Gastrointestinal bleeding: Difference between revisions

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==Background==
==Background==
*Bleeding originating proximal to ligament of Treitz
*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 for bleeding is found in <50% of cases


==Diagnosis==
==Diagnosis==
===History===
===History===
*Hematemesis
*Hematochezia
*Coffee-ground emesis
**Bright red or maroon-colored bleeding that comes from the rectum
*Melena + age <50 suggests upper GI bleed
**Usually represents lower GI bleeding
*Vomiting + retching followed by hematemesis = Mallory-Weiss
**May represent UGIB if bleeding is brisk
*Aortic graft = aortoenteric fistula
***Usually accompanied by hematemesis and hemodynamic instability
*Meds
*Melena
**ASA, steroids, NSAIDs, anticoagulants
**Usually represents bleeding from upper GI source
*ETOH abuse
**May represent bleeding from lower GI source due to slow bleeding
**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==
==DDX==
#Peptic ulcer disease (most common cause)
#Upper GI bleed
#Gastritis/esophagitis
#Diverticular disease
#Gastric/esophageal varices
#Colitis
#Mallory-Weiss Syndrome
##Infectious
#Stress ulcer
##Ischemic (90% of cases occur in age >70yo)
#Adenomatous polyps
#Malignancy
#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)
#Diverticulosis (painless, voluminous)
#Infectious (virus, bacteria, parasites, C. dif)
#Infectious (virus, bacteria, parasites, C. dif)
#Ischemic Colitis 3-12% (acute onset; 90% > 70yo)
#Ischemic Colitis 3-12% (acute onset; 90% > 70yo)
#IBD (fistula-in-ano)
#IBD (fistula-in-ano)
#Mesenteric Vascular Insufficiency (abd pain out of proportion to PE)
#Angiodysplasia
#Angiodysplasia
#Cancer/polyps
#Cancer/polyps
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#Abscess, prolapse, proctitis, impaction
#Abscess, prolapse, proctitis, impaction


===Peds===
===Consider===
#UGIB
#Proctoscopy (22cm from anal verge)
##Esophagitis
#Sigmoidoscopy (60cm from anal verge)
##Gastritis
#Angiography (requries arterial bledding >0.5cc/min)
##Ulcer
#CT angio
##Esophageal varices
##Mallory-Weiss
#LGIB
##Anal fissure
##Infectious colitis
##IBD
##Polyps
##Intussusception


==Disposition==
==Disposition==
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==Source ==
==Source ==
*Tintinalli
*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]]

Revision as of 22:55, 30 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 for bleeding is found in <50% of cases

Diagnosis

History

  • 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


DDX

  1. Upper GI bleed
  2. Diverticular disease
  3. Colitis
    1. Infectious
    2. Ischemic (90% of cases occur in age >70yo)
  4. Adenomatous polyps
  5. Malignancy


  1. Diverticulosis (painless, voluminous)
  2. Infectious (virus, bacteria, parasites, C. dif)
  3. Ischemic Colitis 3-12% (acute onset; 90% > 70yo)
  4. IBD (fistula-in-ano)
  5. Angiodysplasia
  6. Cancer/polyps
  7. Rectal dz
  8. Hemorrhoids
    1. External (below pectinate); Internal (above)
  9. Ulcer (HIV, syphilis, STDs)
  10. Fissures (painful defecation)
  11. Abscess, prolapse, proctitis, impaction

Consider

  1. Proctoscopy (22cm from anal verge)
  2. Sigmoidoscopy (60cm from anal verge)
  3. Angiography (requries arterial bledding >0.5cc/min)
  4. CT angio

Disposition

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

  • Tintinalli
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