Pspa.net



Initial approach to GI bleeding

– History/Physical

– Symptoms

– Upper GI bleed – hematemesis (coffee grounds vs frankly bloody), melena. Massive UGIB can have hematochezia. Presence of blood clots in stool is more likely LGIB

– Lower GI bleed – hematochezia most typical although right-sided colon lesions can present with melena.

– Orthostatic dizziness, confusion, angina, cool clammy extremities and/or severe palpitations suggest more severe bleeding

– Severe abdominal pain, especially if rebound tenderness or involuntary guarding present, concerning for perforation

– Past medical history

– ALWAYS ask about prior episodes of GI bleeding – up to 60% of UGIB patients are bleeding from same lesion as prior episode

– History of liver disease or alcohol abuse – r/o varices

– History of AAA or aortic graft – r/o aorto-enteric fistula

– History of renal disease, AS, HHT – r/o angiodysplasia

– History of H. pylori – r/o malignancy, PUD

– History of gastroenteric anastomosis – r/o marginal ulcer

– Also important for management, can increase risk of other complications (i.e. aspiration, volume overload, hypoxia, etc.)

– Medications

– Some medications predispose to PUD – NSAIDs, aspirin

– Pill esophagitis

– Predispose to bleeding – anticoagulation, anti-platelets

– Affect clinical presentation – i.e. iron or bismuth change stool color

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– Laboratory tests – check CBC, CMP, coagulation studies +/- cardiac enzymes

– Patients with acute bleed should have normocytic RBCs

– Monitor H&H every 2-8 hours during acute bleed depending on severity

– Microcytic RBCs or IDA suggest chronic blood loss

– BUN to creatinine ratio (in a patient with normal renal perfusion)

– Less than 20:1 suggests LGI source

– Greater than 20:1 suggests UGI source

– Consider serial EKGs if at risk for cardiac ischemia

– Role of nasogastric lavage – use if doubt about upper vs lower source or if need to remove material from the stomach to clear for endoscopy

– General principles of management

– If active bleeding or evidence of hemodynamic instability, admit to ICU

– Even patients admitted to med/surg floor should have EKG monitoring and pulse oximetry

– NPO, supplement O2, two large caliber IV catheters or central venous line

– If high risk for aspiration, consider elective endotracheal intubation

– Stabilize and resuscitate patient prior to endoscopic evaluation if possible

– Blood transfusion – individualized based on patient

– Avoid overtransfusion in variceal bleed → can worsen bleeding

– If active bleeding and INR > 1.5, consider FFP

– Do not have to delay endoscopy if INR ................
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