1 In a patient with blood in the stools who is hemodynamically stable, use history to differentiate upper vs. lower gastrointestinal (GI) bleed as the investigation differs.
| UGIB | LGIB | |
| ClassificationSymptoms | Above Ligament of Treitz
|
Below ligament of Treitz
|
| Sings | Hematemesis, coffee ground emesis, hematochezia (mass rapid bleed), melena, jaundice, purpura, ecchymosis | Hematochezia, melena, guarding (perf?) Jaundice, purpura, ecchymosis DRE: hemorrhoids, fissure, mass, blood Anal inspection |
| Common etiology | Peptic ulcer dz
Esophageal varices Gastritis – PUD (NSAID/EtOH) Erosive esophagitis Mallory-Weiss tear AV malformation / Dieulafoy’s lesions Gastric antral vascular ectasia Malignancy |
CHAND
Colon ulcer, perforation Peds: intussusception, Meckel diverticulum |
Hx:
- The nature and duration of bleeding, including stool color and frequency
- Onset , Quality : BRB, dark, clots, coffee grounds
- Severity: volume of blood in the stool (streaks on outside, mixed ) and toilet
- associated symptoms:
- Recent change in bowel habits: shape, frequency, consistency
- Fever, urgency / tenesmus / ↓ calibre, obstruction, wt loss / fatigue, anorexia: infection / inflammation / malignancy
- Presyncope, chest pain / palpitations, dyspnea at rest or on exertion, lightheadedness, postural symptoms, dizziness, diaphoresis: significant blood loss
- Abdominal Pain
- Painless: varices, diverticulosis, angiodysplagia, carcinoma
- Painful:
- sudden severe – perforation,
- out of proportion with physical findings – sichemic bowel,
- epigastric – PUD,
- rectal (fissure, abscess)
- IBC related: nocturnal diarrhea, cramping, fever, wt ↓, pus / hematochezia,
- oral ulcer – crohn’s, uveitis (blurred vision, photophobia), myalgias, arthritis, rash – erythema nodosum
- relevant PMH:
- previous bleeding episodes, trauma, past abdominal surgeries, previous peptic ulcer disease,
- history of inflammatory bowel disease,
- history of radiation therapy to the abdomen and pelvis, and
- prior history of major organ dysfunction (including cardiopulmonary, renal, and liver disease)
- current/recent medications (including NSAIDs, aspirin, and anticoagulants), and allergies
PEx:
- immediate recording of vital signs with postural changes (orthostatic VS)
- A drop of >10 mm Hg or an increase of >10 beats/min in pulse is indicative of acute blood loss of >800 ml (15% of total circulatory blood volume). Marked tachycardia and tachypnea, associated with hypotension and depressed mental status is indicative of a blood loss of >1500 ml (30% circulatory blood volume)
- cardiopulmonary, abdominal (BS, guarding – perf?)
- DRE (hemorrhoids, fissure, mass, blood) + anal inspection
- Jaundice, purpura, ecchymosis
Ix:
- CBC
- it should be remembered that initial hemoglobin/hematocrit value may not reflect the degree of blood loss due to volume contraction, and may fall significantly after hydration.
- Serum electrolytes, blood urea nitrogen, and creatine.
- In upper gastrointestinal bleeding, the serum BUN may rise without a commensurate rise in serum creatinine. This appears to be due to absorption of proteins from blood in the gastrointestinal tract, and from dehydration (3–5). However, the absence of a rise in blood urea nitrogen does not rule out an upper gastrointestinal source.
- coagulation profile (PT/PTT), particularly if there is any history of liver disease or if the patient has been taking anticoagulant medication
- type and crossmatch
- AXR, FOBT
- ECG for patients >50 yr of age
- younger patients with risk factors for coronary artery disease or history of dysrhythmia, or patients with chest pain/palpitations associated with the bleeding episode
- Endoscopy or colonoscopy – capsule follow-through if both negative for small bowel causes
Nasogastric or orogastric lavage is not required in patients with UGIB for diagnosis, prognosis, visualization, or therapeutic effect
- negative NG aspiration doesn’t r/o UGIB- lavage may not be positive if bleeding has ceased or arises beyond a closed pylorus
- NG yields blood or coffee-ground like material confirms UGIB; however,
- The presence of bilious fluid suggests that the pylorus is open and, if lavage is negative, that there is no active upper GI bleeding distal to the pylorus.
2 In a patient with suspected blood in the stool, explore other possible causes (e.g., beet ingestion, iron, Pepto-Bismol) before doing extensive investigation
Social Hx:
- Smoking, EtOH, travel Hx
- Diet – beets, licorice, Fe
Meds:
- Iron, pepto-Bismol
- NSAIDs, ASA, Plavix, anticoagulants, steroids
3) Look for patients at higher risk for GI bleed (e.g., previous GI bleed, intensive care unit admission, nonsteroidal anti-inflammatory drugs, alcohol) so as to modify treatment to reduce risk of GI bleed (e.g cytoprotection).
