Approach to Approach to Gastrointestinal Gastrointestinal

BleedingBleeding

Approach to Approach to Gastrointestinal Gastrointestinal

BleedingBleeding

Introduction/Epidemiology

Gastrointestinal Bleeding is a common problem in emergency medicine

Mortality is approximately 5 - 10 % with a decrease in the past 15 years.

Vocabulary

Gastrointestinal bleeding comprises Upper & Lower Gastrointestinal bleeding– The difference is defined by location of

source of bleeding - – Either proximal or distal to the ligament of

Treitz (duodenal suspensory ligament that attaches at the junction of duodenum and jejunum)

Prehospital Treatment

Based on patient’s hemodynamic status

If any signs of shock/unstable gastrointestinal bleeding the priorty is rapid transport

Brief initial survey to include airway,breathing, circulation, & mechanism of injury

Prehospital Evaluation

Look for signs of hemorrhagic shock

– Altered mental status

– Cool,clammy skin

– Increased capillary Fill time

– Tachycardia

– Hypotension

Prehospital Treatment

Intubate unresponsive patients & those unable to protect their airway

Transport in Trendelenburg’s position & on left side

No extra time at the scene should be spent establishing intravenous access in unstable patients– Large bore lines should be placed en

route

Prehospital Evaluation

If objective findings of bleeding at the scene - document the amount of blood

If time permits- utilize friends, family, or neighbors for brief history

Transport any medical records or medications if available

Emergency DepartmentTreatment & Evaluation

Regardless of presentation

Require Immediate Resuscitation & Stabilization– Monitor oxygenation with pulse oximetry

Unstable patients require 2 large bore intravenous lines, cardiac monitoring, & frequent vital sign checks

Emergency Department Evaluation &Treatment

Resuscitate using Lactated Ringer’s or Normal Saline - Use boluses from 250 ml to 1000 ml in order to maintain systolic blood pressure above 90 mm Hg

If response is inadequate after 2-3 liters of crystalloid - consider blood transfusions

Emergency Department Management

A nasogastric tube should be placed in all patients with significant gastrointestinal bleeding regardless of presumed source.

Gastric Lavage

– Using large-bore tube

– Room temperature saline should be used.

Emergency Department Management

Transfusions

– Packed Red Blood Cells (PRBC’s)

– Fresh Frozen Plasma (FFP)

– Platelet Transfusions

Clinical Manifestations

GI Bleeding most commonly presents with hematemesis, Coffee-ground emesis, melena or hematochezia.– Hematemesis/coffee-ground emesis

suggests upper GI bleeding.– Melena suggests a source at or proximal

to right colon.– Hematochezia suggests a more distal

colorectal lesion.

GI Bleeding History

Weight loss or changes in bowel habits are classic symptoms of malignancy.

Vomiting or retching is suggestive of a Mallory-Weiss tear.

History of medications should be sought. Alcohol abuse/dependence is strongly

associated with GI bleeding.

Physical Examination

Vital Signs

Skin Findings

A careful ENT examination

Abdominal Examination

Rectal Examination

Initial Diagnostic Studies

Laboratory

– Most important test is to Type & Cross-match for 4-6 units of Packed Red Blood Cells (PRBC’s)

– CBC with platelets

– Coagulation Studies

– Electrolytes, Calcium, BUN, Creatinine, & Glucose & Liver Function Tests.

Initial Diagnostic Studies

Obtain ECG in patients over 40 years old.

Radiography

– Upright Chest X-Ray

– Abdominal Films- Flat, Upright, or Decubitus

Secondary Management

Endoscopy

Drug Therapy

Balloon Tamponade

Surgery

Upper GI Bleeding

• Hematemesis implies an upper GI source. • Symptoms of anemia• The location of pain can be helpful.

Worsened pain and acute GI bleeding: trauma, pancreatitis, or hematobilia.

• Important questions include symptoms, use of alcohol, NSAIDs, anticoagulants, abdominal

trauma, prior Gl bleeding, family history of GI bleeding, recent non-intestinal GI bleeding. • Previous blood transfusions or reactions to them

H I S T O R Y

PHYSICAL EXAMINATIONS

Always document signs indicative of major GI hemorrhage

• Signs of anemia• Supine hypotension • Resting tachycardia • Positive "tilt" test• Peripheral vasoconstriction • Altered mental status • Oliguria. • Look for a nasopharyngeal source • Evidence of portal hypertension• Abdominal surgical scars

DIFFERENTIAL DIAGNOSIS

If hematemesis is present, rule out:

• nasopharyngeal sources:chronic inflammation, polyp, malignancy

• pulmonary sources:tuberculosis, pneumonia, bronkiectasi

• coagulopathy:D.I.C, hemophilia

LABORATORY TESTS

• CBC, coagulation factors, and fibrinolysis.

• LFT, kidney functions

• Plain x-rays of the abdomen, if a viscus

perforation is suspected.

• Endoscopic examination

NASOGASTRIC TUBE

• Regardless of a positive or negative NGT aspirate, if lower vs. upper bleed is

uncertain, leave the tube in for 12-24 hours to detect a rebleed or duodenal reflux of blood.

• A negative NGT does not rule out an upper

GI bleed

All GI bleeders should have a nasogastric tube (NGT) placed

CAUSES

Most common:

40-60%

20-35%

8-15%

8-15%

Peptic Ulcer Disease

Gastritis

Varicies

Mallory-Weiss

Less Common:

Gastric Malignancy Chronic Renal Failure Angiodysplasia of stomach/duodenum Esophagitis Duodenitis Pancreatitis, Pancreatic Neoplasm Leukemias, DIC, Thrombocytopenia

CAUSES

Rare Causes:

Leiomyoma, leiomyosarcoma Aorto-enteric fistula Hemobilia Duodenal diverticula Collagen Vascular Diseases Mucocutaneous syndromes Osler-Weber-Rendu, Peutz-Jeghers

CAUSES OF UPPER GI BLEEDING (cont’d)

ALGORITHM FOR ACUTE GI BLEEDING

Patient presents with acute GI bleeding- Evaluate ABC- Determine past or current bleeding- Draw blood for CBC, PT, aPTT, crossmatch

Stable Unstable- Give oxygen by mask- IV catheter- Insert Foley catheter - Give blood as needed- Correct coagulopathy

Stabilized Remain unstable:Surgical approach

- H & PE- NG aspirate/lavage- Identify prognostic factors- Endoscopy

Summary

Regardless of presentation, begin

with immediate resuscitation and

stabilization.