Difference between revisions of "Gastrointestinal bleeding"

 
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==Background==
+
*Adults
*Bleeding originating proximal to ligament of Treitz
+
**[[Upper GI Bleeding]]
 
+
**[[Lower GI Bleeding]]
==Diagnosis==
+
*[[GI Bleeding (Peds)]]
===History===
 
*Hematemesis
 
*Coffee-ground emesis
 
*Melena + age <50 suggests upper GI bleed
 
*Vomiting + retching followed by hematemesis = Mallory-Weiss
 
*Aortic graft = aortoenteric fistula
 
*Meds
 
**ASA, steroids, NSAIDs, anticoagulants
 
*ETOH abuse
 
**Peptic ulcer disease, gastritis, varices
 
*Pseudo-melena
 
**Iron or bismuth use
 
===Physical Exam===
 
*Tachycardia, hypotension
 
*Liver disease
 
**Spider angiomata, palmar erythema, jaundice, gynecomastia
 
*Coagulopathy
 
**Petechiae/purpura
 
*ENT exam
 
**Swallowed blood may result in coffee-ground emesis or melena
 
*Rectal exam
 
 
 
==DDX==
 
#Peptic ulcer disease (most common cause)
 
#Gastritis/esophagitis
 
#Gastric/esophageal varices
 
#Mallory-Weiss Syndrome
 
#Stress ulcer
 
#Malignancy
 
#ENT sources of bleeding
 
#Aortoenteric fistula
 
#Boerhaave
 
#Dieulafoy's lesion
 
#Angiodysplasia
 
#Hemobilia
 
 
 
==Workup==
 
#2 large bore IV
 
#Type and cross
 
#CBC & serial Hb
 
#Chemistry
 
##BUN/Cr >30 suggests UGI if no hx of renal failure (incr absorption/digestion of hb)
 
#Coags (if INR > 1.5 transfuse FFP)
 
#LFTs
 
#Guaiac
 
#?ECG (if >50 yo or if suspicious for silent MI)
 
#?CXR (if suspect perforation)
 
#?NG lavage
 
##Controversial
 
###Pros
 
####Positive aspirate proves strong evidence for an UGI source of bleeding
 
####Can assess presence of ongoing active bleeding
 
####Can prepare pt for endoscopy
 
###Cons
 
####Uncomfortable
 
####Negative aspirate does not conclusively exclude UGI source
 
####Provides useful information in only minority of pts w/o hematemesis
 
####Erythromycin 200mg IV can provide equal endoscopy conditions as lavage
 
 
 
==Treatment==
 
#IVF
 
#Blood
 
##Indications for tranfusion:
 
###Continued active bleeding
 
###Failure to improve perfusion and vital signs after infusion of 2L NS
 
#FFP as needed
 
#PPI
 
##Pantoprazole/esomeprazole 80mg x 1; then 8mg/hr
 
##Lansoprazole 60mg x 1; then 6mg/hr
 
#Octreotide
 
##25-50mcg x 1; then 25-50 mcg/hr
 
###Use lower dosage for elderly or severe liver disease
 
#Ceftriaxone
 
#Endoscopy
 
#Surgery
 
#Balloon tamponade (for life-threatening hemorrhage if endoscopy is not available)
 
##Sengstaken-Blakemore tube
 
###Tube consists of gastric and esophageal balloons
 
####First inflate gastric balloon; if bleeding continues inflate esophageal balloon
 
#####Esophageal pressure must not exceed 40-50 mmHg
 
###Adverse reactions are frequent
 
####Mucosal ulceration
 
####Esophageal/gastric rupture
 
####Tracheal compression (consider intubation prior to balloon insertion)
 
 
 
==Disposition==
 
*Consider admission for:
 
#Age >60yr
 
#Transfusion required
 
#Initial Sys BP < 100
 
#Red blood in NG lavage
 
#History of cirrhosis or ascites on exam
 
#History of vomiting red blood
 
*Consider discharge for Glasgow-Blatchford Bleeding Score of 0 (ALL of the following)
 
#BUN <18
 
#Hb >13 (men), Hb >12 (women)
 
#Sys BP >110
 
#HR <100
 
#Pt did NOT present w/ melena
 
#Pt did NOT present w/ syncope
 
#No hepatic disease
 
#No cardiac failure
 
 
 
===Consider===
 
#Proctoscopy (22cm from anal verge)
 
#Sigmoidoscopy (60cm from anal verge)
 
#Angiography (requries arterial bledding >0.5cc/min)
 
#CT angio
 
 
 
==DDX==
 
===Adult===
 
#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
 
##IBD
 
##Polyps
 
##Intussusception
 
 
 
==Disposition==
 
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 ==
 
*Tintinalli
 
*Erythromycin infusion or gastric lavage for upper gastrointestinal bleeding: a multicenter randomized controlled trial. Pateron D et al. Ann Emerg Med. (2011)
 
  
 
[[Category:GI]]
 
[[Category:GI]]
 +
[[Category:Symptoms]]

Latest revision as of 23:10, 28 November 2019