GI Bleeding

1
GI Bleeding

• Tintinalli Chapter 74

2
GI Bleeding

• Poor prognostic factors
• Hemodynamic instability
• Repeated hematemesis or hematochezia
• Failure to clear with gastric lavage
• Older than 60
• Coexistent organ system disease

3
Pathophysiology

• Upper GI Bleed (above ligament of Treitz)
• Peptic ulcer disease
• 60
• Erosive gastritis / esophagitis / duodenitis
• 15
• Esophageal / gastric varicies

4
Pathophysiology

• Mallory-Weiss syndrome
• Other
• Stress ulcer
• AV malformation
• Malignancy

5

• Lower GI Bleed
• Diverticulosis
• Angiodysplasia
• Other
• Carcinoma
• Hemorrhoids
• Inflammatory bowel disease
• Polyps
• Infectious gastroenteritis

6
Diagnosis

• History
• Physical
• Vitals
• Spider angiomata
• Palmar erythema
• Jaundice
• Petechiae / purpura
• Careful ENT exam
• Abdominal exam
• Rectal exam

7
Diagnosis

• Laboratory data
• CBC
• CMP
• Type and cross
• Coagulation studies
• EKG

8
Diagnosis

• Diagnostic studies
• Plain Abd / Chest films are of no value
• Neither are barium studies
• Barium also limits endoscopy and angiography
• Angiography bleeding rate gt 0.5-2.0 ml / min
• Scintigraphy bleeding rate 0.1 ml / min
• Endoscopy

9
Treatment

• ABCs first
• 2 large IVs with NS
• Blood if clinically indicated
• NG tube in all patients with significant GI
  bleeding regardless of the source.

10
Treatment

• Room temp irrigation of stomach if clots or blood
  returned.
• No benefit from cold water
• Endoscopy
• Diagnostic and therapeutic

11
Treatment

• Drugs
• Somatostatin / octreotide
• Octreotide 50 ug iv bolus then 50 ug q 8-24 hrs
• Longer acting than somatostatin
• As effective as sclerotherapy for varices
• Vasopressin
• Multiple adverse reactions. Not as effective as
  octreotide
• PPIs

12
Treatment

• Other
• Sengstaken-Blakemore tube
• Surgery

13
Treatment

• Disposition
• Admission
• Significant bleeding
• Unstable vitals
• High risk variables
• HcT lt 30
• Initial SBP lt100
• Red blood in NG lavage
• History of cirrhosis (or ascites on exam)
• History of vomiting red blood
• Discharge
• Require endoscopy for risk stratification first.