Transcript Gastrointestinal Bleeding

Gastrointestinal Bleeding
Case…
 Hassan is 45 y/o saudi gentleman,
presents to ED at KKUH early morning,
C/O vomiting blood.
 How would you approach?
 How would you manage?
Gastrointestinal Bleeding
PERSPECTIVE
Epidemiology
o Gastrointestinal (GI) bleeding is a relatively
common problem countered in emergency
medicine
that
often
requires
early
consultation and hospital admission.
Gastrointestinal Bleeding
o The overall mortality rate for GI bleeding is
approximately 10% and has not changed
significantly since the 1960s.
o Diagnostic modalities have improved much
more than therapeutic techniques.
Gastrointestinal Bleeding
o GI bleeding is often easy to identify when
there is clear evidence of vomiting blood or
passing blood in the stool, but the clinical
presentation may be subtle, with signs and
symptoms of hypovolemia, such as
dizziness, weakness, or syncope.
Gastrointestinal Bleeding
o The approach to GI bleeding depends on
whether the hemorrhage is located in the
proximal or the distal segment of the GI tract
(i.e., upper or lower GI bleeding).
o These segments are anatomically defined by
the ligament of Treitz in the duodenum.
Gastrointestinal Bleeding
o Lower GI bleeding (LGIB) affects a smaller
portion of patients and results in
proportionally fewer hospital admissions than
UGIB.
Gastrointestinal Bleeding
o GI bleeding can occur in persons of any age
but most commonly affects people in their
40s through 70s (mean age, 59 years).
o Most deaths caused by GI bleeding occur in
patients older than 60 years. UGIB is more
common in men than in women (in a 2 : 1
ratio), whereas LGIB is more common in
women.
Gastrointestinal Bleeding
o Significant UGIB requiring admission is more
common in adults, whereas LGIB requiring
admission is more common in children.
Gastrointestinal Bleeding
DIAGNOSTIC APPROACH
Differential Considerations
o Peptic ulcer disease, gastric erosions, and
varices account for approximately three
fourths of adult patients with UGIB.
Gastrointestinal Bleeding
o Diverticulosis and angiodysplasia account for
approximately 80% of adults with LGIB. In
children, esophagitis, gastritis, and peptic
ulcer disease are the most common causes
of UGIB, and infectious colitis and
inflammatory bowel disease are the most
common causes of LGIB.
Gastrointestinal Bleeding
o In children younger than 2 years of age,
massive LGIB is most often a result of
Meckel’s diverticulum or intussusception.
o At all ages, anorectal abnormalities are the
most common cause of minor LGIB.
Gastrointestinal Bleeding
o Despite improved diagnostic techniques, no
source of bleeding is identified in
approximately 10% of patients with GI
bleeding.
o In patients with abdominal aortic grafts who
present to the emergency department (ED)
with GI bleeding, the possibility of
aortoenteric fistula should be considered.
Gastrointestinal Bleeding
o Prompt surgical consultation in the ED
should be obtained if this is suspected,
because bleeding can be massive and fatal.
Gastrointestinal Bleeding
Rapid Assessment and Stabilization
o Most patients with GI bleeding are easy to
diagnose because they present to the ED
complaining of vomiting blood or passing
black or bloody stool.
o The diagnosis is confirmed quickly by
examination of the stool for the presence of
blood.
Gastrointestinal Bleeding
o Patients with suspected GI bleeding who are
hemodynamically unstable should undergo
rapid evaluation and resuscitation.
o They should be undressed quickly to permit
placement of cardiac and oxygen saturation
monitors, and supplemental oxygen should
be given as needed.
Gastrointestinal Bleeding
o At
least
two
large-bore
peripheral
intravenous lines should be placed (minimum
18-gauge); blood should be drawn for
hemoglobin or hematocrit, platelet count,
prothrombin time (PT), and type and screen
or type and crossmatch studies; and
crystalloid resuscitation should be initiated.
Gastrointestinal Bleeding
o Intravenous crystalloid fluid should be given
as a 2-L bolus in adults or 20 mL/kg in
children until the patient’s vital signs have
stabilized or the patient has received 40
mL/kg of crystalloid in an adult or 60 mL/kg
as a child.
