Difference between revisions of "Gastrointestinal bleeding"

Line 3: Line 3:
 
*Upper GI bleeds are most common source for blood detected in the lower GI system
 
*Upper GI bleeds are most common source for blood detected in the lower GI system
 
*80% of lower GI bleeding will resolve spontaneously
 
*80% of lower GI bleeding will resolve spontaneously
*Cause for bleeding is found in <50% of cases
+
*Cause of bleeding found in <50% of cases
 +
 
 +
==False Positive Guaiac==
 +
#Red meat
 +
#Red jello
 +
#Fruit and vegetables
 +
##(Melon, broccoli, radish
 +
#Iron (causes GI bleed by irritation)
  
 
==Diagnosis==
 
==Diagnosis==
 
===History===
 
===History===
*Hematochezia
+
*Type of blood
**Bright red or maroon-colored bleeding that comes from the rectum
+
**Hematochezia
**Usually represents lower GI bleeding
+
***Bright red or maroon-colored bleeding that comes from the rectum
**May represent UGIB if bleeding is brisk
+
***Usually represents lower GI bleeding
***Usually accompanied by hematemesis and hemodynamic instability
+
***May represent UGIB if bleeding is brisk
*Melena
+
****Usually accompanied by hematemesis and hemodynamic instability
**Usually represents bleeding from upper GI source
+
**Melena
**May represent bleeding from lower GI source due to slow bleeding
+
***Usually represents bleeding from upper GI source
 +
***May represent bleeding from lower GI source due to slow bleeding
 +
*Medications
 +
**Salicylates, NSAIDs, warfarin
 +
 
 +
===Physical Exam===
 +
#Consider anoscopy if source of bleeding cannot be identified on external exam
 +
 
 +
==Workup==
 +
#Labs
 +
##CBC
 +
###Chemistry
 +
###BUN may be elevated if bleeding occurs from site high in GI tract
 +
##Coags
 +
##LFTs
 +
##Type and screen
 +
#ECG (if concern for silent ischemia inn pts likely to have CAD)
 +
#Imaging
 +
##CTA
 +
###Requires brisk bleeding rate (0.5 cc/min) for detectio
 +
##Proctoscopy (22cm from anal verge)
 +
##Sigmoidoscopy (60cm from anal verge)
  
 
==DDX==
 
==DDX==
Line 46: Line 74:
 
#Anal fissure
 
#Anal fissure
  
 
+
==Treatment==
===Consider===
+
#IVF
#Proctoscopy (22cm from anal verge)
+
#Correct coagulopathy
#Sigmoidoscopy (60cm from anal verge)
+
#Blood
#Angiography (requries arterial bledding >0.5cc/min)
+
##Give if continued active bleeding and failure to improve perfusion after 2L NS
#CT angio
+
#?NGT
 +
##Hematochezia unexpectedly originates from upper GI source 10-15% of cases
 +
#Sigmoidoscopy/colonoscopy
 +
#Surgery if endoscopy fails or not available
  
 
==Disposition==
 
==Disposition==
Rockall score
+
Discharge:
 
+
**Bleeding from hemorrhoids, anal fissures, or known IBD (hemodynamically stable)
===Home (very low risk)===
+
**No gross blood on rectal exam (hemodynamically stable)
#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 ==
 
==Source ==

Revision as of 19:26, 31 July 2011

Background

  • Loss of blood from the GI tract distal to the ligament of Treitz
  • Upper GI bleeds are most common source for blood detected in the lower GI system
  • 80% of lower GI bleeding will resolve spontaneously
  • Cause of bleeding found in <50% of cases

False Positive Guaiac

  1. Red meat
  2. Red jello
  3. Fruit and vegetables
    1. (Melon, broccoli, radish
  4. Iron (causes GI bleed by irritation)

Diagnosis

History

  • Type of blood
    • Hematochezia
      • Bright red or maroon-colored bleeding that comes from the rectum
      • Usually represents lower GI bleeding
      • May represent UGIB if bleeding is brisk
        • Usually accompanied by hematemesis and hemodynamic instability
    • Melena
      • Usually represents bleeding from upper GI source
      • May represent bleeding from lower GI source due to slow bleeding
  • Medications
    • Salicylates, NSAIDs, warfarin

Physical Exam

  1. Consider anoscopy if source of bleeding cannot be identified on external exam

Workup

  1. Labs
    1. CBC
      1. Chemistry
      2. BUN may be elevated if bleeding occurs from site high in GI tract
    2. Coags
    3. LFTs
    4. Type and screen
  2. ECG (if concern for silent ischemia inn pts likely to have CAD)
  3. Imaging
    1. CTA
      1. Requires brisk bleeding rate (0.5 cc/min) for detectio
    2. Proctoscopy (22cm from anal verge)
    3. Sigmoidoscopy (60cm from anal verge)

DDX

  1. Upper GI bleed
  2. Diverticular disease
    1. Painless bleeding
    2. Up to 90% of episodes resolve spontaneously
    3. Can result in massive hemorrhage
  3. Vascular ectasia
    1. Angiodysplasia, AVM
  4. Inflammatory bowel disease
  5. Colitis
    1. Infectious
    2. Ischemic
      1. 90% of cases occur in age >70yo
      2. Colon is predisposed to ischemia due to poor vascular ciculation, high bacterial count
      3. Causes: aneurysmal rupture, vasculitis, hypercoagulable, CV insult, IBS, slow motility
      4. Most cases resolve on own; 20% of cases requires surgical intervention
  6. Mesenteric Ischemia
    1. Medical emergency that often leads to bowel necrosis
    2. Causes: thrombosis/embolism of SMA, mesenteric vein thrombosis, low arterial flow
    3. Associated w/ A fib, CHF, MI, age >60yo
    4. CT only 64% Sn, angiography is imaging study of choice
  7. Meckel Diverticulum
  8. Malignancy / polyps
  9. Hemorrhoids
    1. Massive hemorrhage is unusual
  10. Rectal ulcer
  11. Foreign body
  12. Rectal ulcer (HIV, syphilis, STIs)
  13. Anal fissure

Treatment

  1. IVF
  2. Correct coagulopathy
  3. Blood
    1. Give if continued active bleeding and failure to improve perfusion after 2L NS
  4. ?NGT
    1. Hematochezia unexpectedly originates from upper GI source 10-15% of cases
  5. Sigmoidoscopy/colonoscopy
  6. Surgery if endoscopy fails or not available

Disposition

Discharge:

    • Bleeding from hemorrhoids, anal fissures, or known IBD (hemodynamically stable)
    • No gross blood on rectal exam (hemodynamically stable)

Source

  • Tintinalli