Gastrointestinal Bleeding

1- Immediate management of life

life-threatening Bleeding
Recognize Risk Factors for Severe Initial Stabilization Procedures
Gastrointestinal Bleeding :
As with any emergency ABCs first.
Signs, symptoms, or history that may indicate
ongoing hemorrhage are as follows: AIRWAY MANAGEMENT
1- If the patient is having ongoing hematemesis Endotracheal
ndotracheal intubation.
1- Profuse hematemesis or hematochezia 2- If immediat
immediate airway control is not needed oxygen to maintain saturation > 93%
2- Hypotension,
otension, tachycardia, or signs of
BREATHING :
shock . 1- Assess breathing ( See Ahmados papers )
3- Postural
ostural hypotension, tachycardia, or 2- Pulse oxymetery,
lightheadedness CIRCULATION :
4- Possible aortoenteric fistula 1-Assess circulation ( See Ahmados papers )
(history of abdominal aortic aneurysm repair 2-Apply monitor.
or palpable pulsating abdominal mass) 3-Obtain IV access : Insert two large-bore IV (18 gauge or larger)
• BEGIN FLUID RESUSCITATION:
RESUSCIT
5- Previous history of GI bleeding
- Either
Either lactated Ringer's or normal saline to restore intravascular volume.
6- Known or suspected varices • ASSESS THE NEED FOR IMMEDIATE BLOOD TRANSFUSION
1- For persistent hypotension despite the infusion of 2 L of crystalloid
crystalloid :
7- History of diverticulosis - Immediate
I transfusion of cross-matched
matched blood if available.
- If not, then transfuse O-negative
O blood until cross-matched
matched blood is available.
Continue transfusion to maintain systolic blood pressure at > 90 mm Hg.
2- If a patient's hematocrit < 30% + history of ischemic heart disease, consider
early transfusion.
3- Obtain an electrocardiogram (ECG) for any patient :
- Older
O than 50 years;
- With
W a history of ischemic heart disease
- With Significant
S anemia;
- any patient with chest pain, shortness of breath,
breath, or severe hypotension.
If the initial ECG shows ongoing ischemia in the face of ongoing GI bleeding,
then consider immediate transfusion of packed red blood cells.

PERFORM LABORATORY STUDIES,

S Send blood for :
1- Complete Blood Count.
C
2- Determine site of bleeding 2- Type and crossmatch blood.
Once the patient is stabilized, attempt to determine the bleeding site if it is not already obvious. 3- Measure prothrombin & partial thromboplastin time to assess for any coagulopathy.
• In 90% of pa-ents presen-ng with GI hemorrhage, the bleeding has an upper GI source (i.e., proximal to the ligament of Treitz);
Trei 4- Measure serum electrolytes
• n only about 10% of pa-ents is the source of bleeding distal to this proximal por-on of the duodenum
In 5- Renal & Liver
L functions. Blood urea nitrogen is elevated in many with upper GI bleeding.
Diagnostic Characteristics of Upper Gastrointestinal Bleeding (Figure 14-2) Diagnostic Characteristics of Lower Gastrointestinal Bleeding (Figure 14-3) 6- Venous blood gas & lactate may be helpful in assessing tissue perfusion status.

PHYSICAL EXAMINATION
1- General examination : general appearance & mental status;
2- Cardiac examination
3- Pulmonary examination
4- Abdominal
bdominal examination (including noting surgical scars, distention, auscultation
auscultatio
for bruits that may indicate an aneurysm, palpating organ size); skin changes such
as pallor, moisture, telangiectasia, ecchymoses, and petechiae.
5- Rectal examination for hemorrhoids or fissures
6- Stool
tool examination for occult blood are essential.
PERFORM BLADDER CATHETERIZATION
1- If a patient is in shock insert a Foley catheter to monitor urinary output.
2- Order a urine analysis to assess for hematuria, indicate an abdominal aneurysm.

After resuscitation
NASOGASTRIC TUBE LAVAGE
LAV :
If hematemesis
emesis has not been documented :
N
Nasogastric tube lavage with normal saline until aspirate is clear.
• Persistent bleeding during lavage indicates life-threatening
life threatening upper GI bleeding,
and immediate consultation with a gastroenterologist or surgeon for :
HEMATEMESIS HEMATOCHEZIA Emergent Endoscopy
Hematemesis (excluding hemoptysis or swallowed blood from epistaxis
epistaxis) is observed during • An upper GI source is found for suspected lower GI bleeding in up to 15% of pa-ents
upper gastrointestinal bleeding. Lavage prior to endoscopy may improve visualization during endoscopic procedure
presenting with hematochezia.
• Blood or material in the nasogastric lavage tests positive for blood.
• The aspirate will be negative in about 10% of pa-ents with duodenal source of GI hemorr.
In these instances, consider : CORRECT COAGULOPATHY
1- Aortoenteric
ortoenteric fistula (in patients with abdominal aortic aneurysm repair) or - Patients taking Coumadin or those who show signs of hepatic failure (e.g.,
A duodenal source cannot be excluded unless gastric lavage contents reveal bile.
2- Duodenal ulcer. jaundice) may require :
Even if bile is returned, the bleeding may have resolved spontaneously prior to arrival.
• If a patient reports unwitnessed hematemesis and gastric lavage is inconclusive • Otherwise, Bleeding
leeding distal to the ligament of Treitz is associated with hematochezia. 1- Vitamin K
MELENA 2- Fresh frozen plasma
consultation
nsultation with a gastroenterologist for early endoscopy is warranted.
to correct coagulopathy before bleeding can be controlled.
• Melena is rarely associated with lower GI bleeding EXCEPT when motility in the intestinal
MELENA AND HEMATOCHEZIA
tract is decreased. Admission in ICU or Disposition
• Melena is usually due to bleeding from an upper GI source.
BRIGHT RED BLOOD
• Hematochezia from an upper source usually indicates severe hemorrhage and Intensive care unit admission should be reserved for patients with :
• Bright red blood usually indicates : 1- Continued bleeding
corresponds with significant increases in mortality, need for :
1- Hemorrhoidal or 2- Abnormal vital signs
1- Transfusion 2- Complications 33- Need for surgery.
2- Anal fissure source of bleeding. 3- Significant comorbid disease
ABSENCE OF BLEEDING ABSENCE OF BLEEDING 4- Need for transfusion therapy
• If nasogastric lavage reveals bile and no blood
blood, then active bleeding from an upper GI • Spontaneous cessa-on of bleeding occurs in about 80
80–85% of cases without intervention 5- Those at increased risk for re-bleeding
bleeding (i.e., esophageal varices).
source is less likely. although cessation can be intermittent, and bleeding can restart at any time.