Gastrointestinal Bleeding
o Patients who remain unstable after 40 to 60
mL/kg of crystalloid should be given type O,
type-specific, or cross matched blood,
depending on availability.
o Persistently unstable patients should receive
immediate
consultation
with
a
gastroenterologist for UGIB and with a
surgeon for LGIB.
Gastrointestinal Bleeding
o History, physical examination, testing a stool
sample for blood, and measuring hemoglobin
or hematocrit are the keys to diagnosing GI
bleeding in most patients.
Gastrointestinal Bleeding
History
o Patients typically complain of vomiting red
blood or coffee grounds–like material, or
passing black or bloody stool.
o Hematemesis (vomiting blood) occurs with
bleeding of the esophagus, stomach, or
proximal small bowel.
Gastrointestinal Bleeding
History
o Approximately 50% of patients with UGIB
present with this complaint.
o Hematemesis may be bright red or darker
(i.e., coffee grounds–like) as a result of the
conversion of hemoglobin to hematin or other
pigments by hydrochloric acid in the
stomach.
Gastrointestinal Bleeding
o The color of vomited or aspirated blood from
the stomach does not differentiate between
arterial and venous bleeding.
o Melena, or black tarry stool, will result from
the presence of approximately 150 to 200 mL
of blood in the GI tract for a prolonged
period.
Gastrointestinal Bleeding
o Melena is seen in approximately 70% of
patients with UGIB and in one third of
patients with LGIB.
o Black stool that is not tarlike may result from
presence of 60 mL of blood from the upper
GI tract. Blood from the duodenum or
jejunum must remain in the GI tract for
approximately 8 hours before turning black.
Gastrointestinal Bleeding
o Occasionally, black stool may follow bleeding
into the lower portion of the small bowel and
ascending colon.
o Stool may remain black and tarry for several
days, even though bleeding has stopped.
Gastrointestinal Bleeding
o Hematochezia, or bloody stool (bright red or
maroon), most often signifies LGIB but may
be due to a brisk UGIB with rapid transit time
through the bowel in 10 to 15% of patients.
o Because UGIB is much more common than
LGIB, a more proximal source of significant
bleeding must be excluded before assuming
the bleeding is from the lower GI tract.
Gastrointestinal Bleeding
o Approximately two thirds of patients with
LGIB present with red blood from bleeding
per rectum.
o Small amounts of red blood (e.g., 5 mL) from
rectal bleeding, such as bleeding due to
hemorrhoids, may cause the water in the
toilet bowl to appear bright red.
Gastrointestinal Bleeding
o Bright red stools also can be seen after
ingestion of a large quantity of beets; in this
case, Hemoccult testing would be negative
and the patient also will report pink colored
water in the toilet bowl.
Gastrointestinal Bleeding
o In taking the history, specific questions
should address the duration and quantity of
bleeding, associated symptoms, previous
history of bleeding, current medications,
alcohol, nonsteroidal anti-inflammatory drug
use and long-term aspirin ingestion, allergies,
associated medical illnesses, previous
surgery, treatment by nonhospital personnel,
and the response to that treatment.
Gastrointestinal Bleeding
o Patients with GI bleeding may report
symptoms of hypovolemia, such as
dizziness,
weakness,
or
loss
of
consciousness, most often after standing up.
o Other
nonspecific
complaints
include
dyspnea, confusion, and abdominal pain.
Gastrointestinal Bleeding
o Rarely an elderly patient may present with
ischemic chest pain precipitated by
significant anemia due to a GI bleed.
o One in five patients with GI bleeding may
have only nonspecific complaints.
Gastrointestinal Bleeding
o The history is of limited help in predicting the
site or quantity of bleeding.
o Patients with a previously documented GI
lesion bleed from the same site in only 60%
of cases.
Gastrointestinal Bleeding
o Gross estimates of blood loss based on the
volume and color of the vomitus or stool
(e.g., brown or black, pink or red) or the
number of episodes of hemorrhage are
notoriously inaccurate.
Gastrointestinal Bleeding
Physical Examination
o Vital Signs Vital signs and postural changes
in heart rate and blood pressure have been
used to assess the amount of blood loss in
patients with GI bleeding but are insensitive
and nonspecific, with the exception of
significant, sustained heart rate increase and
hypotension.
