Gastrointestinal bleeding

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