Gastro Intestinal BleedingBy: Abdulrahman Sindi

ED Resident

Case ScenarioA 55-year-old male not known to have any

medical illness, presented to the E.D. complaining of blood in his vomitus two times this day.

HR:120BP:95/60RR:22T:36.7

Is the patient stable? What should be done for this patient?What are initial steps in the management?

Epidemiology GI bleeding is relatively common problem

encountered in EDThe mortality rate is is approximately 10%UGIB affects 50-150 people per 100,000 each yearMean age of affected people with GIB is 59 yearsUGIB is more common in men, whereas LGIB is more

common in womenUGIB admission is more common in adults whereas

LGIB admission is more common in children

Differential Considerations

Differential ConsiderationsUpper LowerPeptic ulcer disease

diverticulosis

Gastric erosions

angiodysplasia

varices UGIBMallory-Weiss tear

Cancer/polyp

esophagitis Rectal diseaseduodenitis IBD

Upper Loweresophagitis Anal fissuregastritis Infectious

colitisulcer IBDEsophageal varices

polyps

Mallory-Weiss tear

intussusception

Adult Children

• In children less than 2 years of age massive LGIB is most often due to Meckels diverticulum or intussusception

Rapid Assessment and Stabilization

Patients with suspected GIB who are hemodynamically unstable should be stabilized and evaluated rapidly. Undress and place cardiac and oxygen saturation

monitors. Give supplemental oxygen. 2 large bore peripheral intravenous lines. Take blood for (CBC, PT, type and screen or crossmatch). Give bolus crystalloid. Give type O, type specific or crossmatched blood. Consult the GE in UGIB or surgeon in LGIB if persistently

unstable.

History Hematemesis:: vomiting of blood that occurs in

bleeding of the esophagus, stomach, or proximal bowel (50% in UGIB).

Melena: black tarry stool that results from the presence of 150-200 ml of blood for prolonged period (70% in UGIB and 33% in LGIB).

Hematochezia:

History Hematemesis: vomiting of blood that occurs in

bleeding of the esophagus, stomach, or proximal bowel (50% in UGIB).

Melena: black tarry stool that results from the presence of 150-200 ml of blood for prolonged period (70% in UGIB and 33% in LGIB).

Hematochezia: bright red blood in the stool that mostly occurs with LGIB but can occur in UGIB (66% in LGIB and 10-15% in UGIB).

History Duration, quantity, associated symptoms,

previous history, medications, alcohol, and associated medical illness

Physical ExaminationVitals: hypotension, tachycardia or postural

change in heart rate.General exam: general appearance, mental

status, skin signs and abdomin should be assessed carefully.

Rectal exam: it’s the key to confirm the diagnosis, it does not exclude the diagnosis if negative

Ancillary Testing Occult blood test: it may have positive result 14

days after a major bleed, it has a false positive and negative results,

Clinical labs: CBC, coagulation profile, type and screen and crossmatch

ECG: should be done to all patients over 50, preexisting cardiac insult, anemia, chest pain, S.O.B., persistent

Imaging: CXR if perforation is suspected

Management ReassuranceN.G. tube and gastric lavage:

Aspiration of bloody content diagnoses UGIB, but it does not determine if it is ogoing

False negative results are possible if if bleeding is intermittent, in duodenal bleed, pyloric spasm.

False positive occurs in nasal bleeding.The presence of bile in excludes the possibility of

UGIB.Gastric lavage is helpful to prepare for endoscopyLavage should not performed in pneumoperitoneum.

Management Anoscopy/proctosigmoidoscopy.Endoscopy:

It identifies lesion in 78% to 95% if done within 12 to 24 hours.

Angiography and tagged RBC scan:Angiography is commonly used in LGIBDetects 40% of LGIB site. It is performed ideally in active bleeding. In undetected bleeding tagged RBC scan is

performed.

Management Proton pump inhibitorsOctreotideVasopressinSengstaken-Blakmore Tube:

Stops bleeding in 80% of esophageal varices. Indicated when endoscopy is not readily available and

vasopressin has not slowed the bleeding.Surgery:

Indicated in for all hemodynamically unstable with active bleeding unresponsive to resuscitation

Stengstaken-Blackmore Tube

DispositionVery low criteria for GIB patients

No comorbid diseaseNormal vitalsNegative guaiac testNegative gastric aspirationNormal hemoglobin/hematocritProper understanding for signs and symptoms Immediate access to ERArranged follow up within 24 hours

Risk Stratification

Risk Stratification

L

Thank YouBy Dr. Abdulrahman Sindi