Gastrointestinal Bleeding (Case 22)

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Chapter 29
Gastrointestinal Bleeding (Case 22)

Melissa Morgan DO, Michael Share MD, and Marc Zitin MD

Case: A 70-year-old woman with a past medical history of coronary artery disease, hypertension, and hyperlipidemia presents to the ED complaining of rectal bleeding that has been present all day. Earlier in the day she had a bowel movement and noted bright red blood mixed in with her stool. She complains of dizziness and light-headedness. Her outpatient daily medications include aspirin, simvastatin, and metoprolol. She also admits to taking ibuprofen twice daily for the past week for pain in her knees. She admits to “occasional” drinking and one cocktail each night after dinner.

Differential Diagnosis

Peptic ulcer disease

Arteriovenous malformation

Colon cancer

Hemorrhoids

Esophagogastric varices

Gastric cancer

Diverticulosis

 

Speaking Intelligently

When asked to see a patient with GI bleeding, it is important to remember to first stabilize the patient. It is also important to know whether the bleeding is coming from the upper or lower GI tract; this will affect both acute management and treatment. Upper GI bleeding commonly presents with hematemesis and/or melena. In comparison, lower GI bleeding presents with hematochezia. However, these distinctions are not absolute. A massive upper GI hemorrhage can also present with hematochezia, and a proximal lower GI bleed can present with melena.

PATIENT CARE

Clinical Thinking

• A thorough history and physical exam are the most important steps in differentiating the cause of GI bleeding.

• As stated previously, the management of the patient strongly depends on the cause of bleeding. Patients who are having a massive upper GI hemorrhage will most likely require intubation and observation in the ICU.

• Stabilizing the patient is the first priority, to enable him or her to sustain an intervention to control bleeding, such as endoscopy, an interventional radiology procedure, or surgery.

History

• Has this ever happened before, and if so, does the patient know what the cause of the bleeding was previously?

• Has the patient ever had an endoscopic procedure such as colonoscopy or upper endoscopy?

Current medications? This includes over-the-counter medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), including ibuprofen, aspirin, and naproxen.

Define underlying medical conditions: risk factors for chronic liver disease, injection drug use, hepatitis B or C infection, or chronic alcohol use.

• Did the patient have bloody vomitus or coffee-grounds emesis?

• How much blood was present?

• Was there blood only on the toilet paper or in the toilet bowl as well?

• Does the patient have abdominal pain? If so, determine duration.

Physical Examination

Check the vital signs: Tachycardia and/or hypotension indicates an active or ongoing hemorrhage.

• Look for stigmata of chronic liver disease, including telangiectasias of the abdomen and chest, jaundice, scleral icterus, ascites, and palmar erythema.

Do a thorough abdominal exam: Epigastric tenderness may suggest PUD. Lower abdominal tenderness may suggest colitis.

• The rectal exam is important: black tarry stools (melena) will most likely mean an upper GI source of bleeding; bright red blood usually indicates a lower GI source. Are there masses or hemorrhoids present?

Placement of an NG tube can be helpful when there is concern for an upper GI source of bleeding. Keep in mind that if the fluid aspirated from the tube is clear, this does not exclude an upper GI source. It is important to have bilious return to rule out a duodenal source. If the return is bloody, this indicates an upper GI hemorrhage.

Tests for Consideration

Hemoglobin and hematocrit will help in determining the extent of the blood loss, although acute blood loss may not be evident right away, as equilibration takes time.

$7

Prothrombin time–international normalized ratio (PT/INR) will provide information as to whether the patient has a coagulopathy—possibly related to a medication, liver disease, or malnutrition.

$6

CMP: A BUN elevated in greater than a 20 : 1 proportion to the Cr is consistent with an upper GI hemorrhage.

$12

Type and cross-type for packed red blood cells (RBCs).

$14

EGD will aid in visualization of the esophagus, stomach, and first and second portions of the duodenum to identify and treat the source of bleeding.

$600

Colonoscopy can help in finding the cause of bleeding in the colon such as diverticulosis, arteriovenous malformations (AVMs), polyps, or tumors.

$655

Video capsule endoscopy is mostly used in the outpatient setting to look for occult GI blood loss in the small intestine.
This test consists of swallowing a capsule that contains a camera. As the capsule moves through the GI tract, numerous pictures are taken. The patient wears a recording device for 8 hours and then returns the device to his or her gastroenterologist. The physician reviews the images to look for a source of bleeding.

$723

 

IMAGING CONSIDERATIONS

A tagged RBC scan can detect blood loss at a rate of 0.1 to 0.5 mL/min and is more sensitive than angiography. This is mostly used for lower GI hemorrhages but can occasionally be used for an upper GI hemorrhage when the source is not located by EGD.

$239

→ Angiography requires active blood loss at a rate of 1.0 to 1.5 mL/min for a bleeding site to be visualized. This is usually done after a tagged RBC scan is positive.

$338

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Peptic Ulcer Disease

PUD occurs when the caustic effects of acid and pepsin in the GI lumen overwhelm the ability of the mucosa to resist their effects. Most ulcers occur when the process of mucosal protection is disrupted by Helicobacter pylori infection or use of NSAIDs.

TP

Although gastric and duodenal ulcers are associated with epigastric pain 66% of the time, often the diagnosis is not made until complications such as hemorrhage or perforation occur. Hemorrhage will be evident by melena, hematemesis, or coffee-grounds emesis. Perforation will cause severe abdominal pain and usually presents as an acute abdomen with peritonitis, requiring surgery.

Dx

Endoscopy is the most accurate diagnostic test for PUD and is the appropriate first diagnostic test for GI bleeding. Mucosal biopsies should also be obtained for rapid urease tests to determine whether Helicobacter pylori is present; histologic staining should be done for patients with a negative rapid urease test or for instances when the urease test is not available. However, if the concern is for a perforated ulcer presenting with free intraperitoneal air, endoscopy should not be performed and the treatment is surgical.

Tx