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GI Bleeding
Systems
Upper GI Bleeding:
Patients with acute upper gastrointestinal (GI) bleeding commonly present with
hematemesis (vomiting of blood or coffee-ground like material) and/or melena
(black, tarry stools). The initial evaluation of patients with acute upper GI bleeding
involves an assessment of hemodynamic stability and resuscitation if necessary.
Etiology:
The most common causes of upper gastrointestinal bleeding include the following:
1. Gastric and/or duodenal ulcers ( H.Pylori, NSAID’s, Stress, Increased gastric
acid production)
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4. Angiodysplasia
5. Mass lesions (polyps/cancers)
6. Dieulafoy's lesion
7. Erosive gastritis/duodenitis
8. Mallory-Weiss syndrome
Diagnosis
1. CBC, BMP, liver tests, and coagulation studies.
who are at risk for a myocardial infarction, such as the elderly, patients with a
history of coronary artery disease, or patients with symptoms such as chest pain
or dyspnea.
3. TEG analysis may be helpful in patients who are on long term anticoagulation
or on antiplatelet therapy.
Intial hemoglobin in actively bleeding patients may be normal before fluid
resuscitation, as they are losing whole blood. Patients with acute bleeding also have
normocytic anemia. Microcytic anemia or iron deficiency anemia suggest chronic
bleeding. Patients with acute upper GI bleeding typically have a disproportionately
elevated blood urea nitrogen (BUN)-to-creatinine or urea-to-creatinine ratio (>20:1
to >100:1).
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Home
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endoscopy — Upper Major Journals
endoscopy
is the diagnostic modality of choice for acute
upper GI bleeding. Early endoscopy (within 24 hours) is recommended for most
patients with acute UGI bleeding.
Other diagnostic tests — Other diagnostic tests for acute upper GI bleeding include
CT angiography and a tagged RBC scan, which can detect active bleeding. Tagged
RBC scan is more preferred for minor occult bleeding and CT angiogram is preferred
for active bleeding. Upper GI barium studies are contraindicated in the setting of
acute upper GI bleeding because they will interfere with subsequent endoscopy,
angiography, or surgery.
Treatment of UGI Bleeding:
1. Closely monitor airway, clinical status, vital signs, cardiac rhythm, urine
6. Transfuse for:
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bleeding due to increased portal blood flow and increased prtal pressures.
8. Give fresh frozen plasma for coagulopathy; give platelets for thrombocytopenia
Endosc. 2011 Nov;74(5):971-80. Lavage may dislodge the clot and may
worsen the bleeding. The only indication for NG lavage is if it is unclear
between UGI and LGI bleed. Even then, gentle NG aspiration might be
enough.
11. Give a proton pump inhibitor (eg, protonix 80 mg IV bolus, followed by 8
that have flat pigmented spots or clean bases can receive standard PPI therapy
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(e.g., oral PPI once daily). If there is no rebleeding, the patient may be switched
to oral pantoprazole 40 mg/day. It is unlikely that an IV PPI would be of
significant benefit in patients who do not have active bleeding or other high-risk
stigmata (such as a visible vessel or adherent clots) because their risk of
recurrent bleeding is low. Such patients may be switched to a standard dose oral
PPI immediately following endoscopy. Aliment Pharmacol Ther. 2013
Oct;38(7):721-8 , Am J Gastroenterol. 2014 Jul;109(7):1005-10
12. Continuous vs Intermittent PPI: Intermittent PPI therapy is comparable to
Even though Octreotide is not recommended for routine use in patients with
acute nonvariceal upper GI bleeding, but it can be used as adjunctive therapy in
some cases. There is evidence to support the use of octreotide in variceal and
non-variceal upper GI bleeding (UGB). Ann Intern Med. 1997 Dec
15;127(12):1062-71. As a somatostatin analogue, octreotide binds with
endothelial cell somatostatin receptors, inducing strong, rapid and prolonged
vaso-constriction. Octreotide reduces portal and variceal pressures as well as
splanchnic and portal-systemic collateral blood flows. Octreotide inhibits both
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after bleeding ceases in most patients: ideally within 1 – 3 days and certainly
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within 7 days. Long-term daily PPI therapy should also be provided. If given
for primary prevention (i.e., no established cardiovascular disease), anti-platelet
therapy likely should not be resumed in most patients.
24. In patients with idiopathic (non- H. pylori, non-NSAID) ulcers, long-term
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Ischemic colitis
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Hemorrhoids
Post polypectomy
Malignancy
Inflammatory bowel disease
Infectious colitis
Radiation-induced colitis
In addition, acute lower GI bleeding can occur after therapeutic interventions such as
polypectomy.
Clinical features — A patient with lower gastrointestinal (GI) bleeding typically
reports hematochezia (passage of maroon or bright red blood or blood clots per
rectum). Blood originating from the left colon tends to be bright red in color,
whereas bleeding from the right side of the colon usually appears dark or maroon-
colored and may be mixed with stool. Rarely, bleeding from the right side of the
colon will present with melena.
Diagnosis:
The primary consideration in the differential diagnosis of hematochezia is upper GI
bleeding. Findings that are suggestive of an upper GI source include hemodynamic
instability, orthostatic hypotension, and an elevated blood urea nitrogen (BUN)-to-
creatinine or urea-to-creatinine ratio (>20:1 or >100:1, respectively). Lower GI
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bleed usually doesn’t cause significant rise in BUN as the heme protein from RBC is
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not absorbed into the system. If the suspicion for upper GI bleeding is moderate, a
nasogastric lavage may help identify patients with upper GI bleeding.
Hematochezia associated with hemodynamic instability may be indicative of an
UGIB source, and an upper endoscopy should be performed. A nasogastric
aspirate/lavage may be used to assess a possible upper GI source if suspicion of
UGIB is moderate.
Once an upper gastrointestinal (GI) bleeding source is excluded, colonoscopy is the
initial examination of choice for the diagnosis and treatment of acute lower
GI bleeding. Other diagnostic procedures include tagged RBC scan,
CT angiography, and mesenteric angiography.
Treatment:
The basic principles in the management of acute lower GI bleed was mentioned in
detail by american college of gastroenterology. Am J Gastroenterol. 2016
Apr;111(4):459-74.
Principles of treatment remains the same as UGI bleed except there is no role for
protonix or octreotide. Octreotide, however, can used in lower GI bleed due to rectal
varices.
PEARLS:
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Blood is a great cathartic; UGI bleed is less likely if there are no bowel
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movements.
Alka-seltzer contains ASA
Do not use guiac cards for vomitus. Hcl will always turn the test positive.
Do not fluid over load the variceal bleeders. When their portal
pressure increases, they start bleeding
Gastrointestinal
Sedation, Analgesia and Paralytics
Pneumonia
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