Gastrointestinal Bleeding
o All patients with a history suggesting GI
bleeding
who
are
hypotensive,
are
tachycardic,
or
experience
sustained
posture-induced changes in heart rate of
greater than 20 beats per minute should be
assumed to have a significant hemorrhage.
Gastrointestinal Bleeding
o Normal vital signs do not exclude a
significant
hemorrhage,
and
postural
changes in heart rate and blood pressure
may occur in individuals who are not
bleeding (e.g., elderly patients, many normal
individuals,
individuals
on
certain
medications
such
as
beta-blockers,
individuals with hypovolemia from other
causes).
Gastrointestinal Bleeding
o General
Examination
The
physical
examination is valuable in establishing a
specific diagnosis and assessing the severity
of blood loss and the physiologic response to
that loss.
Gastrointestinal Bleeding
o Careful attention is given to the patient’s
general appearance, vital signs, mental
status (including restlessness), skin signs
(e.g., color, warmth, and moisture to assess
for shock, or presence of lesions such as
telangiectasia, bruises, or petechiae to
assess
for
vascular
diseases
or
hypocoagulable states), pulmonary and
cardiac findings, abdominal examination, and
rectal and stool examination.
Gastrointestinal Bleeding
o Frequent reassessment is important because
a patient’s status may change quickly.
Gastrointestinal Bleeding
o Rectal Examination Rectal and stool
examinations are often key to making or
confirming the diagnosis of GI bleeding.
o The finding of red, black, or melenic stool
early in the assessment is helpful in
prompting early recognition and management
of patients with GI bleeding.
Gastrointestinal Bleeding
o The absence of black or bloody stool,
however, does not exclude the diagnosis of
GI bleeding.
o Regardless of the apparent character and
color of the stool, occult blood testing is
indicated.
Gastrointestinal Bleeding
Ancillary Testing
o Tests for Occult Blood The presence of
hemoglobin in occult amounts in stool is
confirmed by tests such as
( Hemoccult,
HemaPrompt).
o Stool tests for occult blood may have positive
results 14 days after a single, major episode
of UGIB.
Gastrointestinal Bleeding
o False-positive results have been associated
with the ingestion of certain fruits (e.g.,
cantaloupe, grapefruit, figs), uncooked
vegetables (e.g., radish, cauliflower, broccoli)
and red meat, methylene blue, chlorophyll,
iodide,
cupric
sulfate,
and
bromide
preparations.
Gastrointestinal Bleeding
o False-negative results are uncommon but
can be caused by bile or ingestion of
magnesium containing antacids or ascorbic
acid.
o Tests to evaluate gastric contents for occult
blood (e.g., Gastroccult) can be unreliable
and should not be used for this purpose.
o In newborns, maternal blood that is
swallowed may cause bloody stools; the Apt
test may show that it is maternal in origin.
Gastrointestinal Bleeding
o Clinical Laboratory Tests Blood should be
drawn for evaluation of baseline hematocrit
or hemoglobin, coagulation studies (PT and
platelet count), and type and crossmatch
studies (or type and screen studies if the
patient is stable).
o The initial hematocrit may be misleading in
patients with preexisting anemia or
polycythemia.
Gastrointestinal Bleeding
o Changes in the hematocrit may lag
significantly behind actual blood loss.
Infusion of normal saline speeds equilibration
of the hematocrit; however, rapid infusion of
crystalloid in nonbleeding patients also may
cause a decrease in hematocrit by
hemodilution.
Gastrointestinal Bleeding
o In general, patients with a hemoglobin
concentration of 8 g/dL or less (hematocrit
<25%) from acute blood loss usually require
blood therapy.
o After transfusion and in the absence of
ongoing blood loss, the hematocrit can be
expected to increase approximately 3% for
each unit of blood administered (hemoglobin
level increases by 1 mg/dL).
Gastrointestinal Bleeding
o The PT should be used to determine whether
a patient has a preexisting coagulopathy.
o An elevated PT may indicate vitamin K
deficiency, liver dysfunction, warfarin therapy,
or consumptive coagulopathy.
