Gastrointestinal bleeding: Difference between revisions

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==Workup==
==Workup==
===ER===
# 2 large bore IV
# Icon
# CBC & serial Hb
# Chem 7 (BUN/Cr >35 suggests UGI if no hx of RF)
# T&S/T&C
# Coags (if INR > 1.5 transfuse FFP)
# ?Guiac
# LFTs/lipase
# ?CXR if sx perf (diff TTP abd)
# ?ECG (if >50 yo or if suspicious for silent MI)
# NG lavage (controversial)
# IVF/blood
# IV PPI (Protonix 40-80mg x 1, then 8mg/hr)
# Octreotide (suspected varices: 50mcg bolus, then 25mcg/hr)
# Ceftriaxone (if e/o ascites; decreases mortality)
# ?Consider vasopressin/sengstaken-blakemore tube if no access to endoscopy


If aortic graft --> immed surg consult


ER
===Consider===
 
#Proctoscopy (22cm from anal verge)
0) 2 large bore IV
#Sigmoidoscopy (60cm from anal verge)
 
#Angiography (requries arterial bledding >0.5cc/min)
1) Icon
#CT angio
 
2) CBC & serial Hb
 
3) Chem 7 (BUN/Cr >35 suggests UGI if no hx of RF)
 
4) T&S/T&C
 
5) Coags (if INR > 1.5 transfuse FFP)
 
6) ?Guiac
 
7) LFTs/lipase
 
8) *CXR if sx perf (diff TTP abd)
 
9) *ECG (if >50 yo or if suspicious for silent MI)
 
11) NG lavage (controversial)
 
12) IVF/blood
 
13) IV PPI (Protonix 40-80mg x 1, then 8mg/hr)
 
14) Octreotide (suspected varices: 50mcg bolus, then 25mcg/hr)
 
15) Ceftriaxone (if e/o ascites; decreases mortality)
 
16) *Consider vasopressin/sengstaken-blakemore tube if no access to endoscopy
 
*If aortic graft --> immed surg consult
 
 
Consider
 
-Proctoscopy (22cm from anal verge)
 
-Sigmoidoscopy (60cm from anal verge)
 
-Angiography (requries arterial bledding >0.5cc/min)
 
-CT angio
 
== ==
 


==DDX==
==DDX==
===Adult===
===Adult===
 
#UGIB
 
##PUD (Gastric 21%, Duodenal 24%)
-UGIB-
##Gastritis 23%
 
##Esophagitis/Duodenitis 6%
PUD (Gastric 21%, Duodenal 24%)
##Varicies
 
##Mallory-Weiss <15%
Gastritis 23%
##Boerhaave's
 
##Dieulafoy lesion
Esophagitis/Duodenitis 6%
##Angiodysplasia
 
##Hemobilia
Varicies
##Aortoenteric fistula
 
#LGIB
Mallory-Weiss < 15%
#Upper GI bleed
 
#Diverticulosis (painless, voluminous)
Boerhaave's
#Infectious (virus, bacteria, parasites, C. dif)
 
#Ischemic Colitis 3-12% (acute onset; 90% > 70yo)
Dieulafoy lesion
#IBD (fistula-in-ano)
 
#Mesenteric Vascular Insufficiency (abd pain out of proportion to PE)
Angiodysplasia
#Angiodysplasia
 
#Cancer/polyps
Hemobilia
#Rectal dz
 
#Hemorrhoids
Aortoenteric fistula
##External (below pectinate); Internal (above)
 
#Ulcer (HIV, syphilis, STDs)
#Fissures (painful defecation)
 
#Abscess, prolapse, proctitis, impaction
-LGIB-
 
Upper GI bleed
 
Diverticulosis (painless, voluminous)
 
Infectious (virus, bacteria, parasites, C. dif)
 
Ischemic Colitis 3-12% (acute onset; 90% > 70yo)
 
IBD (fistula-in-ano)
 
Mesenteric Vascular Insufficiency (abd pain out of proportion to PE)
 
Angiodysplasia
 
Cancer/polyps
 
Rectal dz
 
Hemorrhoids
 
    External (below pectinate); Internal (above)
 
Ulcer (HIV, syphilis, STDs)
 
Fissures (painful defecation)
 
Abscess, prolapse, proctitis, impaction
 


===Peds===
===Peds===
 
#UGIB
 
##Esophagitis
-UGIB-
##Gastritis
 
##Ulcer
Esophagitis
##Esophageal varices
 
##Mallory-Weiss
Gastritis
#LGIB
 
##Anal fissure
Ulcer
##Infectious colitis
 
##IBD
Esophageal varices
##Polyps
 
##Intussusception
Mallory-Weiss
 
 
-LGIB-
 
Anal fissure
 
Infectious colitis
 
IBDPolyps
 
Intussusception
 


==Disposition==
==Disposition==
Blatchford score
Blatchford score


Rockall score
Rockall score


===Home (very low risk)===
#No comorbid dz
#Normal vitals
#Norma/trace pos guiac
#Normal/near-normal Hb
#Home support
#F/U within 24hrs


