approach to GI bleed

gi-bleed

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

GIbleed

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