By Abdulrahman Sindi ED Resident Case Scenario A 55yearold male not known to have any medical illness presented to the ED complaining of blood in his vomitus two times this day HR120 BP9560 ID: 562863
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Slide1
Gastro Intestinal Bleeding
By: Abdulrahman Sindi
ED ResidentSlide2
Case Scenario
A 55-year-old male not known to have any medical illness, presented to the E.D. complaining of blood in his vomitus two times this day.
HR:120
BP:95/60
RR:22
T:36.7Slide3
Is the patient stable?
What should be done for this patient?
What are initial steps in the management?Slide4
Epidemiology
GI bleeding is relatively common problem encountered in ED
The mortality
rate is is approximately 10%
UGIB affects 50-150 people per 100,000 each year
Mean age of affected people with GIB is 59 years
UGIB is more common in men, whereas LGIB is more common in women
UGIB admission is more common in adults whereas LGIB admission is more common in childrenSlide5
Differential ConsiderationsSlide6
Differential Considerations
Upper
Lower
Peptic ulcer disease
diverticulosis
Gastric erosions
angiodysplasia
varices
UGIB
Mallory-Weiss
tear
Cancer/polypesophagitisRectal diseaseduodenitisIBD
UpperLoweresophagitisAnal fissuregastritisInfectious colitisulcerIBDEsophageal varicespolypsMallory-Weiss tearintussusception
Adult
Children
In children less than 2
years
of age massive LGIB is most
often due to Meckels diverticulum or intussusceptionSlide7
Rapid Assessment and Stabilization
Patients with suspected GIB who are hemodynamically unstable should be stabilized and evaluated rapidly.
Undress and place cardiac and oxygen saturation monitors.
Give supplemental oxygen.
2 large
bore
peripheral intravenous lines.
Take blood for (CBC, PT, type and screen or crossmatch).
Give bolus crystalloid.
Give type O, type specific or crossmatched blood.
Consult the GE in UGIB or surgeon in LGIB if persistently unstable.Slide8
History
Hematemesis:
: vomiting of blood that occurs in bleeding of the esophagus, stomach, or proximal bowel (50% in UGIB).
Melena:
black tarry stool that results from the presence of 150-200 ml of blood for prolonged period (70% in UGIB and 33% in LGIB).
Hematochezia:Slide9
History
Hematemesis: vomiting of blood that occurs in bleeding of the esophagus, stomach, or proximal bowel (50% in UGIB).
Melena: black tarry stool that results from the presence of 150-200 ml of blood for prolonged period (70% in UGIB and 33% in LGIB).
Hematochezia: bright red blood in the stool that mostly occurs with LGIB but can occur in UGIB (66% in LGIB and 10-15% in UGIB).Slide10
History
Duration, quantity, associated symptoms, previous history, medications, alcohol, and associated medical illness Slide11
Physical Examination
Vitals: hypotension, tachycardia or postural change in heart rate.
General exam: general appearance, mental status, skin signs and
abdomin
should be assessed carefully.
Rectal exam: it
’
s the key to confirm the diagnosis, it does not exclude the diagnosis if negativeSlide12
Ancillary Testing
Occult blood test: it may have positive result 14 days after a major bleed, it has a false positive and negative results,
Clinical labs: CBC, coagulation profile, type and screen and crossmatch
ECG: should be done to all patients over 50, preexisting cardiac insult, anemia, chest pain, S.O.B., persistent
Imaging: CXR if perforation is suspectedSlide13
Management
Reassurance
N.G. tube and gastric lavage:
A
spiration of bloody content diagnoses UGIB, but it does not determine if it is ogoing
False negative results are possible if if bleeding is intermittent, in duodenal bleed, pyloric spasm.
False positive occurs in nasal bleeding.
The presence of bile in excludes the possibility of UGIB.
Gastric lavage is helpful to prepare for endoscopy
Lavage should not performed in pneumoperitoneum.Slide14
Management
Anoscopy/proctosigmoidoscopy.
Endoscopy:
It
identifies lesion in 78% to 95% if done within 12 to 24 hours
.
Angiography and tagged RBC scan:
Angiography is commonly used in LGIB
Detects 40% of LGIB site.
It is performed ideally in active bleeding.
In undetected bleeding tagged RBC scan is performed.Slide15
Management
Proton pump
inhibitors
Octreotide
Vasopressin
Sengstaken-Blakmore Tube:
Stops bleeding in 80% of esophageal varices.
Indicated when endoscopy is not readily available and vasopressin has not slowed the bleeding.
Surgery:
Indicated in for all hemodynamically unstable with active bleeding unresponsive to resuscitationSlide16
Stengstaken-Blackmore
TubeSlide17
Disposition
Very low criteria for GIB patients
No comorbid disease
Normal vitals
Negative guaiac test
Negative gastric aspiration
Normal hemoglobin/hematocrit
Proper understanding for signs and symptoms
Immediate access to ER
Arranged follow up within 24 hoursSlide18
Risk StratificationSlide19
Risk Stratification
LSlide20
Thank You
By Dr. Abdulrahman Sindi