Gastrointestinal bleeding

Approach to GI Bleeding

Bayalpata Hospital CMELast updated: 2nd January, 2017

Contributors:Dr. Pawan KB Agrawal, MD General Practice & Dr. Stephen Mehanni, MD Internal Medicine

05/03/2023 Presentation by Dr. Pawan KB Agrawal 2

ObjectivesAfter this session, participants should be able to

1) Describe initial evaluation of GI bleeding2) Distinguish upper from lower GI bleeding3) Recognize common causes of GI bleeding4) Describe acute management of GI bleeding5) Recognize warning signs for GI malignancy


Clinical Case # 1

A 45 years male is brought to emergency with repeated episodes of blood vomiting for 1 day. He is drowsy and can barely talk. His wife reports passing black colored stool this morning.


Clinical Case # 1

A 45 years male is brought to emergency with repeated episodes of blood vomiting since night. He is drowsy and can barely talk. His wife reports passing black colored stool this morning.


Question for HAs and CMAs

What is the first thing you would do for this patient?

Fluid resuscitation


Question for Staff Physicians

What informations would you like to obtain further?

Severity: Frequency, Amount

Etiology: Smoking, Alcohol, Repeated history,

Previous endoscopy finding


GI Bleed: Initial Evaluation Vitals assessment

Resuscitation

History• Hematemesis Vs Hemoptysis• Upper GI bleeding Vs Lower GI bleeding• Etiology• Severity


Key Point #1

Differentiate hematemesis from hemoptysis.


Question

What is the commonest cause of GI bleed?1. Haemorrhoids2. Esophageal varices3. Peptic ulcer disease4. Carcinoma

ANSWER: Peptic ulcer disease


Upper Vs Lower GI Bleed

A 45 years male is brought to emergency with repeated episodes of blood vomiting for 1 day. He is drowsy and can barely talk. His wife reports passing black colored stool this morning.

How can we differentiate upper from lower GI bleeding?


Upper vs Lower GI BleedInclude information on how you can try to distinguish upper from lower GI bleed.

You can include more advanced diagnostics if you think it would be helpful, but remember that the focus should be on what we can do at Bayalpata hospital.

Upper GI Bleed Lower GI BleedHistory

1.Vomiting of blood 1. Fresh blood in stool

2. Passing of black tarry stool ‘Malaena’

2. Etiology

3. Etiology

NG Tube Aspiration1. Frank Blood or coffee colored blood

1. Food particles


Key Point #2

When in doubt, NG tube aspiration can differentiate upper GI bleed from lower GI bleed.


Clinical Case # 2

• A 65 years old female presents to OPD with complain of passing black tarry stool for few days. History reveals that she has been on ibuprofen tablets for few months for her bilateral knee pain.


GI Bleed: Risk Factors• Smoking• Alcohol• NSAIDs• H.pylori• Warfarin • Old age


GI Bleed: DifferentialInclude information about the COMMON causes of GI bleed. Try not to focus on the very rare causes, or the diagnoses that are only possible to make in very advanced centers.

As before, consider having the participants volunteer their answers before you show this information.


GI Bleed: DifferentialCauses of Lower GI bleeding:

1. Haemorrhoids 10%2. Anal Fissures3. Colitis 20%4. Diverticular disease 60%5. Carcinoma 10%


Key Point #3

Peptic ulcer disease constitute majority of cases of upper GI bleed


Clinical Case # 2• A 65 years old female presents to OPD with

complain of passing black tarry stool for few days. History reveals that she has been on ibuprofen tablets for few months for her bilateral knee pain.

• While on inquiry, the old lady suddenly faints and is carried immediately to emergency.


Question• How will you resuscitate?

• Which medicines would you like to give her?


GI Bleed: Management• Upper GI Bleed

• Fluid Resuscitation• Catheterization• PPI• Octreotide in variceal bleed• Blood transfusion

• Next step??• Monitoring


GI Bleed: Management• Lower GI Bleed

• Fluid Resuscitation• Tranexamic acid• Catheterization• Stool softeners in anorectal disease• Blood transfusion

• Next step??• Monitoring


Question

• When should we transfuse blood?

• Answer• <7 g/dl• <8 g/dl with major comorbidities like CAD• <10 g/dl if a procedure is planned.


Key Point #4

Fluid, PPI & blood transfusion are keys to save life in acute upper GI bleed


Clinical Case # 3A 62 years young male present to OPD with upper abdominal pain for 1 week. EHR showed he has visited BH several times over last one year and has been being diagnosed as acid peptic disease.


Question• What are the red flag signs or ‘ALARM’

symptoms in acid peptic disease?


GI Malignancy: Red Flags1. Anemia2. Loss of weight3. Abdominal lump4. Recent onset after 50-60 years of age5. Malaena

Carcinoma


Key Point #5

Always inquire for ALARM symptoms before prescribing for dyspepsia especially in old age.


Summary 1) It is essential to differentiate hematemesis

from hemoptysis.2) NG tube aspiration should be done if doubt

exists to confirm upper GI bleeding.3) Ulcer bleed is responsible for majority of cases

of upper GI bleed.4) Fluid, PPI & Blood transfusion can save life in

acute upper GI bleed.5) We should inquire for RED FLAG signs in old

age with APD.


Questions?


Thank you!

Gastrointestinal bleeding

Health & Medicine

Transcript of Gastrointestinal bleeding