GI bleed​​

INITIAL ASSESSMENT
  • ABC and assess level of consciousness
  • Record vitals; if unstable, call for assistance
  • Urgent CBC, RFT, and coagulation profile; compare with previous values if available
  • Establish adequate IV access with 2 or more 18G or larger IVs
  • Cross-type and reserve 2 units of PRBCs for transfusion if indicated
HISTORY
  • Bleeding Details
  • Onset, amount, color, and frequency of bleeding
  • Prior episodes of bleeding, recent scopes, and baseline hemoglobin
  • Upper GI Bleeding (UGIB)
    • Symptoms: Hematemesis and melena
    • Relevant History: Liver cirrhosis, PUD, esophageal or gastric varices, alcohol use
  • Lower GI Bleeding (LGIB)
    • Symptoms: Fresh bleeding per rectum
    • Relevant History: Liver cirrhosis, hemorrhoids, diverticulosis, colon cancer, IBD
  • Medications: Use of antiplatelets, anticoagulants, or NSAIDs
  • Ask about the last meal: Type and timing
EXAMINATION
  • Perform an abdominal examination
  • Conduct a PR (per rectal) exam
  • Check for signs of hepatic disease
PLAN
Fluid Management and Initial Stabilization
  • If hypotensive or dehydrated, give 1 pint of NS fast
  • Call for assistance and consult gastroenterology for urgent scopes and transfusion of PRBCs as soon as available
Monitoring and Testing
  • Keep the patient NPO, monitor on a cardiac monitor, and maintain IV fluids
  • Send urgent CBC, coagulation profile, and RFT; repeat CBC regularly to monitor status
  • For high-risk cardiovascular patients or those with IHD, send HsTrop, VBG, Lactate, and perform an ECG
Medications and Transfusions
  • Administer Losec 80 mg IV STAT, followed by Losec infusion at 8 mg/hr
  • Transfuse PRBCs to keep hemoglobin above 7, or above 8 if there is preexisting CVD
  • Hold antiplatelets and anticoagulation after consulting with a senior and confirming the indication
  • Consult GI for an EGD within 24 hours; if stable, EGD can be delayed unless variceal bleeding is suspected
  • Patients generally need to be NPO for 6-8 hours for optimal visualization
In Case of LGIB
  • Contact general surgery for further assessment
DIFFERENTIAL DIAGNOSIS
UGIB
  • Causes: PUD or gastritis (from NSAIDs, H. Pylori, alcohol, stress, steroids), varices (esophageal, gastric), trauma (Mallory Weiss), vascular malformations (Dieulafoy’s, AVM, angioectasia), neoplasm, iatrogenic causes, or epistaxis
LGIB
  • Causes: Diverticulosis, hemorrhoids, vascular malformations, colitis, IBD, neoplasm/polyps, or ischemia
MOC