Gastrointestinal Bleeding
o Patients receiving therapeutic anticoagulants
or patients with an elevated PT and evidence
of active bleeding should receive sufficient
fresh frozen plasma to correct the PT.
o Serial platelet counts are used to determine
the need for platelet transfusions (i.e., less
than 50,000/mm3).
Gastrointestinal Bleeding
o Blood Bank Blood should be sent for “type
and hold” or type and crossmatch studies
early in the patient’s care.
o Immediate transfusion needs in unstable
patients can be met with O-positive packed
red blood cells (O-negative packed red blood
cells in women of childbearing age whose Rh
status is unknown).
Gastrointestinal Bleeding
o Type-specific blood is usually available within
10 to 15 minutes.
o Group O blood and type-specific blood are
safe for patients and cause few transfusion
reactions.
Gastrointestinal Bleeding
o Fully crossmatched blood may take 60
minutes to prepare.
o Stable patients can be managed more costeffectively by ordering “type and hold” without
crossmatching for units of blood.
Gastrointestinal Bleeding
o Other Laboratory Tests Electrolytes usually
are normal in patients with GI bleeding.
o However, determination of electrolytes, blood
urea nitrogen, and creatinine may be useful
in a small percentage of patients with GI
bleeding when indicated.
Gastrointestinal Bleeding
o For example, in patients with repeated
vomiting, hypokalemia, hyponatremia, and
metabolic alkalosis may develop, which
usually correct with adequate hydration and
the resolution of vomiting.
Gastrointestinal Bleeding
o Patients with shock often have metabolic
acidosis from lactate accumulation. The
blood urea nitrogen is elevated in many
patients with UGIB as a result of the
absorption of blood from the GI tract and
hypovolemia causing prerenal azotemia.
Gastrointestinal Bleeding
o Electrocardiogram An electrocardiogram
(ECG) should be obtained in all patients with
a GI bleed who are older than 50 years of
age or have preexisting ischemic cardiac
disease, significant anemia, or chest pain,
shortness
of
breath,
or
persistent
hypotension.
Gastrointestinal Bleeding
o Asymptomatic myocardial ischemia (ST
segment depression greater than 1 mm) or
injury (ST segment elevation greater than 1
mm) may develop in the setting of GI
bleeding.
Gastrointestinal Bleeding
o Patients with GI bleeding and clinical or ECG
evidence of myocardial ischemia should
receive packed red blood cells as soon as
possible, as well as appropriate treatment for
myocardial ischemia.
Gastrointestinal Bleeding
o Imaging GI hemorrhage is not an indication
for plain abdominal radiography.
o An upright chest radiograph should be
obtained in patients with UGIB suspected of
aspiration or with signs and symptoms of
bowel perforation (shock with significant
abdominal or peritoneal tenderness).
Gastrointestinal Bleeding
o Subdiaphragmatic air consistent with bowel
perforation is a rare finding with UGIB, but it
is an indication for immediate surgical
consultation and operative repair.
Gastrointestinal Bleeding
DIFFERENTIAL DIAGNOSIS
o Not all patients complaining of vomiting blood
or passing blood in the stool have GI
bleeding.
o Swallowing blood during epistaxis or from the
oral cavity may cause hematemesis or
melena.
Gastrointestinal Bleeding
o Red vomitus may be due to food products
(e.g., Jell-O, tomato sauce, wine), and black
stool may be due to iron therapy or bismuth
(e.g., Pepto-Bismol).
Gastrointestinal Bleeding
o Hypovolemia (and its symptoms) may be due
to vomiting and diarrhea without bleeding.
o Poor oral intake with or without fever also
may result in hypovolemia.
o Usually
the patient’s hemoglobin or
hematocrit is normal or elevated until
hemodilution can occur.
Gastrointestinal Bleeding
o There are many causes of anemia other than
GI bleeding.
o In the absence of suggestive symptoms or
blood in the stool, GI bleeding is less likely to
be the cause of observed anemia.
Gastrointestinal Bleeding
MANAGEMENT
o Quick identification, aggressive resuscitation,
risk stratification, and prompt consultation are
the keys to appropriate emergency
management.
o When the diagnosis of GI bleeding is made,
emergency management of patients can
proceed.
