Divided into UGI (above Treitz's) or LGI (below Treitz's) bleeds.
- PUDs (most common)
- Esophageal and Gastric varices
- Erosive Gastritis ®NSAIDs, Steroids, Alcohol
- Gastric CA
- Aorto-enteric fistula
- UGI bleed
- Diverticula (most common cause of massive, painless LGI bleed)
- AV malformations/Vascular ectasias
- Mesenteric Ischemia (affects small bowel and may present with G(+)ve stools)
- Colonic Ischemia
- Acute infectious colitis
- In children consider intussusception and Meckel's diverticulum
S & S:
- N/V, coffee-ground emesis (UGI), dizziness, Melena (UGI) or BRBPR (hematochezia = LGI)
- Orthostatic. Pt on negative inotropic meds may not demonstrate hemodynamic changes.
- Pt may develop high output cardiac failure, angina, EKG changes c/w ischemia.
- Abdomen must be inspected for scars, caput medusae, distention, tenderness, organomegaly, masses, stool for occult blood.
- 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.
- 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
- 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.
- 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)
- Obtain EKG to R/O ischemia. If present transfuse STAT.
- EsophagoGastroDuodenoscopy - useful if UGI is suspected. Performed if hemodynamically stable. If bleed is active and obscures the exam consider Angiography (both diagnostic and therapeutic).
- 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.
- 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.
- Angiography - both localizes the exact area and vessel that bleeds and eventually treats the bleed. Detects bleed as rapid as 0.5ml/min.
- General Treatment:
Specific 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.
- 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
-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.