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