Gastrointestinal Bleeding
Reassurance
o Patients who present to the ED with
symptoms and signs of GI bleeding are often
frightened by their symptoms.
o They may be concerned about the possibility
of painful procedures and of the real or
perceived risk of death.
Gastrointestinal Bleeding
o These patients and their families should be
treated in a supportive and reassuring
manner.
o They should be provided with accurate
information about their problem, and all
aspects of the care they are receiving should
be explained in a way that they understand.
Gastrointestinal Bleeding
o After initial resuscitation of the patient, it is
important to identify whether the hemorrhage
is proximal or distal to the ligament of Treitz
(i.e., UGIB or LGIB).
o If the patient’s vomitus demonstrates blood,
then the diagnosis of UGIB is confirmed.
Gastrointestinal Bleeding
o If a patient reports bloody or “coffee grounds”
emesis or if melenic stool is present, an
upper GI bleed is more likely.
o Placement
of a nasogastric (NG) tube
formerly was widely undertaken in the belief
that it had both diagnostic and therapeutic
benefit.
Emergency management of patients with gastrointestinal bleeding. ED, emergency department; IV,
intravenous; LGIB, lower gastrointestinal bleeding; UGIB, upper gastrointestinal bleeding.
Gastrointestinal Bleeding
o In patients who have hematochezia, an
upper GI origin for the bleeding often is
associated with signs and symptoms of
shock, because rapid transit time of large
quantities of blood is producing the
hematochezia.
Gastrointestinal Bleeding
o Because up to 10 to 15% of patients with
hematochezia have UGIB, it has been
recommended that an NG tube be inserted in
most cases of LGIB, but there is no evidence
to support an improved outcome related to
this practice.
Gastrointestinal Bleeding
o Typically, a clinical decision is made
regarding the likelihood of an upper versus
lower GI origin for the bleeding, and
endoscopy is then performed based on that
determination.
o If the first endoscopy approach fails to
identify the bleeding site, often endoscopy of
the other end of the GI tract is necessary.
Gastrointestinal Bleeding
Anoscopy/Proctosigmoidoscopy
o Patients with mild rectal bleeding who do not
have obviously bleeding hemorrhoids should
undergo anoscopy or proctosigmoidoscopy.
o If bleeding internal hemorrhoids are
discovered, and the patient does not have
portal hypertension, the patient may be
discharged with appropriate treatment and
follow-up evaluation for hemorrhoids.
Gastrointestinal Bleeding
o If hemorrhoids are not detected, it is
important to determine if the stool above the
rectum contains blood.
o The absence of blood above the rectum in a
patient who is actively bleeding indicates that
the source of bleeding is in the rectum.
Gastrointestinal Bleeding
o The presence of blood above the anoscope
or sigmoidoscope does not invariably
indicate a proximal source of bleeding,
because retrograde passage of blood into the
more proximal colon commonly occurs.
o Such patients need further evaluation.
Gastrointestinal Bleeding
Endoscopy
o Endoscopy is the most accurate diagnostic
tool available for the evaluation of UGIB.
o It identifies a lesion in 78% to 95% of patients
with UGIB if it is performed within 12 to 24
hours of the hemorrhage.
o Accurate identification of the bleeding site
allows for risk stratification with respect to
predicting rebleeding and mortality.
Gastrointestinal Bleeding
o Endoscopy-based triage significantly reduces
o hospitalization rates and costs of treating
upper GI bleeding.
o Significant
advances
in
endoscopic
hemostasis also make it of therapeutic value
in select patients (e.g., for banding or
sclerosing of varices).
o Colonoscopy is an effective tool for diagnosis
and selected treatment of LGIB.
Gastrointestinal Bleeding
Angiography and Tagged Red Blood
o Cell Scan Angiography can detect the
location of UGIB in two thirds of patients
studied.
o Since the advent of endoscopy, however, the
use of angiography has decreased
significantly, and today angiography is used
in only 1% of patients with UGIB.
