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GI Bleeding
Initial Evaluation Approach to the Patient Sources Upper GI Bleeds Lower GI Bleeds Etiology Management Admission Orders
History
HPI
Hematemesis (coffee grounds vs. bright red) Hematochezia Melena - dark, tarry stool Pain symptoms
PMHx
ulcer disease, joints, skin
Social Hx
EtOH
Medications
NSAIDs, steroids, ASA, Plavix, Coumadin, Lovenox, Heparin, Iron
Work Up
Labs
CBC
Serial HgB Platelets
BMP
BUN, Cr
Type and Crossmatch Coagulation studies Stool WBCs to eval for infectious etiol 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
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
Acute LGIB: <3d Chronic LGIB: > several days Hematochezia Blood in Toilet Clear NGT aspirate Normal Renal Function Usually Hemodynamically stable
<200ml : no effect on HR** >800ml: SBP drops by 10mmHg, Hr increases by 10 >1500ml: possible shock OR 10% Hct: tachycardia* 20% Hct: orthostatic hypotension 30% Hct: shock
Lower GI Bleed
Etiology of hematochezia
Diverticular-17-40% Angiodysplasia-9-21% Colitis (ischemic, infectious, chronic IBD, radiation injury)-2-30% Neoplasia, post-polypectomy-2-26% Anorectal Disease (including rectal varices)-4-10% Upper GI Bleed-0-11% Small Bowel Bleed-2-9%
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 (>2u pRBC) 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
Obscure GI Bleed
Present: Fe Defic anemia Etiology:
Younger than 40
Tumors Meckels diverticulum Dieulafoys lesion Crohns Disease Celiac Disease
Greater than 40
Angioectasia NSAID enteropathy Celiac
Gerson LB. Clin Gastroenterol & Hepatol 2009;7:828-833.
Obscure GI Bleed
Work Up
EGD, Colonoscopy both neg Repeat CE, PE or DE, angiography
Tumors
Celiac Disease
References
Harrisons Principles of Internal Medicine 14th edition Gastrointestinal Atlas.com endoscopy photos Pocket Medicine, 3rd edition Barnet J and H Messmann H. Diagnosis and management of lower gastrointestinal bleeding. Nat Rev Gastroenterol Hepatol 6, 637-646 (2009). Gerson LB. Recurrent Gastrointestinal Bleeding After Negative Upper Endoscopy and Colonoscopy. Clin Gastroenterol & Hepatol 2009;7:828-833. Melmed GY and Simon KL. Capsule Endoscopy: Practical Applications. Clin Gastrolenterol & Hepatology 2005;3:411-422. AGA Institute. AGA Institute Medical Position Statement on Obscure Gastrointestinal Bleeding. Gastroenterology 2007;133:1694-1696.
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