Gastrointestinal Bleeding
PCOM Internal Medicine Residents
2004
GI Bleeding
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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
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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:
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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
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Proximal to the Ligament of Treitz
70% of GI Bleeds
• Lower GI Tract
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Distal to the Ligament of Treitz
30% of GI Bleeds
Localization of Bleeding
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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
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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
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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
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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
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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
• Harrison’s Principles of Internal Medicine 14th edition
• Gastrointestinal Atlas.com endoscopy photos
THE END