Gastrointestinal Bleeding
o Angiography is used more commonly in
patients with LGIB and usually in consultation
with a general surgeon.
o Although angiography rarely diagnoses the
cause of bleeding, it does identify the site of
bleeding in approximately 40% of patients
who have LGIB and in 65% of patients who
eventually require surgical intervention.
Gastrointestinal Bleeding
o Angiography ideally is performed during
active bleeding; this may be apparent from
persistently unstable vital signs or continued
transfusion requirements to establish or
maintain
an optimal
hematocrit level.
hemoglobin
or
Gastrointestinal Bleeding
o Arterial embolization can be used in selected
cases of LGIB.
o In some patients with more indolent or
elusive bleeding, a nuclear isotope–tagged
red blood cell scan, usually performed from
the inpatient unit, may identify the bleeding
site.
Gastrointestinal Bleeding
Gastric Acid Secretion Inhibition
o All patients with peptic ulcer disease
documented by endoscopy should receive
therapy with a proton-pump inhibitor (e.g.,
omeprazole).
o There is no documented benefit to initiating
this
therapy
or
administering
H2
antihistamines in the ED for patients with
UGIB, however.
Gastrointestinal Bleeding
Octreotide (Somatostatin Analogues)
o Patients with documented esophageal
varices and acute upper GI bleeding should
receive an intravenous infusion of octreotide
at 25–50 μg/hour for a minimum of 24 hours
while being observed in the intensive care
unit (ICU).
Gastrointestinal Bleeding
o Octreotide is a useful addition to endoscopic
sclerotherapy and decreases rebleeding
occurrences.
o Octreotide may also reduce the incidence of
lower
GI
rebleeding
angiodysplasia.
secondary
to
Gastrointestinal Bleeding
Vasopressin
o Intravenous vasopressin has been used in
the treatment of UGIB, most commonly in
patients with variceal hemorrhage.
o Controlled studies have not shown a positive
effect of vasopressin on overall mortality,
however.
Gastrointestinal Bleeding
o These results, combined with a relatively
high rate of serious complications (9% major
o and 3% fatal), suggest that
vasopressin should be limited.
use
of
o A trial of vasopressin may be warranted in an
exsanguinating patient with suspected
variceal bleeding, especially if endoscopy is
not immediately available.
Gastrointestinal Bleeding
o The recommended dose of vasopressin is 20
units given intravenously over 20 minutes
and then 0.2 to 0.4 unit per minute.
o Consultation with a gastroenterologist is
advisable.
Gastrointestinal Bleeding
Sengstaken-Blakemore Tube
o Placement of a Sengstaken-Blakemore tube
stops hemorrhage in approximately 80% of
patients bleeding from esophageal varices.
o The Linton tube may be superior to the
Sengstaken-Blakemore tube in patients with
bleeding gastric varices; however, either of
these tubes is rarely used.
Gastrointestinal Bleeding
o In general, these tubes should not be used
without endoscopic documentation of the
source of bleeding because complications
are common and significant (14% major, 3%
fatal).
Gastrointestinal Bleeding
o A trial of balloon tamponade should be
considered, however, in an exsanguinating
patient with probable variceal bleeding in
whom endoscopy is not immediately
available and vasopressin has not slowed the
hemorrhage.
o Consultation
with
a
surgeon
or
gastroenterologist is advisable.
Gastrointestinal Bleeding
Surgery
o Surgery is indicated for all hemodynamically
unstable patients with active bleeding who do
not respond to appropriate intravascular
volume replacement, correction of any
coagulopathy, and endoscopic intervention (if
available).
o The mortality rate for patients undergoing
emergency procedures for GI bleeding is
approximately 23%.
Gastrointestinal Bleeding
o Generally, surgery is indicated whenever the
risk of ineffective medical therapy and
continued hemorrhage outweighs that of
surgical morbidity and mortality.
Gastrointestinal Bleeding
o Emergency surgical consultation should be
considered when blood replacement exceeds
5 units within the first 4 to 6 hours or when 2
units of blood is needed every 4 hours (after
replacement of initial losses) to maintain
normal cardiac output.
Gastrointestinal Bleeding
DISPOSITION
Risk Stratification
o Risk
stratification
involves
combining
historical, clinical, and laboratory data to
determine the risk of death and rebleeding in
patients presenting to an ED with GI
bleeding.
