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Case…
PERSPECTIVE
Epidemiology
o relatively common problem
orequires early consultation and hospital
admission.
Gastrointestinal Bleeding
GI bleeding
o is often easy to identify
…….when there is clear evidence of vomiting
blood or passing blood in the stool.
o may be subtle,
………with signs and symptoms of
hypovolemia, such as dizziness, weakness,
or syncope.
Gastrointestinal Bleeding
DIAGNOSTIC APPROACH
Differential Considerations
History
In 50%
oPatients typically complain of vomiting
red blood or coffee grounds–like material,
or passing black or bloody stool.
oHematemesis (vomiting blood) occurs
with bleeding of the esophagus, stomach,
or proximal small bowel.
Gastrointestinal Bleeding
History
oHematemesis may be bright red or
darker (i.e., coffee grounds–like) as
a result of the conversion of
hemoglobin to hematin or other
pigments by hydrochloric acid in the
stomach.
Gastrointestinal Bleeding
DDX
o Bright red stools also can be seen after
ingestion of a large quantity of beets
symptoms of hypovolemia
…..dizziness, weakness, or loss of
consciousness, most often after standing up.
Physical Examination
oVital signs and postural changes in heart rate
and blood pressure are insensitive and
nonspecific, with the exception of significant,
sustained heart rate increase and hypotension.
Gastrointestinal Bleeding
o general appearance
o vital signs
o mental status (including restlessness)
o skin signs (e.g., color, warmth, and moisture to
assess for shock, or presence of lesions such
as telangiectasia, bruises, or petechiae to
assess for vascular diseases or
hypocoagulable states)
o pulmonary and cardiac findings
o abdominal examination
Gastrointestinal Bleeding
Ancillary Testing
Tests for Occult Blood
oThe presence of hemoglobin in occult
amounts in stool is confirmed by tests such as
( Hemoccult, HemaPrompt).
False-positive
o associated with the ingestion of
o certain fruits (e.g., cantaloupe, grapefruit, figs),
o uncooked vegetables (e.g., radish, cauliflower,
broccoli)
o red meat
o methylene blue, chlorophyll, iodide, cupric
sulfate, and bromide preparations.
Gastrointestinal Bleeding
False-negative
Clinical Laboratory
o The initial hematocrit may be misleading in
patients with preexisting anemia or
polycythemia.
Gastrointestinal Bleeding
Imaging
o No need for plain abdominal radiography
unless aspiration or with signs and symptoms
of bowel perforation.
DIFFERENTIAL DIAGNOSIS
oSwallowing blood during epistaxis or from the
oral cavity may cause hematemesis or melena.
oRed vomitus may be due to food products
(e.g., Jell-O, tomato sauce, wine), and black
stool may be due to iron therapy or bismuth
(e.g., Pepto-Bismol).
Gastrointestinal Bleeding
MANAGEMENT
oQuick identification
oAggressive resuscitation
oPrompt consultation
Gastrointestinal Bleeding
Anoscopy/Proctosigmoidoscopy
oPatients with mild rectal bleeding who do not
have obviously bleeding hemorrhoids should
undergo anoscopy or proctosigmoidoscopy.
oIf bleeding internal hemorrhoids are
discovered, and the patient does not have
portal hypertension, the patient may be
discharged with appropriate treatment and
follow-up evaluation for hemorrhoids.
Gastrointestinal Bleeding
Endoscopy
oEndoscopy is the most accurate diagnostic
tool available for the evaluation of UGIB.
Sengstaken-Blakemore Tube
oRarely used in tertiary care centre.
oShould not be used without endoscopic
documentation of the source of bleeding
because complications are common and
significant (14% major, 3% fatal).
Gastrointestinal Bleeding
Surgery
oFor all hemodynamically unstable patients
with active bleeding who do not respond to
medical therapy.
DISPOSITION
Risk Stratification
oRisk stratification involves combining
historical, clinical, and laboratory data to
determine the risk of death and rebleeding in
patients presenting to an ED with GI bleeding.
Gastrointestinal Bleeding