Gastrointestinal bleeding
Workup
ER
0) 2 large bore IV
1) Icon
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
Adult
-UGIB-
PUD (Gastric 21%, Duodenal 24%)
Gastritis 23%
Esophagitis/Duodenitis 6%
Varicies
Mallory-Weiss < 15%
Boerhaave's
Dieulafoy lesion
Angiodysplasia
Hemobilia
Aortoenteric fistula
-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
-UGIB-
Esophagitis
Gastritis
Ulcer
Esophageal varices
Mallory-Weiss
-LGIB-
Anal fissure
Infectious colitis
IBDPolyps
Intussusception
Disposition
Blatchford 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
-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
Red fruits and meats
(Bananas, turnips, broccoli)
Methylene blue
Chlorophyll
Iodide
Cupric sulfate
Bromide
Iron (causes GI bleed by irritation)
Source
3/12/06 DONALDSON (adapted from Rosen), Kaji