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

HPI
Hematemesis (coffee grounds vs. bright red) Hematochezia Melena - dark, tarry stool Pain symptoms

PMHx
ulcer disease, joints, skin

Social Hx
EtOH

Medications
NSAIDs, steroids, ASA, Plavix, Coumadin, Lovenox, Heparin, Iron

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

Labs
CBC
Serial HgB Platelets

BMP
BUN, Cr

Type and Crossmatch Coagulation studies Stool WBCs to eval for infectious etiol Imaging studies?

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

History NG Tube EGD Colonoscopy Tagged RBC Scan Angiography

50% present with hematemesis

NGT with positive blood on aspirate

11% of brisk bleeds have hematochezia

Melena (black tarry stools)this develops with approximately 150-200cc of blood in the upper GI tract. Stool turns black after 8 hours of sitting within the gut.

Risk Factors
NSAID use H. pylori infection Increased age

Upper GI Bleeding accounts for approximately 350,000 hospitalizations per year.

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

Esophageal Tumor

Gastric Carcinoma

Acute LGIB: <3d Chronic LGIB: > several days Hematochezia Blood in Toilet Clear NGT aspirate Normal Renal Function Usually Hemodynamically stable

<200ml : no effect on HR** >800ml: SBP drops by 10mmHg, Hr increases by 10 >1500ml: possible shock OR 10% Hct: tachycardia* 20% Hct: orthostatic hypotension 30% Hct: shock

Stops spontaneously (80 - 85% of the time)

Etiology of hematochezia
Diverticular-17-40% Angiodysplasia-9-21% Colitis (ischemic, infectious, chronic IBD, radiation injury)-2-30% Neoplasia, post-polypectomy-2-26% Anorectal Disease (including rectal varices)-4-10% Upper GI Bleed-0-11% Small Bowel Bleed-2-9%

Barnet J and H Messmann H. Nat Rev Gastroenterol Hepatol 6, 637-646 (2009).

Colon Carcinoma

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.

ICU admit indications

Significant bleeding (>2u pRBC) 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

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

IVF: NSS @ ?cc/h Medications: I.V. Protonix, convert medications to i.v., hold antihypertensives Labs: serial H/H, type and cross, coags, Chem 7, LFTs Consults: GI, +/- Surgery

Present: Fe Defic anemia Etiology:

Younger than 40
Tumors Meckels diverticulum Dieulafoys lesion Crohns Disease Celiac Disease

Greater than 40

Angioectasia NSAID enteropathy Celiac

Gerson LB. Clin Gastroenterol & Hepatol 2009;7:828-833.

Work Up
EGD, Colonoscopy both neg Repeat

CE, PE or DE,
angiography

PillCam SB 11 mm x 26 mm 1 camera 2 frames per second Std optics / 1 lens Standard lighting control

PillCam SB 2 11 mm x 26 mm 1 camera 2 frames per second New optics / 3 lenses Advanced Automatic Light Control

Standard angle of view (AOV) 140

Depth of field 0-30 mm

Extra wide angle of view (AOV) 156

Depth of field 0-30 mm

Bleeding

Suspected Crohns

Tumors

Celiac Disease

Harrisons Principles of Internal Medicine 14th edition Gastrointestinal Atlas.com endoscopy photos Pocket Medicine, 3rd edition Barnet J and H Messmann H. Diagnosis and management of lower gastrointestinal bleeding. Nat Rev Gastroenterol Hepatol 6, 637-646 (2009). Gerson LB. Recurrent Gastrointestinal Bleeding After Negative Upper Endoscopy and Colonoscopy. Clin Gastroenterol & Hepatol 2009;7:828-833. Melmed GY and Simon KL. Capsule Endoscopy: Practical Applications. Clin Gastrolenterol & Hepatology 2005;3:411-422. AGA Institute. AGA Institute Medical Position Statement on Obscure Gastrointestinal Bleeding. Gastroenterology 2007;133:1694-1696.

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