Gastrointestinal Bleeding

Aka: Gastrointestinal Bleeding, Acute Gastrointestinal Hemorrhage, Acute Gastrointestinal Bleeding Management, GI Bleed, Hematochezia, Melena

1. See Also
   1. Gastrointestinal Occult Bleeding
2. Sources of acute Gastrointestinal Bleeding
   1. Upper Gastrointestinal Bleeding (70%)
      1. Annual Incidence (U.S.): 100-200 per 100,000
   2. Small Intestinal Bleeding (5%)
   3. Lower Gastrointestinal Bleeding (24%)
      1. Annual Incidence (U.S.): 20-27 per 100,000
3. Exam: Vital Signs
   1. Orthostatic Blood Pressure and Pulse
   2. Oxygen Saturation
   3. Follow urine output
4. Signs: Identify gastrointestinal source of blood
   1. Signs of upper GI sources of blood
      1. Hematemesis (present in 50% of Upper GI Bleed)
      2. Nasogastric aspirate positive for blood
   2. Signs of lower GI sources of blood
      1. Blood per rectum occurs with any GI source
      2. Hematochezia (seen in 80% of all GI Bleeding)
         1. Grossly bloody, maroon or dark red stool
         2. Usually correlates with Lower GI Bleeding
         3. Brisk Upper GI Bleeding may cause (11%)
      3. Melena (Black tarry stool)
         1. Black tarry stool requires 150 to 200 cc blood
         2. Black non-tarry stool requires 60 cc blood
         3. Blood must be in GI tract 8 hours to turn black
         4. Stool remains black for several days in GI tract
         5. Melana source
            1. Present in 70% of Upper GI Bleeding
            2. Present in 33% of Lower GI Bleeding
      4. Blood in toilet (e.g. Hemorrhoid source)
         1. Toilet water may appear bright red from 5 cc blood
5. Evaluation
   1. Upper GI Bleeding evaluation
      1. See Upper GI Bleed
      2. See Upper GI Bleeding Score
      3. See Upper GI Endoscopic Evaluation of Bleeding
      4. Indication
         1. Hematemesis and
         2. Blood on nasogastric aspirate
   2. Lower GI Bleeding evaluation
      1. See Lower GI Bleed
      2. See Colonoscopy in GI Bleeding
      3. Indication
         1. No Hematemesis and
         2. Nasogastric lavage/aspirate with bile but no blood
6. Labs
   1. Complete Blood Count
      1. Baseline Hemoglobin (trails bleeding by 24 hours)
   2. Blood Type and Cross-match
   3. Coagulation Factors
      1. Prothrombin Time
      2. Platelet Count
7. Management: Acute
   1. ABC Management
      1. Oxygen
      2. Intravenous Access
         1. Two large bore IV (18 gauge)
         2. Start with isotonic saline (NS or LR)
      3. Intravenous fluid Resuscitation
         1. Crystalloid 10 cc/kg boluses until stable
         2. Reassess after 3 boluses (30 cc/kg)
         3. Consider transfusion for unstable after 3 boluses
      4. Endotracheal Intubation indications (aspiration risk)
         1. Altered mental status
         2. Massive Upper GI Bleeding
   2. Intensive Care Unit admission Indications
      1. Significant bleeding
      2. Hemodynamically unstable
   3. Transfusion Packed Red Blood Cells
      1. Indications
         1. Hemoglobin 8 g/dl or Hematocrit 25%
         2. Brisk active bleeding
         3. Cardiopulmonary symptoms
         4. Cardiopulmonary comorbidity
      2. Do not base transfusion in acute bleeding on labs
         1. Hemoglobin And Hematocrit lag bleeding by 24 hours
         2. Active unstable bleeding requires Blood Products
         3. Base transfusion on Hemodynamic status
         4. Base on response to crystalloid (after 30 cc/kg)
      3. Once stabilized blood count may direct transfusion
         1. Transfuse for Hemoglobin 8 g/dl (Hematocrit 25%)
         2. Expect 1 mg/dl Hemoglobin increase/unit transfused
         3. Expect 3% Hematocrit increase/unit transfused
   4. Transfusion Fresh Frozen Plasma indications
      1. INR (Prothrombin Time) prolonged 1.5 times normal
   5. Transfusion platelet indications
      1. Platelet Count <50,000/mm3
      2. Aspirin or NSAID related GI Bleeding (no evidence)
      3. Clopidogrel (Plavix) use
      4. Cirrhosis (No evidence)
8. Management: Modalities
   1. See Upper GI Bleeding
   2. See Lower GI Bleeding
9. References
   1. Henneman in Marx (2002) Rosen's Emergency, p 194-200
   2. Fallah (2000) Med Clin North Am 84(5):1183-208
   3. Terdiman (1998) Postgrad Med 103(6):43-64