GI Bleeding Foundations

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Foundations of GI Bleeding

Definitions:

Gastrointestinal bleeding comes in 2 flavors- upper GI bleed (UGIB) and lower GI bleed (LGIB).

Anatomically, the ligament of Treitz is the dividing line between upper and lower GI Bleeding.

Clinically the distinction is often made based on the presence or absence of melena vs. the presence or absence of bright red blood (BRB) and the orifice that the BRB is emanating from - i.e. hematemesis vs. hematochezia.

melena is typically described as black/dark tarry stool. Melena gets its dark color from hemoglobin that has been altered by stomach acid and/or digestive enzymes. The most common causes of melena/UGIB are gastric and duodenal ulcers, and NSAID induced gastritis.

hematemesis is when there's BRB in the vomit. It's pretty much always bad. Unless it's just from a Mallory Weiss tear in which case it's fine, don't worry about it.

hematochezia is when there's BRB in the poop. This is often due to either hemorrhoids or diverticulosis. Note that diverticulitis does not tend to cause LGIB.

Neither the presence of melena nor the presence of hematochezia are definitive for differentiating upper vs. lower GI bleed. ___% of the time UGIB has BRB PR and ___% of the time LGIB has melena. So why are we even talking about this then...?

Epidemiology:

Important Risk Factors

Mortality:

Key Decision Points:

upper or lower source?

requires admission or can be discharged?

requires emergent, urgent, or outpatient specialist attention, or do they require a specialist at all?

requires imaging?

requires transfusion?

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Important Style Points:

If:

chief complaint on tracking board is blood per rectum, dark stools, anemia

Then:

grab a guiac card and developer, and blood consent form before you go into the room so you have it with you when you walk in there.

Questions to ask:

history of GI bleeds/peptic ulcers

taking PPI?

NSAIDs? Anticoagulants?

easy bleeding/bruising?

taking iron supplements or pepto bismol? (can cause dark stools that seem like a GI bleed but there isn't one)

menstrual cycle?

Things to look for on exam:

pallor

systolic flow murmur (caused by anemia)

aortic stenosis murmur (AS can cause GI AVMs aka Heyde's Syndrome)

rectal: hemorrhoids (internal and external), fissures, fistulas, lacerations

Orders to shotgun if you're having an impossibly busy shift:

CBC, CMP, Type and Screen, urine preg, ekg

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Case Questions:

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UGIB Workup

Diagnosis hinges on endoscopy. Almost always, endoscopy will be performed prior to colonoscopy.

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UGIB Management Pearls

Acutely Ill UGIB:

NGT or no NGT?

transfusion threshold and target?

Blakemore Tube?

Not acutely ill UGIB:

NGT or no NGT?

Disposition/Risk Stratification:

Sick - ICU

Not sick or only a little sick:

Glasgow Blatchford

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Case to Focus on:

64yom presents complaining of BRB PR. VS 78, 102/66, 18, 98%

What are the three most likely causes of this patient's presentation?

What is my initial workup and management for those 3 things?

What do I need to ask/find out to make sure it's not one of the more deadly causes of LGIB?

What is the worst thing that this could be, i.e. what has the highest mortality rate for this presentation?

Is there a risk stratification system that I can use to determine this patient's disposition?

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LGIB Workup & Management

Most common causes of LGIB:

hemorrhoids (_%)

found on examination, no further workup required

diverticulosis (__%)

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LGIB Management Pearls

Simplifying your dispo:

Sorry, a risk stratification tool for LGIB does not exist. Go with your gut. Pun intended.

Hemorrhoids

__evidence based treatments__

Diverticulosis

The Badness:

aortoenteric fistula - if you see this, it's bad. Have an extremely low threshold for activating MTP. Get them into the OR and away from you as quickly as possible.