Gastrointestinal bleeding: Difference between revisions

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==Background==
{{GI bleeding pages}}
*Bleeding originating proximal to ligament of Treitz
 
==Diagnosis==
===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 14:06, 12 March 2022