breath. • Occult blood.

12. Diagnosis: • It is not difficult to diagnose bleeding, but it may be difficult to locate the source of bleeding. • History: change in bowel pattern, presence of pain or tenderness, recent intake of food and what kind, alcohol consumption, such drugs as aspirin or steroids. • Complete blood count (CBC) (hemoglobin, hematocrit, platelets) and coagulation studies (partial thromboplastin time, prothrombin time with international normalized ratio) may show abnormalities.

13. Continue….. • Lower and Upper Endoscopy: identifies source of bleeding, determines risk of re-bleeding, and provides endoscopic therapy if needed. • Imaging may detect etiology of bleeding. • Test of stool for occult blood.

15. Management: • Based on Etiology. • Emergency Intervention. • Nasogastric Intubation. • Other Measures.

16. Based on Etiology: • If aspirin or NSAIDs are the cause, discontinue medication and treat bleeding. • If ulcer is the cause, medications, dietary and lifestyle modifications. • Therapeutic endoscopic procedure (cautery, injection). • Surgery may be indicated for cancers, inflammatory diseases, and vascular disorders.

18. Emergency Intervention: • Patient remains on NPO status. • I.V. lines and oxygen therapy initiated. • If life-threatening bleeding occurs, treat shock, administer blood replacement, intra-arterial vasopressin or embolization. • Surgical therapy, if indicated.

19. Nasogastric Intubation: • An NG tube should be in place for most patients with acute or upper GI bleeding. • If the aspirate continues to be bloody after 2 to 3 L of tap water lavage, the patient may have an active bleed requiring more emergent intervention or endoscopic therapy.

20. Other Measures……… • Electrocoagulation using a heater probe. • Injection of sclerosant or epinephrine. • Endoscopy used in conjunction with management measures as well as in diagnostic evaluation. • Pharmacotherapy depends on cause; can include histamine blockers as either continuous I.V. (preferred) or bolus infusion to block the acid-secreting action of histamine. Intra-arterial vasopressin can be used to slow or stop active bleeding from diverticulum or vascular ectasia. • Surgery is indicated when more conservative measures fail.

21. Complications: • Hemorrhage. • Shock. • Death.

22. Nursing Assessment: • Obtain history regarding: • Change in bowel patterns or hemorrhoids. • Change in color of stools (dark black, red, or streaked with blood). • Alcohol consumption. • Medications, such as aspirin, NSAIDs, antibiotics, anticoagulants, corticosteroids. • Hematemesis. • Other medical conditions. • Evaluate for presence of abdominal pain or tenderness. • Monitor vital signs and laboratory tests for changes that indicate bleeding (hemoglobin, hematocrit, platelet count, coagulation studies). • Test for occult blood, if indicated.

23. Nursing Diagnoses: • Deficient Fluid Volume related to blood loss. • Imbalanced Nutrition: Less Than Body Requirements related to nausea, vomiting, diarrhea.

24. Nursing Interventions: 1. Attaining Normal Fluid Volume: • Maintain NG tube and NPO status to rest GI tract and evaluate bleeding. • Monitor intake and output as ordered to evaluate fluid status. • Monitor vital signs as ordered. • Observe for changes indicating shock, such as tachycardia, hypotension, increased respirations, decreased urine output, change in mental status. • Administer I.V. fluids and blood products as ordered to maintain volume.

25. Continue……… 2. Attaining Balanced Nutritional Status: • Weigh daily to monitor caloric status. • Administer I.V. fluids, TPN if ordered to promote hydration and nutrition while on oral restrictions. • Begin liquids when patient is no longer NPO. Advance diet as tolerated. Diet should be high-calorie, high-protein. Frequent, small feedings may be indicated. • Offer snacks; high-protein supplements.

26. Patient Education and Health Maintenance: • Discuss the cause and treatment of GI bleeding with patient. • Instruct patient regarding signs and symptoms of GI bleeding: melena, emesis that is bright red or coffee ground‌ color, rectal bleeding, weakness, fatigue, shortness of breath. • Instruct patient on how to test stool or emesis for occult blood, if applicable.

27. QUESTIONS……..