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
Harrisons Principles of Internal Medicine 14th edition Gastrointestinal Atlas.com endoscopy photos

THE END