GI BLEED

 

Etiology:

Divided into UGI (above Treitz's) or  LGI (below Treitz's) bleeds.

UGI BLEED:

  1. PUDs (most common)
     
  2. Esophageal  and Gastric varices
     
  3. Mallory-Weiss
     
  4. Erosive Gastritis NSAIDs, Steroids, Alcohol
     
  5. Gastric CA
     
  6. Aorto-enteric fistula

LGI BLEED:

  1. UGI bleed
     
  2. Diverticula (most common cause of massive, painless LGI bleed)
     
  3. AV malformations/Vascular ectasias
  4. CA
     
  5. Hemorrhoids
     
  6. Mesenteric Ischemia (affects small bowel and may present  with G(+)ve stools)
  7. Colonic Ischemia
     
  8. Acute infectious colitis
     
  9. IBD
     
  10. In children consider intussusception and Meckel's diverticulum

S & S:

  1. N/V, coffee-ground emesis (UGI), dizziness, Melena (UGI) or BRBPR (hematochezia = LGI)
     
  2. Orthostatic. Pt on negative inotropic  meds may   not demonstrate hemodynamic changes.
  3. Pt may develop high output cardiac failure, angina, EKG changes c/w  ischemia.
     
  4. Abdomen must be inspected for scars, caput medusae, distention, tenderness,  organomegaly, masses, stool for occult blood.

DX: 

  1. Guaiac exam: reliable for stool  testing in case of  LGI bleed. Is unreliable in gastric lavage aspirate (UGI) since the gastric acidic pH and ingested food interferes with Hematoccult.
            
  2. NG lavage is commonly positive if  UGI bleed, but may as well be negative if bleed  subsided or if this is very distal bleed (duodenum). Also it is mandatory to notice bile in lavage and if present, indicates UGI bleed.
     
  3. Avoid NG tube if suspicion of varices exists. Many will disagree with this statement, yet I believe that if one suspects varices to be the cause of bleed , NGT has no place and endoscopy should be employed.
     
  4. SMA commonly will show BUN. CBC may initially show normal Hct. Hct generally  falls by  2-3 points q 500 ml of blood. Obtain LFT's and Coags (may be a clue to  bleed)
     
  5. Obtain EKG to R/O ischemia. If present transfuse STAT.
     
  6. EsophagoGastroDuodenoscopy - useful if UGI is suspected. Performed if hemodynamically stable. If bleed is active and obscures the exam consider Angiography  (both diagnostic and therapeutic).
     
  7. FlexSigmoidoscopy ( followed by Colonoscopy if the prior not diagnostic) - useful for LGI. This is performed on a pt that is hemodynamically stable. If bleed is active - Angio or Tc 99.
     
  8. Tc-99m labeled RBC (bleeding scan)-is the first choice tool for dx of distal bleed. Detects bleeds as slow as  0.1ml/min. It identifies the segment of colon that bleeds. If this is positive do Angiograph. If negative - Colonoscopy. 
  9. Angiography - both localizes the exact area and vessel that bleeds and eventually treats the bleed. Detects bleed as rapid as 0.5ml/min.

Treatment:

  1. General Treatment:
     
    • O2, IVF via two large bore IVs.
    • Cardiac monitor
    • Transfuse PRBC (and/or FFP if pt is on anticoagulants) as indicated by CBC, VS, EKG.
       
  2. Specific Treatment :   
    • IV H2 blockers or PO PPIs- for UGI bleeders
    • Antbx as a prophylaxis in case of UGI bleed 2ry to varices.
    • Vit K and FFP - for pt who has INR
    • Vasopressin - its use is controversial but can be used in case of variceal bleed. Give as 100 U in 250 D5 @ u/min with increments of  0.3 u/min q 30 min until hemostasis is achieved. Concomitantly IV Nitro or b -Blockers are given.                         
    • EGD with injection or Balloon  tamponade - for varices
    • Consider ICU admission  if  PRBC transfusion required, if Hct continues to drop,  or if pt's overall condition (hx of CHF, angina) needs more intense monitor.
    • Consult Surgery  for  uncontrolled  bleed, ruptured esophagus, mesenteric ischemia.

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