3-
3 Further evaluation of gastrointestinal bleeding
Once the patient's hemodynamic status has stabilized, a more thorough examination should be done.
History
Inquire about history of GI bleeding :
• Esophageal varices,, alcohol or nonsteroidal anti inflammatory drug (NSAID) use, oral anticoagulation, recent weight loss, change in caliber of stools, abdominal pain suggesti
anti-inflammatory ve of ulcer or gastritis, liver disease, or abdominal surgery.
suggestive
• Inquire about history of hemorrhoids
hemorrhoids,, anal fissures, or rectal trauma (e.g., rectal intercourse, placement of foreign objects in rectum)
Physical Examination
VITAL SIGNS CARDIOPULMONARY EXAM EXAMINATION ABDOMINAL EXAMINATIO
EXAMINATION RECTAL EXAMINATION
Evaluate the patient for : • Epigastric tenderness : common with gastritis or peptic ulcer disease. • Obtain a stool sample for hemoccult testing,
Reassess vitals signs every 15 min. • Evidence of cardiac dysfunction • A patient whose complaints of abdominal pain are out of proportion to the examination and who also has • Check for evidence of :
(i.e., murmurs, rubs, gallops, melena should be considered at risk for mesenteric ischemia
ischemia. - hemorrhoids or
arrhythmias). • Significant tenderness or peritoneal signs
sig may indicate perforation - anal fissures.
• Lungs for abnormal sounds • Examine the patient for signs of chronic liver disease : indicate esophageal varices.
suggestive of - heart failure or (hepatosplenomegaly, ascites, enlarged
ed abdominal vessels, jaundice
jaundice,, asterixis, palmar erythema).
- infectious process. • Inspect the patient for surgical scars indicate previous abdominal surgery or vascular repair.
Special Examinations
UPPER GASTROINTESTIN
GASTROINTESTINAL BLEEDING LOWER GASTROINTESTINAL
AL BLEEDING
Endoscopy: ( Diagnostic & Therapeutic ) Colonoscopy: ( Diagnostic & Therapeutic )
• If the patient is actively bleeding, endoscopy should be performed as soon as • Modality
odality of choice for diagnos
diagnosis + therapeutic intervention.
possible.
Anoscopy/Proctosigmoidoscopy
• If the patient is stable and has no active bleeding, can performed within 24
• Examination of the rectum & distal sigmoid colon should be undertaken as soon as the patient has been stabilized.
hours.
Barium Enema
Angiography • This radiographic study is not commonly used as a diagnostic study for lower GI bleeding BECAUSE: It interferes
interfere not with
• Angiography is used in only about 1% of pa-ents with upper GI bleeding. endoscopic visualization & visceral angiography.
• It may be useful if endoscopy cannot identify a bleeding source even when Mesenteric Angiography
active bleeding is suspected. • If the bleeding rate is es-mated to be greater than 0.5
0.5–1
1 mL/min, angiography allows for selec-ve emboliza-on or
vasopressin infusion.
Technetium Red Cell Scintigraphy
• Techne-um bleeding scans may be indicated if the bleeding rate is greater than 0.1 mL/min.
• A portion of the patient's red blood cells are labeled with technetium
technetium-99m
99m and reinfused, followed by scanning.

Monitoring for Rebleeding

GASTRIC LAVAGE
• After placement of a nasogastric tube, continue reassessment for rebleeding by using intermittent low continuous suction.
• Continued bleeding or rebleeding is an indication for emergent endoscopy.
STOOL
• Record frequency, color, and approximate amount of stool passed by the patient.
• Continued passage of bright red, maroon, or melenic stools may indicate need for further studies or transfusion.

HEMOGLOBIN AND HEMATOCRIT

• Frequent checking of hemoglobin
oglobin and hematocrit (every 4 hours) iss essen-al
essen- in pa-ents with ac-ve bleeding a?er th
they are hemodynamically stabilized.