Gastrointestinal Bleeding

Hendrata,dr, M.Biomed, SpPD

 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?