GI bleeds can range from small hemorrhoids to exsanguinating bleeds, and we need a systems-based approach to help resuscitate, diagnose, risk stratify and treat.
A
- pseudo-GI bleed from swallowed blood
- risk aspiration from hematemesis
B
- pseudo-GI bleed from hemoptysis
C: CARDIOVASCULAR
- Dysfunctional LV: CHF puts patient at higher risk of GI bleed
- Outflow: aorto-enteric fistula
D
E: ENDO
- Electrolyte: cirrhotic patients who bleed are also at risk for hypoglymic
F
- high urea: acute sign of upper GI bleed, chronic uremia interferes with platelets
G: ABDOMINAL
- Ammonia: cirrhosis risk for varices
- Dyspepsia, PUD
- Mesenteric ischemia
- Appy/tic: diverticular bleed
- No motion: tumour
- Loose stool: colitis, infectious or inflammatory
H: HEME
- Hgb: anemia from bleed +/- prior
- Early platelet: bleed more if thrombocytopenic or on anti-platelets
- Make coagulation: bleed more if anti-coagulated
- Elevate dimer/decrease fibrin: bleed more if fibrinogen
I: INTOX
- Ingest: alcohol
- Natural
- Treat: NSAID, anti-platelet, anti-coagulant; iron pseudo-melena
- OTC: NSAID, aspirin; peptobismol pseudo-melena
- X toxic alcohol
J: joint, skin, bones
- examine for hemorrhoids, fissure
A systems-based approach also helps risk-stratify patients, using the Blatchford score: C (history of CHF, presenting with syncope, tachycardic, hypotensive, low Hemoglobin), F (high urea), G (history liver disease, melena on exam)
Putting this together we can combine resuscitation, diagnosis, risk stratification and treatment:
- A r/o swallowed blood, assess need for intubation +/- variceal balloon tamponade
- B r/o hemoptysis, give supplemental oxygen
- C assess HR/BP/ECG and risk (CHF or syncope); give fluids +/- RBC, urgent endoscopy if unstable; consider aorto-enteric fistula
- D
- E: check glucose
- F: check urea
- G: consider specific treatment: octreotide/antibiotics for varices, PPI for PUD, surgery for mesenteric ischemia, antibiotics for colitis
- H: correct Hgb, Platelets, coag
- I: consider stopping/reversing meds
- J: examine for hemorrhoids