Upper GI Bleeding

Question 1

Etiology and patho

Answer 1

Most serious loss of blood from UGI characterized by sudden onset
Insidious occult bleeding can also be a major problem
Severity depends on bleeding origin (venous, capillary, arterial)

Question 2

Hematemesis

Answer 2

Obvious bleeding
Bloody vomitus
Appears fresh, bright red blood or “coffee grounds”

Question 3

Melena

Answer 3

Obvious bleeding
Black, tarry stools
Caused by digestions of blood in GI tract
Black appearance due to iron
The longer the passage of blood through intestines, the darker the stool color, caused by breakdown of Hgb and release of iron
Cause of bleeding is not always easy to determine

Question 4

Occult bleeding

Answer 4

Small amounts of blood in gastric secretions, vomitus, or stools
Undetectable by appearance
Detectable by guaiac test

Question 5

Bleeding from arterial source…

Answer 5

Profuse, blood is bright red

*Bright red blood indicates the it has not been in contact w/ stomach acid secretions

Question 6

Coffee ground vomitus reveals…

Answer 6

Blood has been in stomach for some times

blood has been changed by gastric secretions

Question 7

Massive upper GI hemorrhage…

Answer 7

Loss of more than 1500 mL of blood
OR
Loss of 25% of intravascular blood volume

Question 8

Common causes of UGI bleeding

Answer 8

Esophageal origin
Stomach and duodenal origin
Drug-induced origin
Systemic disease region

Question 9

Esophageal origin causes of bleeding

Answer 9

Chronic esophagitis

• GERD
• Mucosa-irritating drugs (aspirin, NSAIDs, corticosteroids)
• Alcohol
• Cigarettes

Question 10

Stomach and duodenal origin causes of bleeding

Answer 10

Peptic ulcer disease
-Bleeding ulcers account for 40% of cases of UGI bleeding
-R/t H. pylori or drug use (NSAIDs)
Gastric cancer
Hemorrhagic gastritis
Polyps
Stress-related mucosal disease (SRMD)
-Also called physiologic stress ulcers
-Occurs in pts w/ severe burns or trauma, or after major surgery

Question 11

Endoscopy

Answer 11

Primary tool for diagnosing source of bleeding
Before performing:
-Lavage may be needed for clearer view
-NG or orogastric tube placed, and room temp water or saline used
-Do not advance tube against resistance!

Question 12

Lab studies

Answer 12

CBC
BUN measurement
Serum electrolyte measuremetns
PT, PTT
Liver enzyme measurements

Question 13

Blood replacement

Answer 13

Hbg and Hct provide baseline for further treatment
Initial Hct may be normal and may not reflect loss until 4-6 hrs after fluid replacement
-Initially, losses of plasma and RBC are equal

Question 14

Endoscopic Hemostasis Therapy

Answer 14

Goal: to achieve coagulation or thrombosis in bleeding artery
-useful for gastritis, Mallory-Weiss tear, esophageal and gastric varices, bleeding peptic ulcers, polyps

Question 15

Thermal (Heat) Probe

Answer 15

Coagulates tissue by directly applying heat to site

*Endoscopic hemostasis

Question 16

Endoscopic hemostasis techniques

Answer 16

Thermal probe
Electrocoagulation probe (mulltipolar and bipolar)
Argon plasma coagulation (APC)
Neodymium yttrium -aluminum-garnet (Nd-YAG) laser

Question 17

Drug therapy

Answer 17

During acute phase, used to:
- decrease bleeding
- decrease HCl acid secretion
- Neutralize HCl acid that is 
Injection therapy w/ epinephrine during endoscopy for acute hemostasis

Question 18

Drug therapy for bleeding due to ulceration

Answer 18

Epinephrine
-Produces tissue edema -> pressure on bleeding source
Usually combined w/ other therapies

Question 19

Acid reducers drug therapy

Answer 19

Acidic environment can alter platelet function and clot stabilization
Histamine-2 receptor (H2R) blockers
-Inhibit action of histamine at H2 receptors and decrease HCl acid secretion
-Cimetidine
-Ranitidine

Question 20

Proton Pump Inhibitors (PPIs)

Answer 20

Acid reducer
Suppresses gastric secretion by inhibiting H+, K+, ATPase enzyme system
Inhibits gastric acid pump
-Pantoprazole
Esomeprazole
*No proven ability to control active bleeding

Question 21

Somatostatin or Somatostatin analog octreotide

Answer 21

Drug therapy
Used for upper GI bleeding
Reduces blood flow to the GI organs and acid secretion
Given IV boluses for 3-7 days after onset of bleeding

Question 22

S/Sx of shock

Answer 22

Low BP
Rapid, weak pulse
Increased thirst
Cold, clammy skin
Restlessness
Monitor VS q 15-30 min and inform HCP of any significant changes

Question 23

Nursing dx

Answer 23

Decreased cardiac output
Deficient fluid volume
Ineffective peripheral tissue perfusion
Anxiety

Question 24

Health promotion

Answer 24

Pt w/ hx of chronic gastritis or peptic ulcer disease is at high risk
Pt who has had one major bleeding episode is more likely to have another
Pt w/ cirrhosis or previous UGI bleed is also at high risk

Question 25

Patient teaching

Answer 25

Disease process and drug therapy
Avoidance of gastric irritants
-alcohol
-smoking
-stress-inducing situations
Take only prescribed medications
Methods of testing vomitus/stools for occult blood
Potential adverse effects related to GI bleeding
Prompt treatment of upper respiratory infection in pt w/ esophageal varices
If aspirin must be prescribed, enteric-coated tablets can be substituted for regular tablets
Taking meds w/ meals or snacks lessens potential irritating effects

Question 26

Acute interventions

Answer 26

IV maintenance
Accurate I/O record
-Urine output hourly
-At least 0.5 mL/kg/hr indicates adequate renal perfusion
-urine specific gravity should be measured (normal: 1.005-1.025)

Question 27

If NG tube is inserted

Answer 27

Keep in proper position
Observe for aspirate blood
Effectiveness of gastric lavage is questionable

Question 28

Hemorrhage that is result of chronic alcohol abuse

Answer 28

Closely observe for delirium tremens

• agitation
• uncontrolled shaking
• sweating
• vivid hallucinations