GI Bleeding¶

Matthew Meyers

Background¶

Intraluminal blood loss anywhere from the nasopharynx/oral cavity to the anus
Don’t forget epistaxis or oropharyngeal bleeding as possible source of melena
IV PPI prior to endoscopy may ↓ need for endoscopic therapy but does not impact transfusion requirement, rebleeding risk, need for surgical intervention, or mortality
Classification: relative location to the Ligament of Treitz (LoT)
Upper = proximal to LoT
- PUD, gastritis (alcohol, stress, NSAIDs, ASA), esophagitis, variceal bleed, Mallory-Weiss tear, AVM, Dieulafoy’s lesion, aorto-enteric fistula, gastric antral vascular ectasias, malignancy
Lower = distal to LoT
- Diverticular bleed, ischemic/infectious/IBD/radiation colitis, malignancy, angiodysplasia, anorectal (hemorrhoids, anal fissure), Meckel’s diverticulum, post-polypectomy bleed

Hematemesis (very specific for upper GI bleed), hematochezia (usually lower although brisk upper possible), melena (usually upper), coffee-ground emesis, epigastric/abdominal pain, acute or chronic, hx of GI bleed and prior endoscopies, NSAID use, alcohol use, anticoagulant use, hx of cirrhosis
Exam: VITALS – assess stability to determine resuscitation needs, MICU vs. floor; orthostatic vs, rectal exam every time (smear stool on white tissue paper to look for melena), look for signs of cirrhosis (jaundice, palmar erythema, ascites, spider angiomata)

CBC, PT/INR, CMP, Lactic Acid, Blood Gas
EGD: usually best
Difficulty localizing GIB: pill-capsule, balloon enteroscopy Meckel’s scan, tagged RBC scan
Massive lower GI bleeds will require arteriography

Secure airway (intubation) if comatose, extremely combative, or massive hematemesis
At least 2 large bore IV’s (> 18 gauge) – ask nurses directly to ensure these are placed
Maintain active type and screen
Bolus IVF to maintain MAP >65H/H monitoring q6-q12 hours; transfusions as indicated
IV PPI (pantoprazole) 40 mg BID if thought to be upper/possible ulcer
If cirrhotic, Ceftriaxone 1g daily for empiric SBP prophylaxis
If possibility of variceal bleed: Octreotide IV 50 mcg x1 then 50 mcg/hr drip x 3-5 days
NPO if unstable vs. clear liquids (no reds or purples) until morning for EGD
Never give prep to a patient for colonoscopy (GoLytely) without discussing with GI fellow
Consult gastroenterology to facilitate endoscopy
If endoscopy is unable to stop bleeding IR is next who can embolize
If embolization fails EGS for source removal