Running head: GASTROINTESTINAL BLEED

Best Practice for a Gastrointestinal Bleed in Hospital

Vanessa Benning

Bryant & Stratton College

Nursing 301: Nursing Care of the Adult

Professor Crystal Morrow

June 6, 2018
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Background Information

One of the highest preventable rates of morbidity and mortality within a hospital setting

is gastrointestinal bleeding and its management. This bleeding involves anything from the

gastrointestinal tract; the mouth, esophagus, stomach, small intestine, large intestine, and the

anus. The bleeds can start out microscopic, however even those can be dangerous. They can

lead to anemia over time or create larger bleeds that lead to death. Upper GI bleeds (mouth to

duodenum) account for over 20,000 deaths in the United states annually. This is estimated to be

every 50-100 people per 100,000 patients annually according to NCBI (NCBI, 2012). The most

common of all gastrointestinal bleed cases were recorded as: gastric ulcer, duodenal ulcer,

esophageal varices, and Malory-Weiss tear. With a gastrointestinal bleed there runs the risk of

mortality, however if you make it through this complication there are also extra costs the patient

will have to undertake. The average cost for a variceal upper gastrointestinal bleed is $16,595

more than the stay without complication. This is a significant increase for both the hospital and

the patient. (NCBI, 2008) Most gastrointestinal bleeding cases are preventable, and awareness to

the healthcare team is essential in bringing these numbers down.

How does a gastrointestinal bleed happen?

Bleeding in the gastrointestinal tract can come from a number of digestive disorders.

Some of the most common are gastritis (caused from NSAID’s, infections, Chron’s disease,

severe injuries), peptic ulcers (caused by H. pylori, NSAID’s), colitis (ulcers in the large

intestine), inflammatory bowel disease, diverticulosis, hemorrhoids or anal fissures, colon

polyps, blood vessel abnormalities (angiodysplasia – abnormally large blood vessels in your GI

tract), and cancerous tumors. Signs of a gastrointestinal bleed really depend on how much

bleeding is really happening, and where it is coming from. Some signs of bleeding in the upper
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GI tract include abdominal cramps, dizziness or faintness, pallor, shortness of breath, bright red

blood in vomit, vomit that looks like coffee grounds, black or tarry stool, or dark blood mixed

with stool. If the bleed is lower in the GI tract you will most likely see things in your stool. This

will show black or tarry stool, dark blood mixed with stool, or stool mixed or coated with bright

red blood. (Medline plus, 2018) When these symptoms show a test called an endoscopy is

ordered. This test uses a flexible instrument inserted through the mouth or rectum to view the

inside of the GI tract. The most important thing is to find out where the bleeding is coming

from. If the bleed is acute you may go into immediate shock, and this is an emergency situation.

The symptoms to watch out for in a shock situation would be a severe drop in blood pressure,

little or no urination, a rapid pulse, or unconsciousness. Although if the conditions are right

anyone can get a GI bleed, there are some risk factors that put some into harms way more than

others. These risk factors can be peptic ulcer disease, NSAID use, steroid use, alcohol abuse,

burns, trauma, infectious diarrhea, and cigarette smoking (Emedicine, 2018).

Incidence of GI bleeding

Upper gastrointestinal bleeding is responsible for over 300,000 hospitalizations per year

in the United States alone. An additional 100,000 to 150,000 develop these GI bleeds while in

the hospital. According to MH Medical the annual cost of treating nonvariceal acute upper GI

bleeding in the United States exceeds $7 billion. (MH Medical, 2018) With the range of

presentations of GI bleeding symptoms pinpointing the severity and location can be a difficult

task. In patients with a nonvariceal upper GI bleed 80% of patients will stop bleeding

spontaneously with no urgent intervention needed. However, in the case of variceal hemorrhage

only 50% of patients stop bleeding spontaneously. Those patients whose variceal bleeding
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stopped also have a high risk of recurrent bleeding within 6 week’s time. We have come some

way forward with care of GI bleeding since our history 10 years ago.

With that said, there is still a long way to go with preventing and stopping GI bleeds. The

mortality rates are still at eye catching numbers, and something that needs to be noticed. The

mortality rate for upper GI bleeds has significantly reduced with the development of new

medications and diagnostic testing. The mortality rate for the upper GI bleed is only 2% to 14%,

and researchers state this is due to older patients having common morbidities along with

polypharmacy. The numbers are a little more staggering in the case of a variceal bleed. The

mortality rate is between 15% and 50% for a single bleeding episode, and as high as 70-80% in

those with continuous bleed. This is the reason that 1/3 of all cirrhosis deaths can account to a

GI bleed incidence (Hospital Medicine, 2018, p. 156).

Complications

When there is reason to believe there is a GI bleed rapid assessment and resuscitation

should proceed. Some patients might even need intubation to reduce the risk of aspiration.

