Acute GI Bleeding Flashcards
Compare the presentation of upper vs. lower GI bleed.
Upper (proximal to ligament of Treitz): typically melena (very dark, tarry pungent); can be BRB if fast bleed
Lower (distal to ligaent of Treitz): typically hematochezia (BRB, dark red, maroon); can be ~melena if slow bleed
DDx - acute upper GI bleed
Peptic ulcer disease (duodenal ulcer, gastric ulcer, gastritis)
Esophagitis (reflux, etc.)
Varices (esophageal, gastric)
Gastritis
Duodenitis
Mallory-Weis tear
Dieulafoy vascular malformation (submucosal dilated arterial lesions)
Aortoenteric fistula (after aortic surgery)
Neoplasm (usually not an emergency)
Portal gastropathy
Angiodysplasia
DDx - acute lower GI bleed
Diverticulosis Angiodysplasia IBD Colorectal cancer/polyps Ischemic colitis Hemorrhoids Fissures
Describe the important elements to focus on during initial assessment of the patient w/acute GI bleed.
- History
- Physical
- Severity of blood loss
- Initial labs
- Initial resuscitative measures
- Determine the need for emergent intervention/triage
- Find the underlying cause.
- Determine need/candidacy for intervention
- Intervene and stop the bleeding
What history is important in differentiating the cause of GI bleeding?
Type of bleeding (location, variceal vs. non-variceal)
- Hematemesis (upper GI)
- Coffee grounds emesis (upper GI, lower rate of bleeding)
- Melena (UGI 90% of the time)
- Hematochezia (LGI or rapid upperG I)
Age
Symptoms: abdominal pain, emesis before hematemesis, rectal pain, fever, diarrhea
History of prior GI bleeding
Comorbidities: alcohol and tobacco use, GERD, renal failure, malignancy, CAD, HF, AAA repair, liver disease
Previous endoscopies
Medications: anticoagulants, NSAIDs/ASA
What parts of the physical exam should be focused on in assessing GI bleeding?
Vitals
Hemodynamic stability - tachycardia, hypotension/orthostasis, signs of shock (cold/clammy extremities, thready pulse, poor mentation)
- Orthostasis ~20% blood volume loss
- Shock ~40% blood volume loss
Appearance
CV, Pulm
Abdominal exam, rectal exam
Stigmata of liver disease
Initial testing to order in assessing GI bleeding?
H/H or CBC, PT/INR, pTT, type and cross, CMP
Monitor Hgb Q4-8hrs until stable for 24 hrs
Initial resuscitative measures in acute GI bleeding?
- 2+ large bore IV’s (18 gauge or larger) w/aggressive fluid resuscitation +/- transfusion
- Cardiorespiratory support as indicated (AMS, active massive hematemesis, hypoxia)
- Consider NG tube (BRB is an adverse prognostic indicator)
- NPO
- Hold anticoagulation
- Transfuse other blood products if underlying coagulopathy
- PPI (before endoscopy)
- Octreotide
Who gets transfused in acute GI bleeding?
Individualized decision based on age, underlying CV status, baseline Hgb, rapidity of blood loss, current Hct, markers of tissue hypoxia
- Typically if <7
- Consider <10 if older w/comorbidities, tachycardia/hypotension
Who should be admitted to the ICU?
Multiple adverse prognostic factors (>60, multiple comorbidities, coagulopathy, portal HTN, hematemesis is BRB, hx AAA repair)
Hemodynamic/CP instability despite adequate volume resuscitation
Persistent hematemesis
Concern for variceal bleed
Who should/might be consulted in the setting of an acute GI bleed?
GI (emergency or routine)
Surgical (uncontrolled bleeding, bleeding associated w/acute abdomen, recurrent bleeding)
IR (bleeding scan, angiography)
Specific Rx for acute gastritis
Discontinue NSAIDs
Oral PPI
Check for H. pylori/treat if present
Advance diet as tolerated
Forrest classification of bleeding ulcers?
Grade IA, IB, IIA - acute bleeding or non-bleeding visible vessels
Grade IIB - adherent clot
IIC or III - ulcer with flat, clean base
Management of bleeding ulcers?
If high risk for re-bleeding (IA, IB, IIA, IIB): endoscopic hemostasis, admit to monitored bed/ICU, continue IV PPI, H. pylori testing/treatment, advance diet as tolerated
If IIC or III - no indication for endoscopic hemostasis; complete H. pylori testing/treatment
Indication for emergent procedures?
Hemodynamic instability
Hypovolemic shock
Certain etiologies (varices, vascular-enteric fistula)
