Transcript Gastro intestinal bleeding

Gastro Intestinal
Bleeding
By: Abdulrahman Sindi
ED Resident
Case Scenario
 A 55-year-old male not known to have any medical
illness, presented to the E.D. complaining of blood in
his vomitus two times this day.
 HR:120
 BP:95/60
 RR:22
 T:36.7
 Is the patient stable?
 What should be done for this patient?
 What are initial steps in the management?
Epidemiology
 GI bleeding is relatively common problem encountered
in ED
 The mortality rate is is approximately 10%
 UGIB affects 50-150 people per 100,000 each year
 Mean age of affected people with GIB is 59 years
 UGIB is more common in men, whereas LGIB is more
common in women
 UGIB admission is more common in adults whereas
LGIB admission is more common in children
Differential Considerations
Differential Considerations
Adult
Children
Upper
Lower
Upper
Lower
Peptic ulcer
disease
diverticulosis
esophagitis
Anal fissure
gastritis
Infectious colitis
Gastric erosions
angiodysplasia
ulcer
IBD
varices
UGIB
polyps
Mallory-Weiss
tear
Cancer/polyp
Esophageal
varices
intussusception
esophagitis
Rectal disease
Mallory-Weiss
tear
duodenitis
IBD
• In children less than 2 years of age massive LGIB is most
often due to Meckels diverticulum or intussusception
Rapid Assessment and
Stabilization
 Patients with suspected GIB who are hemodynamically
unstable should be stabilized and evaluated rapidly.
 Undress and place cardiac and oxygen saturation monitors.
 Give supplemental oxygen.
 2 large bore peripheral intravenous lines.
 Take blood for (CBC, PT, type and screen or crossmatch).
 Give bolus crystalloid.
 Give type O, type specific or crossmatched blood.
 Consult the GE in UGIB or surgeon in LGIB if persistently
unstable.
History
 Hematemesis:: vomiting of blood that occurs in
bleeding of the esophagus, stomach, or proximal bowel
(50% in UGIB).
 Melena: black tarry stool that results from the presence
of 150-200 ml of blood for prolonged period (70% in
UGIB and 33% in LGIB).
 Hematochezia:
History
 Hematemesis: vomiting of blood that occurs in bleeding
of the esophagus, stomach, or proximal bowel (50% in
UGIB).
 Melena: black tarry stool that results from the presence
of 150-200 ml of blood for prolonged period (70% in
UGIB and 33% in LGIB).
 Hematochezia: bright red blood in the stool that mostly
occurs with LGIB but can occur in UGIB (66% in LGIB
and 10-15% in UGIB).
History
 Duration, quantity, associated symptoms, previous
history, medications, alcohol, and associated medical
illness
Physical Examination
 Vitals: hypotension, tachycardia or postural change in
heart rate.
 General exam: general appearance, mental status, skin
signs and abdomin should be assessed carefully.
 Rectal exam: it’s the key to confirm the diagnosis, it
does not exclude the diagnosis if negative
Ancillary Testing
 Occult blood test: it may have positive result 14 days
after a major bleed, it has a false positive and negative
results,
 Clinical labs: CBC, coagulation profile, type and screen
and crossmatch
 ECG: should be done to all patients over 50,
preexisting cardiac insult, anemia, chest pain, S.O.B.,
persistent
 Imaging: CXR if perforation is suspected
Management
 Reassurance
 N.G. tube and gastric lavage:
 Aspiration of bloody content diagnoses UGIB, but it does
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not determine if it is ogoing
False negative results are possible if if bleeding is
intermittent, in duodenal bleed, pyloric spasm.
False positive occurs in nasal bleeding.
The presence of bile in excludes the possibility of UGIB.
Gastric lavage is helpful to prepare for endoscopy
Lavage should not performed in pneumoperitoneum.
Management
 Anoscopy/proctosigmoidoscopy.
 Endoscopy:
 It identifies lesion in 78% to 95% if done within 12 to 24
hours.
 Angiography and tagged RBC scan:
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Angiography is commonly used in LGIB
Detects 40% of LGIB site.
It is performed ideally in active bleeding.
In undetected bleeding tagged RBC scan is performed.
Management
 Proton pump inhibitors
 Octreotide
 Vasopressin
 Sengstaken-Blakmore Tube:
 Stops bleeding in 80% of esophageal varices.
 Indicated when endoscopy is not readily available and
vasopressin has not slowed the bleeding.
 Surgery:
 Indicated in for all hemodynamically unstable with active
bleeding unresponsive to resuscitation
Stengstaken-Blackmore Tube
Disposition
 Very low criteria for GIB patients
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No comorbid disease
Normal vitals
Negative guaiac test
Negative gastric aspiration
Normal hemoglobin/hematocrit
Proper understanding for signs and symptoms
Immediate access to ER
Arranged follow up within 24 hours
Risk Stratification
Risk Stratification
L
Thank You
By Dr. Abdulrahman Sindi