-Home (very low risk)-
===Ward/Stable (low risk)===
#Age <60
#Initial SBP >100
#Normal vitals x 1hr
#No transfusion req
#No major comorbid
#No liver dz


No comorbid dz
===ICU===
 
#Normal or dec Hct
Normal vitals
#Blood in NG doesn't clear
 
#SBP<100, HR>100
Norma/trace pos guiac
#Gauaic +/- stool
 
Normal/near-normal Hb
 
Home support
 
F/U within 24hrs
 
 
-Ward/Stable (low risk)-
 
Age <60
 
Initial SBP >100
 
Normal vitals x 1hr
 
No transfusion req
 
No major comorbid
 
No liver dz
 
 
-ICU-
 
Normal or dec Hct
 
Blood in NG doesn't clear
 
SBP<100, HR>100
 
Gauaic +/- stool
 


==False Positive Guaiac==
==False Positive Guaiac==
 
#Red fruits and meats
 
##(Bananas, turnips, broccoli)
Red fruits and meats
#Methylene blue
 
#Chlorophyll
(Bananas, turnips, broccoli)
#Iodide
 
#Cupric sulfate
Methylene blue
#Bromide
 
#Iron (causes GI bleed by irritation)
Chlorophyll
 
Iodide
 
Cupric sulfate
 
Bromide
 
Iron (causes GI bleed by irritation)
 


==Source ==
==Source ==
3/12/06 DONALDSON (adapted from Rosen), Kaji
3/12/06 DONALDSON (adapted from Rosen), Kaji


[[Category:GI]]
[[Category:GI]]

Revision as of 05:56, 14 March 2011

Workup

ER

  1. 2 large bore IV
  2. Icon
  3. CBC & serial Hb
  4. Chem 7 (BUN/Cr >35 suggests UGI if no hx of RF)
  5. T&S/T&C
  6. Coags (if INR > 1.5 transfuse FFP)
  7. ?Guiac
  8. LFTs/lipase
  9. ?CXR if sx perf (diff TTP abd)
  10. ?ECG (if >50 yo or if suspicious for silent MI)
  11. NG lavage (controversial)
  12. IVF/blood
  13. IV PPI (Protonix 40-80mg x 1, then 8mg/hr)
  14. Octreotide (suspected varices: 50mcg bolus, then 25mcg/hr)
  15. Ceftriaxone (if e/o ascites; decreases mortality)
  16. ?Consider vasopressin/sengstaken-blakemore tube if no access to endoscopy

If aortic graft --> immed surg consult

Consider

  1. Proctoscopy (22cm from anal verge)
  2. Sigmoidoscopy (60cm from anal verge)
  3. Angiography (requries arterial bledding >0.5cc/min)
  4. CT angio

DDX

Adult

  1. UGIB
    1. PUD (Gastric 21%, Duodenal 24%)
    2. Gastritis 23%
    3. Esophagitis/Duodenitis 6%
    4. Varicies
    5. Mallory-Weiss <15%
    6. Boerhaave's
    7. Dieulafoy lesion
    8. Angiodysplasia
    9. Hemobilia
    10. Aortoenteric fistula
  2. LGIB
  3. Upper GI bleed
  4. Diverticulosis (painless, voluminous)
  5. Infectious (virus, bacteria, parasites, C. dif)
  6. Ischemic Colitis 3-12% (acute onset; 90% > 70yo)
  7. IBD (fistula-in-ano)
  8. Mesenteric Vascular Insufficiency (abd pain out of proportion to PE)
  9. Angiodysplasia
  10. Cancer/polyps
  11. Rectal dz
  12. Hemorrhoids
    1. External (below pectinate); Internal (above)
  13. Ulcer (HIV, syphilis, STDs)
  14. Fissures (painful defecation)
  15. Abscess, prolapse, proctitis, impaction

Peds

  1. UGIB
    1. Esophagitis
    2. Gastritis
    3. Ulcer
    4. Esophageal varices
    5. Mallory-Weiss
  2. LGIB
    1. Anal fissure
    2. Infectious colitis
    3. IBD
    4. Polyps
    5. Intussusception

Disposition

Blatchford score

Rockall score

Home (very low risk)

  1. No comorbid dz
  2. Normal vitals
  3. Norma/trace pos guiac
  4. Normal/near-normal Hb
  5. Home support
  6. F/U within 24hrs

Ward/Stable (low risk)

  1. Age <60
  2. Initial SBP >100
  3. Normal vitals x 1hr
  4. No transfusion req
  5. No major comorbid
  6. No liver dz

ICU

  1. Normal or dec Hct
  2. Blood in NG doesn't clear
  3. SBP<100, HR>100
  4. Gauaic +/- stool

False Positive Guaiac

  1. Red fruits and meats
    1. (Bananas, turnips, broccoli)
  2. Methylene blue
  3. Chlorophyll
  4. Iodide
  5. Cupric sulfate
  6. Bromide
  7. Iron (causes GI bleed by irritation)

Source

3/12/06 DONALDSON (adapted from Rosen), Kaji

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