Risk Factors
- Long-term NSAID, anticoagulant Tx, steroids, CCB, SSRIs
- EtOH use, smoking
- Liver cirrhosis, chronic renal insufficiency
- H. Pylori infection
- Multiple comorbidities / ICU admission
- hx of GI bleeds
4) In a patient with obvious GI bleeding, identify patients who may require timely treatment even though they are not yet in shock.
Hemodynamic status should be assessed immediately upon presentation and resuscitative measures begun as needed
- Blood transfusions should target hemoglobin >= 7 g/dl,
- higher hemoglobins targeted in patients with clinical evidence of intravascular volume depletion or comorbidities, such as coronary artery disease
- Risk assessment should be performed to stratify patients into higher and lower risk categories and may assist in initial decisions such as timing of endoscopy, time of discharge, and level of care
- higher risk clinical features (e.g., tachycardia, hypotension, bloody emesis or nasogastric aspirate in hospital) endoscopy within 12 h may be considered to potentially improve clinical outcomes
- All patients with hemodynamic instability (shock, orthostatic hypotension), those with evidence of severe bleeding (eg, a decrease in hematocrit of at least 6 percent, or transfusion requirement greater than two units of packed red blood cells) or continuous active bleeding should be admitted to an intensive care unit for resuscitation and close observation.
- Dischargefromtheemergencydepartmentwithoutinpatient endoscopy may be considered in patients with
- urea nitrogen < 18.2 mg/dl; hemoglobin >= 13.0 g/dl for men (12.0 g/dl for women),
- systolic blood pressure >= 110 mm Hg; pulse < 100 beats / min; ‘
- and absence of melena, syncope, cardiac failure, and liver disease,
- as they have < 1% chance of requiring intervention
- Patients with UGIB should generally undergo endoscopy within 24 h of admission, following resuscitative efforts to optimize hemodynamic parameters and other medical problems
- Pre-endoscopic (PPI) (e.g., 80 mg bolus followed by 8 mg/h infusion) decrease the proportion of patients who have higher risk stigmata of hemorrhage at endoscopy and who receive endoscopic therapy.
- However, PPIs do not improve clinical outcomes such as further bleeding, surgery, or death
- If endoscopy will be delayed or cannot be performed, intravenous PPI is recommended to reduce further bleeding
Red Flags
- HPI:
- HoTN, Syncope, Tachycardia, Diaphoresis (?shock), syncope
- Wt loss over months / years, fatigue, night sweats(?cancer)
- PEx:
- HoTN, tachycardia
- Pale, diaphoretic, shock
Hemorrhage Classification
| Class 1 | Class 2 | Class 3 | Class 4 | |
| Blood loss | 750ml | 750-1500ml | 1500-2000ml | >2000ml |
| HR | N | 100-120 | >120 | >140 |
| BP | N | N, postural HoTN | may see narrow pulse pressure | HoTN |
| CNS | N | Anxious | Agitated | Dec LOC |
| RR | N | ↑ | ↑↑ | ↑↑↑ |
| U/O | ↓ | ↓↓ | Minimal | None |
| Replacement fluid | NS | NS/Hartmann | Mix – NS, colloid, plasma | Blood and colloid |
5) In a stable patient with lower GI bleeding, look for serious causes (e.g., malignancy, inflammatory bowel disease, ulcer, varices) even when there is an apparent obvious cause for the bleeding (e.g., do not attribute a rectal bleed to hemorrhoids or to oral anticoagulation).
Visible rectal bleeding occurring in adults warrants an evaluation in all cases
- Low risk patients (eg, a young otherwise healthy patient with self-limited rectal bleeding that is most likely due to an internal hemorrhoid)
- may be evaluated in the outpatient setting. The extent of evaluation depends, at least in part, upon the patient’s age
- High risk patients, including those with hemodynamic instability, serious comorbid diseases, persistent bleeding, the need for multiple blood transfusions, or evidence of an acute abdomen, should be promptly resuscitated and hospitalized.
- A gastroenterologist and general surgeon should be involved early in the hospital course of high risk individuals.
- Once the bleeding is suspected to be coming from a lower GI source, colonoscopy is the initial examination of choice for diagnosis and treatment
6) In a patient with an upper GI bleed,
a) Include variceal bleeding in your differential,
b) Use history and physical examination to assess the likelihood of a variceal bleed as its management differs.
Consider variceal bleeding in al pt with UGIB and a Hx of liver cirrhosis
- Pt needs regular endoscopies to monitor varices and prevent bleeds
- Abx prophylaxis if UGIB and cirrhosis to prevent SBP (spontaneous bacterial peritonitis)
Risk Factors:
- Cirrhosis with portal HTN
- development of gastric / esophageal varices
- ascites
- active EtOH use
Hx:
- Massive painless UGIB
- Risk of portal HTN
PE:
- Signs of Liver dz:
- Jaundice, petechiae, ecchymosis, spider nevi, caput medusa, ascites, hepatomegaly
Ix: Endoscopy
Tx:
- Acute: somatostatin analogue: Octreotide, endoscopic variceal ligation
- Unstable: balloon tamponade, TIPS (Transjugular intrahepatic portosystemic shunt)
- Chronic: non-selective B-blocker: propranolol to ↓HR and prevent rebleed
Preparing for the CCFP Exam 2015 
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