NURSING CARE OF GASTRO INTESTINAL TRACT BLEEDING

Purwoko Sugeng H

Introduction
Upper gastrointestinal (GI) bleeding commonly presents with hematemesis (vomiting of blood or coffee-ground like

material) and/or melena and Hematochezia (usually indicate severe bleeding). A nasogastric tube lavage that yields blood or coffee-ground like material confirms the diagnosis and predicts whether bleeding is caused by a high-risk lesion.

Introduction
Upper GI bleeds are considered medical emergency, and require admission to hospital for urgent diagnosis and management.
Proximal bleeding to Ligament of Treits.

Epidemiology
Incidence 150/100,000 population per year.
Overall mortality 10% in those admitted to

hospital.
Mortality 30 % in the elderly.

 A prospective series of 1000 cases of severe UGI bleeding at

the UCLA and West Los Angeles Veterans Administration Medical Centers published in 1996 found the following distribution of causes: Peptic ulcer disease 55 % Esophagogastric varices 14 % Arteriovenous malformations 6 % Mallory-Weiss tears 5 % Tumors and erosions 4 %each Dieulafoy's lesion 1 % Other 11 %

*Management of upper gastrointestinal bleeding in the patient with chronic liver disease. Jutabha R; Jensen DM Med Clin North Am 1996

Etiology

Patient assessment

Patient resuscitation

Risk assessment

Upper Endoscopy

Low risk lesion

High risk lesion

Medical Rx

Endoscopic Rx

Rebleed

Surgery

Acute GI bleeding:
Immediate Assessment

Stabilization of hemodynamic status

Identify the source of bleeding

Stopping the active bleeding

Treat the underlying

Prevent recurrent bleeding

Initial patient assessment

Initial approach to the patient with acute upper gastrointestinal bleeding should include near simultaneous completion of the following:

Patient resuscitation and stabilization. Brief clinical history. Limited physical examination. Both a gastroenterologist and a surgeon should be promptly notified of all patients with severe acute UGI bleeding.

Patient resuscitation and stabilization

Check vital signs
Assess airway and breathing Assess circulatory status (postural

hypotension) Obtain intravenous access Replace volume Transfuse blood (if necessary) Measure urine output

Cont.

Inspect airway Clear airway Check ventilation Supplemental oxygen Endotracheal intubation: Intubation and mechanical ventilation should be considered for the following patients:

in shock from massive bleeding. on going hematemesis, especially if the bleeding is torrential. severe agitation. depressed sensorium. depressed respiratory status.

 A quick assessment of the circulatory status should be

made by:
pulse rate. measuring the supine blood pressure checking for pallor and agitation patients with normal supine blood pressure should be

checked for postural hypotension.

 Intravenous access At least two large bore (14 to 18 gauge) peripheral intravenous lines should be inserted for access and volume replacement. Central Venous Catheter (CVC) A CVC is usually not indicated because volume can easily be replaced with large bore peripheral IV lines. However a CVC may be useful in the following conditions:
failure to establish peripheral IV access patients who have an unstable cardiac disease or cirrhosis, in whom measurement of left ventricular filling pressure is necessary to accurately assess volume status.

 Volume replacement:

Volume should be replaced using crystalloids, such as 0.9% NaCl solution (normal saline) or Ringer's lactate, as rapidly as the patient's cardiopulmonary status will allow, to stabilize vital signs

Guidelines for transfusion of blood and blood products in Upper GI Bleed

Symptoms related to poor tissue oxygenation (e.g. angina).

If there is continued acute bleeding despite therapy.

If the patient is clinically shocked despite crystalloids. If the hematocrit is low (in elderly, high risk patient Hct

<30%, and in young, otherwise healthy patients <20%).

(<50,000/microL) , then fresh frozen plasma and platelets transfusion should be given, respectively.

If there is coagulopathy (INR>1.5) or thrombocytopenia

Nasogastric tube
Patients with definite or suspected acute upper gastrointestinal bleeding should have a

nasogastric (NG) tube inserted. There is no contraindication to NG tube placement in patients suspected to have esophageal or gastric varices.

Once the NG tube has been placed, the stomach should be lavarged with tap water or normal saline at room temperature and then the tube should be connected to a gravity bag

Brief History
Previous history of an upper gastrointestinal bleeding, if so what was the cause. Symptoms or previous history of peptic ulcer

disease.

Use of NSAID's, aspirin or anticoagulants. Previous history of liver disease.

Risk factors for liver disease (e.g. alcohol consumption, h/o blood transfusion, h/o hepatitis or jaundice).
Recent history of vomiting or retching.

Brief History

History of heartburn. Abdominal pain. Any previous surgeries, especially recently. Any co morbid illnesses (e.g. cardiac, pulmonary or neurological illness, bleeding disorders, etc). abdominal aortic aneurysm (AAA), or abdominal aortic vascular graft aortoenteric fistula Melena. Hematochezia.

Laboratory investigations

CBC PT (INR), aPTT Type and cross match blood Creatinine, urea, Liver function tests HBSag and anti-HCV if liver disease is suspected ECG in patients over 50 years of age or h/o cardiac disease (boz they are more pron to develop M.I.)

Risk assessment
Mild to Moderate Upper GI Bleeding
The patient is < 60 years of age, and has no

chronic medical illness.

There is no sign of hemodynamic instability. Hematocrit is > 30%.

Risk assessment
Severe Upper GI Bleeding
The patient is > 60 years old. There are signs of hemodynamic instability (Pulse

>100/min, SBP < 100 or postural hypotension).

