Gastrointestinal bleeding

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Workup

ER

0) 2 large bore IV

1) Icon

2) CBC & serial Hb

3) Chem 7 (BUN/Cr >35 suggests UGI if no hx of RF)

4) T&S/T&C

5) Coags (if INR > 1.5 transfuse FFP)

6) ?Guiac

7) LFTs/lipase

8) *CXR if sx perf (diff TTP abd)

9) *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

-Proctoscopy (22cm from anal verge)

-Sigmoidoscopy (60cm from anal verge)

-Angiography (requries arterial bledding >0.5cc/min)

-CT angio

DDX

Adult

-UGIB-

PUD (Gastric 21%, Duodenal 24%)

Gastritis 23%

Esophagitis/Duodenitis 6%

Varicies

Mallory-Weiss < 15%

Boerhaave's

Dieulafoy lesion

Angiodysplasia

Hemobilia

Aortoenteric fistula


-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

IBDPolyps

Intussusception


Disposition

Blatchford score

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

3/12/06 DONALDSON (adapted from Rosen), Kaji