Since an active GI bleed is so serious in nature (high mortality rate) the patient will need a step

up in care to the intensive care unit for constant monitoring. While in that higher area of care

there are many complications that can arise for the staff and patient. The first common issue

with a GI bleed would be anemia. Prolonged blood loss can create a significant loss of iron for

the individual. Since your red blood cells contain hemoglobin (responsible for carrying oxygen

to your cells) there can be many symptoms that need immediate attention. Some of the

symptoms are: chest pain, dizziness, weakness, fatigue, headaches, shortness of breath, and lack

of mental clarity. Along with the blood loss anemia, you can also account for hypovolemia. This

is a severe loss of blood volume and loss of body fluid, which can cause severe effects on the
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body. The heart will find it difficult to pump blood to the organs and can become fatal if

untreated since the body systems will just stop working. Once the organs start failing the body

can then go into shock. This is a dangerous condition and needs emergent attention. The

consequences of shock are: extremely low blood pressure, blue lips and fingernails, chest pain,

confusion, dizziness, anxiety, pale skin, decreased or no urine output, racing but weak pulse,

shallow breathing, unconsciousness, and even irreversible organ damage or death (Live Strong,

2018).

Treatment

Labs and Diagnostics

The doctor will most likely order a stool sample test to start things off if small

bleed is expected. The stool will be collected in a container and tested for occult bleeding.

The next set of lab tests would be a blood sample. This will tell the staff the extent of

your bleeding and if you have anemia.

Once the blood tests have been run they will start with some of the diagnostic

testing. The first step is the least invasive and this would be the gastric leverage

procedure. During this procedure they pass a tube through your nose or mouth into your

stomach. From there they empty the contents of your stomach to find the source of the

bleeding. They use this diagnostic test by itself, or sometimes before another procedure

to empty out the stomach contents. Another test they will use for diagnostics would be an

endoscopy. With this test they use a camera to find the exact locations of bleeding, and

the health of the organs. There are a few tests that they can use for this which are

enteroscopy (examining the small intestine), capsule endoscopy (you swallow a capsule

containing a camera that naturally moves its way through your digestive tract taking
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pictures), colonoscopy (a scope that is entered through the rectum to view the colon), and

a flexible sigmoidoscopy (a tube with a light and camera that enters the rectum).

Another approach the doctor might use to take a look without being as invasive

would be to do some imaging tests. These tests would include a abdominal CT scan,

lower GI series (this is where they use x-ray technology and a chalky liquid called

Barium to view your intestinal tract), upper GI series (this is similar to the lower GI

series, however also uses an fluoroscopy), angiogram (this is a special kind of x-ray that

threads catheters through your large arteries), and radionuclide scan (this procedure uses

a mixture of your blood and radioactive die to light up in imaging and find the source of

bleeding). If the source cannot be found with all these least invasive tests, then more

invasive procedures need to be considered.

The last option is always to use surgery to diagnose, however in the direst of cases

this may be the only option. The first of the two surgical diagnostic surgeries would be

the laparotomy. During this procedure a single cut to the abdomen is made to explore the

possible areas of bleeding, and then will treat the area before closing. The second on this

list would be the laparoscopy. During this procedure the surgeon makes several small

holes in the abdomen and inserts tools and a special camera. This will help locate the

source of bleeding and attempt to repair (NIH, 2018).

Medications and Treatments

The treatments for an upper GI bleed can be crucial in stopping the bleed. One of

the treatments used is an endoscopic thermal probe. This treatment can be used to stop

the bleeding by burning the blood vessels or effected tissues. Another endoscopic

treatment would be giving an endoscopic injection. Here they can stop the bleeding by
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injecting diluted epinephrine at the site of bleeding. Endoscopic clips can also be useful

to stop bleeding. The bleeding is stopped by placing endoscopic clips on the effected

blood vessel or tissue to block exit-ways. Endoscopic bands are another way to stop

bleeding in either the esophagus or hemorrhoidal. If the area is hard to treat with these

other tools the option of endoscopic intravariceal cyanoacrylate injection can be used.

Here they insert a special glue to treat verices in the stomach. Then finally is the

angiograph embolization. During this procedure they inject particles directly into your

blood vessel to stop the bleeding (Mayo Clinic, 2018).

Along with procedural treatment there also may be some medications prescribed

to help with the symptoms or the bleed itself. Here is a list of some of the medications,

and why they would be used.

Ranitidine – (H2 antagonist) This medication blocks the histamine-induced gastric acid

secretions from the parietal cells of the gastric mucosa lining of the stomach.

Zantac – (H2 antagonist)

Omeprazole / Sodium Bicarbonate – (Proton pump inhibitor) This medication reduces

the production of acid by the stomach. This works by irreversibly blocking the enzyme

H+/K+ ATPase which controls acid production.

Deprizine – (H2 antagonist)

Zantac 150 – (H2 antagonist)

Aluminum Hydroxide – (Antacids / Phosphate binders) This medication is used as an

antacid to neutralize stomach PH. It is also decreases the amount of phosphate absorbed

in the digestive tract.

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Vasopressin – (Antidiuretic hormone) This medication promotes reabsorption of water

from the kidneys, and also is a powerful vasoconstrictor.

