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Acute Gastrointestinal HemorrhageIntroductionMedical emergencyCommon complication of critical illnessBleeding from upper or lower GI tractLigament of Treitz: (suspends the intestines and is attached to the diaphragm)Bleeding proximal to ligament: Upper GIEsophagus, Stomach, and DuodenumPUD, SRES, Varices, Mallory Weiss TearsBleeding distal to ligament: Lower GIJejunum, Ileum, Colon, and RectumDiverticula, Cancer, Inflammatory diseaseGastric Parietal and Mucous CellsParietal cells make hydrochloric acidMucus creates the barrier that protects our stomachsFunctions of Gastric Parietal CellsParietal Cells– forms HCl AcidBreaks down food and protein bondspH in the stomach is low (acidic), about 1.5 to 2 from the hydrochloric acid. Need proton pump to push new hydrochloric acid into the already acidic environment of the stomach. An H2 inhibitor slows production of hydrochloric acid, PPI prevents transport into the stomachFunctions of Gastric Mucous CellsGlycoprotein mucus - forms gelMaintains mucosal-luminal pH gradientEpithelial mucous cells - secretes bicarbonateAugments action of glycoprotein mucusEpithelial cell structureProtects against damage of gastric secretionsEtiology of Upper GI BleedPeptic Ulcer Disease (PUD)PathoBreakdown of gastro-duodenal mucosa gastric secretions auto-digest layers of stomach damages blood vessels hemorrhagePrimary CausesNSAIDSHelicobacter pyloriBacteria from food, contaminatedLikes to get into the stomach and lives in the mucousal lining, acts as an agent that penetrates the epithelial layer, lets the acid come in and deteriorate the liningStress-Related Erosive Syndrome (SRES)PathoStress ulcerDevelop rapidly within hoursLimited to the stomachPrimary Causes: Increased acid productionDecreased mucosal blood flowHigh Risk Patients:Post-op, Trauma, Shock, Burns (very susceptible), Acute Neurological Disease Esophageal VaricesPortal hypertensionVessels become engorged and dilated (varices) vulnerable to damage from gastric secretions rupture and hemorrhageEtiology of Lower GI BleedDiverticulaPathoSac-like herniation of the lining of the small intestine or colon - Sigmoid Colon most commonHigh fat-Low fiber diet lead to weakening of liningLeads to inflammation, bleeding, perforationCaused by high fat / low fiber dietComplication of this is the diverticula perforating AssessmentTo Take away from this slide: HR. RR. urine output. Hypotensive. Confused. Lethargic. Skin: Cool & paleAssess Type of BleedingUpper GI Bleed S/SHematemesis (two kinds) Bright red: Profuse bleeding ( acid contact)Varicies Coffee-ground: Slow bleed ( acid contact) Gastric acid converts bright red hemoglobin to brown hematin PUD Melena Digestion of blood from an upper GI bleed May take several days to clear after the bleeding has stoppedLooks like tar Lower GI Bleed S/SHematocheziaMassive lower GI hemorrhageBlood in GI tract increases peristalsis and diarrheaRed colored Blood streaked stoolHemorrhoids – aka “Piles”If the guaiac strip turns blue, it means it’s positive for blood. Give calcium gluconate for low Ca levels after the 3rd transfusionHyperkalemia: low or high pulse rate, tall t waves, the pt be restless and weakDiagnostic Procedures (don’t focus on these, just be aware)EndoscopyPatient must be hemodynamically stableArea to be visualized should be cleared of bloodTagged RBC or angiogramDone if endoscopy fails to identify source of bleedingWireless Capsule EndoscopyCan evaluate the areas of the small intestineManagement Control/Stop BleedingProcedures for bleeding in PUDEndoscopic thermal therapyEndoscopic injection therapyInjecting NS theory behind it is that it puts so much pressure on the vessels it occludes it and it stops bleedingVagotomy and pyloroplasty Vagotomy means they cut the vagas nerve, to stop the production of acetylcholineProcedures for bleeding in SRESIntraarterial injectionTotal gastrectomy Oversew ulcersMedications for bleeding in VaricesSomatostatin (GHI) / Octreotide (Sandostatin): Used in combination to reduce portal HTN Vasopressin (Pitressin): Constricts splanchnic arterial bed reducing portal HTNBeta blockers: Reduce portal HTN - Prophylactic treatment of varices; *Not for Acute BleedingBalloon TamponadeHigh risk of airway compromise - Occlusion/AspirationGastric PerforationMedical EmergencySudden, severe, generalized abdominal pain, rebound tenderness and rigidityRemember abd rigidityFever, leukocytosis, persistent tachycardiaStabilizationIV fluids: Crystalloids, Blood, Blood productsHb: 7 gm/dL & Hct: 21%How many units of PRBC would be needed to raise the client’s Hb to 9 gm/dL & Hct to 27%?2 units of PRBC : Hb 9 gm/dL & Hct: 27%. Central lineSupplemental oxygenIntubation: Decrease risk for aspirationLarge-bore NG tube: Gastric lavage Urinary catheter: Monitor urine outputNotes from bottom of slideGive IV fluids first! The bleeding is the problem, not the lack of O2. You’ll eventually give them O2, but they must be fluid resuscitated first If a person has esophageal varices, you don’t necessarily want to put an NG tube in, but you have to because you have to get the blood out of their gut. Gastric lavage: the dr will tell you to lavage til clear with room temp water. They used to use ice water to do this because of the vasoconstriction properties of the cold. But that does something about making them alkalotic (shift to the left, which is bad). All the vessels constrict, but the constricted cells don’t use oxygen as easily. Prophylactic and TreatmentAntacids - (1-3 hrs after meals and bedtime) Work on pHHelicobacter pylori - (PUD, SRES)Antibiotics - Amoxicillin, Flagyl, TetracyclineWork on bacteria causing the problemH2 Receptor AntagonistsTagamet, Pepcid, ZantacWork on reducing production of acidProton Pump Inhibitors - (Parietal Cells) Protonix, Nexium, Prilosec Slow the transport of HCl downProstaglandin E - (Mucous Cells) Cytotec (Increases HCO3, mucous)Carafate (Gastric acid Barrier)Work on mucous cells, increasing bicarbNursing ManagementAssess Gastric Fluid:pH monitoring: keep pH > 4Litmus paper or direct NG tube probes Monitor: Presence of bright-red or coffee-ground emesis. Bloody NG aspirate. Bright-red, black, or dark-red stools Gastric Lavage:Large-bore NG tube. Irrigate (“Clear” return solution)Water vs. Normal salineRoom temperature solutions vs. ice cold solutionsDocument amount instilled and aspirated ................
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