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| ==Workup==
| | {{GI bleeding pages}} |
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| ER
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| 0) 2 large bore IV
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| 1) Icon
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| 2) CBC & serial Hb
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| 3) Chem 7 (BUN/Cr >35 suggests UGI if no hx of RF)
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| 4) T&S/T&C
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| 5) Coags (if INR > 1.5 transfuse FFP)
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| 6) ?Guiac
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| 7) LFTs/lipase
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| 8) *CXR if sx perf (diff TTP abd)
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| 9) *ECG (if >50 yo or if suspicious for silent MI)
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| 11) NG lavage (controversial)
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| 12) IVF/blood
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| 13) IV PPI (Protonix 40-80mg x 1, then 8mg/hr)
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| 14) Octreotide (suspected varices: 50mcg bolus, then 25mcg/hr)
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| 15) Ceftriaxone (if e/o ascites; decreases mortality)
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| 16) *Consider vasopressin/sengstaken-blakemore tube if no access to endoscopy
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| *If aortic graft --> immed surg consult
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| Consider
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| -Proctoscopy (22cm from anal verge)
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| -Sigmoidoscopy (60cm from anal verge)
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| -Angiography (requries arterial bledding >0.5cc/min)
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| -CT angio
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| == ==
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| ==DDX==
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| ===Adult===
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| -UGIB-
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| PUD (Gastric 21%, Duodenal 24%)
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| Gastritis 23%
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| Esophagitis/Duodenitis 6%
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| Varicies
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| Mallory-Weiss < 15%
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| Boerhaave's
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| Dieulafoy lesion
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| Angiodysplasia
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| Hemobilia
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| Aortoenteric fistula
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|
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| -LGIB-
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| Upper GI bleed
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| Diverticulosis (painless, voluminous)
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| Infectious (virus, bacteria, parasites, C. dif)
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| Ischemic Colitis 3-12% (acute onset; 90% > 70yo)
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| IBD (fistula-in-ano)
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| Mesenteric Vascular Insufficiency (abd pain out of proportion to PE)
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| Angiodysplasia
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| Cancer/polyps
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| Rectal dz
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| Hemorrhoids
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| External (below pectinate); Internal (above)
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| Ulcer (HIV, syphilis, STDs)
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| Fissures (painful defecation)
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| Abscess, prolapse, proctitis, impaction
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|
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| ===Peds===
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| -UGIB-
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| Esophagitis
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| Gastritis
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| Ulcer
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| Esophageal varices
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| Mallory-Weiss
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| -LGIB-
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| Anal fissure
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| Infectious colitis
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| IBDPolyps
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| Intussusception
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| ==Disposition==
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| Blatchford score
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| Rockall score
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| -Home (very low risk)-
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| No comorbid dz
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| Normal vitals
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| Norma/trace pos guiac
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| Normal/near-normal Hb
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| Home support
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| F/U within 24hrs
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| -Ward/Stable (low risk)-
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| Age <60
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| Initial SBP >100
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| Normal vitals x 1hr
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| No transfusion req
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| No major comorbid
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| No liver dz
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|
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| -ICU-
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| Normal or dec Hct
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| Blood in NG doesn't clear
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| SBP<100, HR>100
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| Gauaic +/- stool
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|
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| ==False Positive Guaiac==
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| Red fruits and meats
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| (Bananas, turnips, broccoli)
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| Methylene blue
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| Chlorophyll
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| Iodide
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| Cupric sulfate
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| Bromide
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| Iron (causes GI bleed by irritation)
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|
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| ==Source ==
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| 3/12/06 DONALDSON (adapted from Rosen), Kaji
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| [[Category:GI]] | | [[Category:GI]] |
| | [[Category:Symptoms]] |
