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
BMP
BUN, Cr
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 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
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
References
Harrisons Principles of Internal Medicine 14th edition Gastrointestinal Atlas.com endoscopy photos
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