There is active bleeding (bright red hematemesis, bright

red blood in NG tube or hematochezia with hypotension).

Drop in hematocrit of 6% or more.

There is severe co morbid disease (liver, cardiac, pulmonary

or renal)

Endoscopic diagnosis & treatment

Upper Endoscopy is the procedure of choice in majority of

patients with an acute upper gastrointestinal bleeding, for the following reasons:
It can define the source of bleeding in the majority of

patients with an upper gastrointestinal bleeding.

It can stratify the patients risk of rebleeding. It can provide endoscopic therapy for esophageal and

gastric varices, peptic ulcer disease and vascular malformations.

Other diagnostic tests

For acute UGI bleeding include angiography and a tagged red blood cell scan, which can detect active bleeding. UGI barium studies are contraindicated in the setting of acute UGI bleeding because they will interfere with subsequent endoscopy,

angiography, or surgery.

Balloon Tamponade
Sengstaken-Blakemore tube can control variceal hemorrhage in 40 80% patients Inflate gastric balloon first, the esophageal balloon if no improvement

Medication
Somatostatin:or its analog octreotide, which have been best studied in the treatment of variceal bleeding, may also reduce the risk of

bleeding due to nonvariceal causes . It can be used as adjunctive therapy before endoscopy, or when endoscopy is unsuccessful, contraindicated, or unavailable.
*Somatostatin or octreotide compared with H2 antagonists and placebo in the management of acute nonvariceal upper gastrointestinal hemorrhage: a meta-analysis. Imperiale TF; Birgisson S Ann Intern Med 1997 *Failures of endoscopic therapy for bleeding peptic ulcer: an analysis of risk factors. Choudari CP; Rajgopal C; Elton RA; Palmer KR Am J Gastroenterol

Medication
Erythromycin two randomized controlled trials (one

involving 105 patients and the other involving 41 patients), which have suggested that a single dose of intravenous Erythromycin given 20 to 120 minutes before endoscopy can significantly improve visibility, shorten endoscopy time, and reduce the need for a second-look endoscopy. Erythromycin promotes gastric emptying based upon its ability to be an agonist of motilin receptors. Treatment appeared to be safe in both studies. Thus, this approach can be considered in patients who are likely to have a stomach full of blood such as those with severe bleeding. A reasonable dose would be to give 3 mg/kg intravenously over 20 to 30 minutes, 30 to 90 minutes prior to endoscopy.

*Erythromycin intravenous bolus infusion in acute upper gastrointestinal bleeding: a randomized, controlled, double-blind trial. AFrossard JL; Spahr L; Queneau PE; Giostra E; Burckhardt B; Ory G; De Saussure P; Armenian B; De Peyer R; Hadengue A . Gastroenterology 2002 *Erythromycin improves the quality of EGD in patients with acute upper GI bleeding: a randomized controlled study. Coffin B; Pocard M; Panis Y; Riche F; Laine MJ; Bitoun A; Lemann M; Bouhnik Y; Valleur P Gastrointest Endosc 2002

Medication
Acid suppression . In the setting of active UGI bleeding, acid suppressive therapy with H2 receptor

antagonists has not been shown to significantly lower the rate of ulcer rebleeding. By contrast, high dose antisecretory therapy with an intravenous infusion of proton pump inhibitor (IV PPI with pantoprazole or omeprazole) blood transfusion in high-risk ulcer bleeders treated with endoscopic therapy.
*Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Dorward S; Sreedharan A; Leontiadis GI; Howden CW; Moayyedi P; Forman D Cochrane Database Syst Rev. 2006 *Proton pump inhibitors versus H2-antagonists: a meta-analysis of their efficacy in treating bleeding peptic ulcer. Gisbert JP; Gonzalez L; Calvet X; Roque M; Gabriel R; Pajares JM Aliment Pharmacol Ther 2001 *Estrogen/progesterone treatment of diffuse antral vascular ectasia. Manning RJ Am J Gastroenterol 1995

Surgical
If all the previous trearment fail consider the surgical treatment

Identify bleeding source:

1. N-G tube differentiate between upper/lower GI bleeding. 2. Lavage color and rapidity of clearing; clear the field for esophagogastroduodenoscopy (EGD). 3. Initial EGD: within 24 hrs of bleeding.

Stopping the active bleeding:

Most effective method: endoscopic therapy Laser therapy: requires significant training. Thermal contact: mono- (greater tissue injury) and bipolar electrocautery, heater probes. Widely available and require minimal training. Injection therapy: epinephrine (1:10,000 dilution) with or without various sclerosant solutions. ( or + thermal contact). Rubber band ligation, metal clips.

Treating the underlying

Causes of acute Upper GI bleeding

Ulcers: duodenal, gastric, esophageal Varices: esophageal, gastric, duodenal Mallory-Weiss tear Dieulafoy's lesions Arteriovenous malformations Portal hypertensive gastropathy Gastric antral vascular ectasias (watermelon stomach) Erosions Aorto-enteric fistula Crohn's disease Malignancy Hemobilia Pancreatic source Foreign body ingestion or bezoar Caustic ingestion No site found

Riwayat penyakit

Nyeri (kalau ada) Perkiraan jumlah darah

Keadaan umum

Gejala hipovolemi

kesadaran

Tanda anemia

TTV

Defisit volume cairan b.d kehilangan darah akut

Kerusakan pertukaran gas b.d penurunan kapasitas angkut oksigen

Ansietas b.d sakit kritis, ketakutan akan kematian

Resti terhadap infeksi b.d aliran intravena

Thank you