Gastrointestinal Bleeding
o Patients can be sorted into four risk
categories: very low, low, moderate, and high
risk.
o Some patients present to the ED with a
vague complaint of vomiting blood or passing
blood from the rectum in whom detailed
history and examination allows a diagnosis of
hemorrhoid, or anal fissure, or there may be
little or no objective evidence of significant GI
bleeding.
Gastrointestinal Bleeding
o These patients can be categorized as very
low risk and can be sent home without further
diagnostic tests.
o Before
discharge, patients should be
educated about the signs and symptoms of
significant GI bleeding and when to return to
the ED or when to call their primary care
physician.
Gastrointestinal Bleeding
o They should be given specific education
about the possible or actual cause of the
bleeding and specific treatment for that
disorder.
o They should be educated about the side
effects of any medications.
Gastrointestinal Bleeding
o Patents should undergo specific follow-up
evaluation within 24 to 36 hours.
o They should be instructed to avoid aspirin,
nonsteroidal anti-inflammatory drugs, and
alcohol.
Gastrointestinal Bleeding
o Patients with low-risk, moderate-risk, and
high-risk criteria are more complicated and
require further assessment.
o Historically, nearly all patients with significant
GI bleeding were admitted to the hospital. As
health care has changed, a greater emphasis
has been placed on outpatient management
of select
Gastrointestinal Bleeding
o low-risk patients with GI bleeding. Studies
have shown that combining clinical and
endoscopic criteria provides an accurate
estimation of the risk of rebleeding and
mortality in patients with UGIB.
Gastrointestinal Bleeding
o These combined criteria have been used to
identify patients with UGIB at low risk, who
can be discharged home, and patients at
moderate or high risk, who need to be
admitted to an appropriate care site in the
hospital.
Gastrointestinal Bleeding
o Patients with clinical evidence of GI bleeding
should undergo endoscopy as soon as it is
available for final risk stratification, inpatient
triage, and determination of appropriate
treatment.
Gastrointestinal Bleeding
o If endoscopy is not immediately available,
patients with low clinical risk may be admitted
to an ED observation unit or short-stay
hospital bed until endoscopy can be
performed.
Gastrointestinal Bleeding
o Patients with moderate clinical risk criteria
may be admitted to an inpatient floor,
intermediate care unit, or ICU, as indicated
by specific patient management needs and
depending
institution.
on
the
capabilities
of
the
Gastrointestinal Bleeding
o Patients with high clinical risk should be
admitted to a closely monitored step-down
unit or an ICU.
 The
timing of endoscopy depends on
availability, the acuity of the patient, the need
for emergent therapy, the need to determine
final care site, and the need to minimize
length of stay.
Gastrointestinal Bleeding
o Patients with LGIB that is not clearly due to
hemorrhoids, fissure, or proctitis should be
admitted to an inpatient bed.
o Patients with low risk may be admitted to an
inpatient floor bed and prepared for a nuclear
medicine imaging study (e.g., red blood cell–
labeled study) or colonoscopy.
Gastrointestinal Bleeding
o Patients with high-risk criteria should be
admitted to a step-down unit or ICU and
considered for angiography to identify the
site of LGIB.
Gastrointestinal Bleeding
o Patients with moderate-risk criteria require
individualized determination of the most
appropriate inpatient care site (floor,
intermediate care bed, or ICU) and the most
useful diagnostic studies (nuclear imaging or
angiography).
Gastrointestinal Bleeding
o Consultation with a surgeon should be
obtained if it appears that more than 5 units
of blood is required to achieve hemodynamic
stability or if there is reasonable suspicion
that operative intervention may be needed.
Gastrointestinal Bleeding
o This is especially true of patients older than
65 years of age. In general, the older the
patient, the more aggressive the surgical
management ought to be.
o Patients with a history of varices, persistent
postural changes in heart rate, or significant
bleeding of bright red blood per rectum are
more likely to require surgery than are
patients without these findings.
Gastrointestinal Bleeding
o Emergent vascular surgical consultation is
needed for patients who have abdominal
aortic grafts who present to the ED with GI
bleeding, because of the possibility of an
aortoenteric fistula.
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