11. GI Hemorrhage Flashcards
Epidemiology of GI Bleed
- 300,000 hospitalizations annually
- 20,000 deaths annually
- Upper GI bleeds are more common in men, increase with age, and have a mortality of 6%
- Lower GI bleeds stop spontaneously in 80-85% and have a mortality of 2-4%
Spectrum of GI Bleeding
- Acute GI Bleeding
- Chronic GI Bleeding
- OCCULT - difficult to see, detected by stool guaiac cards and/or anemia
- OVERT - clinically evident
- Acute on Chronic GI Bleeding - acute episode of chronic bleed
Ligament of Treitz Anatomy and Clinical Utility
Ligament of Treitz - tissue connecting the duodenum to the diaphragm
Its clinical utility is that it divides the GI tract into upper and lower portions
- Melena (black tarry stools) is believed to be from a bleed originating above the ligament
- Hematochezia (bright red blood) is believed to be from a bleed originating below the ligament
Sources of GI Bleeding
-
85% UPPER TRACT
- Oropharynx
- Esophagus
- Stomach
-
5% MIDDLE TRACT
- Jejunum
- Ileum
-
10% LOWER TRACT
- Appendix
- Cecum
- Ascending Colon
- Transverse Colon
- Descending Colon
- Sigmoid Colon
- Rectum
MELENA
Etiology
Pathophysiology
Clinical Presentation
ETIOLOGY:
- UGI bleed (or could be from the small bowel or right colon)
- Epistaxis
- Oral Cavity Bleeding
- Blood ingestion
- Meds - Iron Pills, Pepto-Bismol
PATHOPHYSIOLOGY:
Degradation of blood by GI tract bacteria
CLINICAL PRESENTATION:
Black, tarry, foul smelling stools
HEMATEMESIS
Clinical Presentation/Etiology
CLINICAL PRESENTATION/ETIOLOGY:
- Bright Red Blood - moderate-severe, possibly ongoing UGI bleed
- Coffee Ground-Like Material - more limited UGI bleed
HEMATOCHEZIA
Etiology
Clinical Presentation
ETIOLOGY:
- Lower GI Bleed
- 5-10% of cases are due to a VERY BRISK upper GI bleed > 1 L
CLINICAL PRESENTATION:
- Bright red blood per rectum that may or may not be mixed with stool
OCCULT BLEED
Diagnostic Evaluation
Clinical Presentation
DIAGNOSTIC EVALUATION:
- (+) Fecal Occult Blood Test
and/or
- Iron Deficiency Anemia
CLINICAL PRESENTATION:
No visible blood loss
Initial Evaluation and Management of a GI Bleed Patient
- DETERMINE BLEEDING SEVERITY by assessing blood pressure and heart rate
- NORMAL BP, NORMAL HR –> suggests <10% loss of TBV –> MINOR
- Orthostasis- > 20 mm Hg drop in SBP or > 20 BPM rise in HR –> suggests 10-20% loss of TBV –> MODERATE
- Shock –> >20-25% loss of TBV –> SEVERE
- RESUSCITATION
- If hemodynamically unstable, establish vascular access with 2 large bore IVs
- IV Saline or Lactated Ringers
- If airway is compromised like in a severe UGI bleed, provide oxygen with endotracheal tube
- Monitor vital signs frequently
TRANSFUSIONS???
- If patient continues to be hemodynamically unstable and/or has a low blood count (Hgb < 7 in young, healthy / Hgb < 9 in elderly, sick)
- Give 1 unit/gram under 7
- Warmed blood should be given to patients requiring >3 L of blood (6 units)
- ALL HEMODYNAMICALLY UNSTABLE ARE ADMITTED TO ICU
BLOOD THINNERS???
- Consult prescriber to help weigh risk of reversing/holding anticoagulants against risk of continued bleeding
- In patients have active bleeding and coagulopathy (prolonged PT/INR), transfuse with Fresh Frozen Plasma to supplement lost coagulation factors
- In patients with low platelets, transfuse with platelets
- HISTORY AND PHYSICAL
HISTORY
- Medical Problems - prior GI bleeds, liver disease (clotting facors can be disrupted in cirrhosis)
- Medications - NSAIDs and aspirin (ulcers), blood thinners
- Onset
- Events leading up to bleeding episode
- Characteristics of stool
- Associated Symptoms Abdominal Pain, Dysphagia/Odynophagia, Weight Loss
PHYSICAL
- Digital rectal exam
4. LABS - CBC
- BMP
- LFTs
- Type and Screen
- PT/PTT
FYI-
- Hgb and Hct may take 1-3 days to reflect true blood loss. Monitor every 2-8 hrs depending on severity
- MCV - normocytic (acute), microcytic (chronic)
- BUN - elevtion suggests UGIB
- Iron Studies - IDA suggests chronic blood loss
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