Zegerid – (Proton pump inhibitor)

Amphojel – (Antacid / Phosphate binders)

Careone Acid Reducer – (H2 antagonist)

Equaline Heartburn Relief – (H2 antagonist)

Vasostrict – (Antidiuretic hormones)

(Drugs, 2018)

Alternative Medicine and Nutritional Support

While you have internal bleeding, you are losing lots of fluids and electrolytes.

This in turn can put you into shock, and ultimately death if ignored. Some of the home

remedies that are out there to take care of your fluid loss would be drinking plenty of

water, take emergen-C, and drink diluted pear juice. Another thing that may be helpful

are antibiotic agents to help keep infections at bay. Some home remedies for that would

include olive leaf extract, and wild oregano oil. Wild oregano oil is also an anti-

inflammatory and has been known to speed up healing. As for diet, Live Strong states

that keeping an elemental (liquid, pre-digested) diet is key to remission from episodes.

Combining that with probiotic use helps to repopulate the good bacteria and give the

digestive system a rest. If soothing is what you are looking for, they also suggest aloe

vera juice. It sooths the intestinal inflammation, heals wounds, increases tissue

suppleness, and has antiviral properties. Antioxidants can also be extremely helpful in

healing. Coenzyme Q10 is an antioxidant that reduces damage from free radicals and

promotes repair of tissues. The absorption of this antioxidant can be greatly increased if
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you use any cold pressed oil containing omega-3 essential fatty acids along with it.

Glucose is another thing that has great healing powers. Taking some N-Acetyl

Glucosamine (NAG) can help synthesis of tissue molecules – including intestinal mucosa

(Listen to Your Gut, 2018).

Nursing Interventions

The first step in nursing care would be to do a rapid clinical assessment on the

patient. Also, any patients that are already in shock the nursing team should perform

rapid resuscitation. It is also important to gain quick access to the venous system,

because peripheral shutdown may occur. If the patient is conscious it is very important to

ask them of possible causes, any history, and medicines they are on, if they consumed

alcohol, and if they use any drugs. Gaining a pulse, blood pressure, respirations, and

mental state are next in line for care. A blood sample can also be taken to rule out

anemia, check hemoglobin count, platelet count, and prothrombin time. At this time a

risk assessment will be taken (there are specific ones focusing on GI bleeding) and

recorded. The one thing to remember most in this process is that maintaining circulation

is more important than finding the source of the bleed. We need to try and maintain body

homeostasis as best we can, and then we can solve the problem. If bleeding is extreme a

blood transfusion may be ordered and need to be administered. At this point the patient is

most likely admitted to the unit and will be on constant monitoring from the nursing staff.

If the physician decides to go the mechanical way to control the bleed they may use a

gastric balloon. This is the nurses job to insert this balloon, and then the nurse’s role

turns to observation. These tubes need constant care, and aspirations need to be taken of

contents and studied for traces of blood. The nurse will also be inflating the balloon, and
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deflating the balloon per care instruction and policy. The nurse needs to pay close

attention to the vital signs, aspirate, and urine output of the patient. The main thing the

nurse needs to remember is that assessment is essential to helping the patient. There is a

secondary reason as to why this bleeding is occurring, so assessing all things (airway,

breathing, circulation) is necessary (Nursing Times, 2018). Below are some of the

nursing interventions that you would see on a hospital floor.

- Fatigue r/t loss of circulating blood volume, decreased ability to transport oxygen

 Assess severity of fatigue on a scale from 0-10, assess frequency of fatigue,

activities and symptoms associated with increased fatigue, ability to perform

ADL’s, times of increased energy, ability to concentrate, mood, and usual

pattern of activity

 Encourage the client to try complementary and alternative therapy such as

guided imagery, massage therapy, mindfulness, and acupressure

- Fear r/t threat to well-being, potential death

 Assess a source of fear with the patient

 Stay with the client when they express fear; provide verbal and nonverbal

reassurances of safety if safety is within control

 Encourage the client to express feelings in a narrative form

- Deficient fluid volume r/t gastrointestinal bleeding

 Watch for signs of hypovolemia, including thirst, restlessness, headaches, and

inability to concentrate. Thirst is often the first sign of dehydration

 Recognize symptoms of cyanosis, cold clammy skin, weak thready pulse,

confusion, and oliguria as late signs of hypovolemia

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 Check orthostatic blood pressures with client lying, sitting, and standing

- Acute pain r/t irritated mucosa from acid secretion

 Ask the client to identify a comfort-function goal, a pain level, that will allow

the client to perform necessary or desired activities easily.

 Describe the adverse effects of unresolved pain

 Determine the client’s current medication use

(Nursing Diagnosis Book, 2018)

Summary

From moment of admission to end of care – a gastrointestinal bleed requires emergent

attention from the nursing team. They follow the patient from admission, assessment,

diagnostics, treatment, possible resuscitation, and discharge. The number one step is maintaining

airway, breathing, and circulation. Then finding the source of the bleed is vitally important to

success. Having a plan, involving the care team, including the patient, and using resources

available will help create patient centered care. With the utmost attention to this unrecognized

killer there is a possibility to increase positive outcomes for our patients.

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