Gastrointestinal Hemorrhage
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Contents |
More Specific Terms
Introduction
- Bleeding from the gastrointestinal (GI) tract may be considered upper or lower GI hemorrhage ( bleeding proximal or distal to the jejunum).
Clinical-manifestations
- postural hypotension suggests moderate bleeding (10-20% of circulating volume)
- supine hypotension suggests severe bleeding (> 20% of circulating volume)
- hematemesis suggests upper GI bleed
- melena suggests bleeding proximal to the cecum
- bright red blood per rectum suggests an anorectal or left colon bleed
- maroon-colored stool suggests a right colon or distal cecum bleed
- Risk factors for increased morbidity & mortality
- age > 60 years
- more than 1 comorbidity
- severe blood loss (> 5 units)
- hemodynamic instability
- bright red hematemesis with hypotension
- multisystem failure
- variceal bleeding
- peptic ulceration (> 2 cm)
- recurrent hemorrhage (within 72 hours)
- emergency surgery
Laboratory
- type & screen ( cross-match if transfusion is indicated)
- complete blood count ( CBC)
- hemoglobin & hematocrit are poor indicators of acute blood loss
- platelets
- PT/ aPTT
- serum chemistries
Diagnostic-procedures
- electrocardiogram in elderly patients
Management
- assessment & restoration of hemodynamic stability
- two large bore intravenous ( IV) catheters (14-18 gauge), central venous catheter adds no additional benefit
- normal saline or lactated ringers to restore volume
- urine output is best measure of adequate fluid replacement
- hetastarch 5% ( Hespan) until blood products available
- transfusion therapy
- packed red blood cells ( RBC) to maintain hematocrit > 25% or > 30% in patients with cardiopulmonary disease
- correct coagulopathy with fresh frozen plasma ( FFP)
- thrombocytopenia ( platelets < 40,000/ mm3) should be corrected with platelet transfusions or with therapy directed at the cause of the thrombocytopenia
- massive transfusion (> 6 units)
- blood warming
- monitor for hypocalcemia from citrate in blood products
- aspiration of gastric contents to confirm upper GI bleed
- gastric lavage with normal saline
- coffee ground-like material, strong + occult blood
- false negatives with: intermittent bleeding, duodenal bleed without reflux to stomach
- use of iced saline or norepinephrine of no value
- gastric lavage increases likelihood of early endoscopy but not better patient outcomes [3]
- digital rectal examination or anoscopy: masses, hemorrhoids, gross or occult blood, melena
- specific measures to control bleeding
- specific measures for comorbidities
- also see algorithm for management of GI bleed
More General Terms
References
- Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 346-348
- Medical Knowledge Self Assessment Program (MKSAP) 11, 14, American College of Physicians, Philadelphia 1998, 2006
- Huang ES et al. Impact of nasogastric lavage on outcomes in acute GI bleeding. Gastrointest Endosc 2011 Nov; 74:971. PMID: [1]
- Pallin DJ and Saltzman JR. Is nasogastric lavage in patients with acute upper GI bleeding indicated or antiquated? Gastrointest Endosc 2011 Nov; 74:981. PMID: [2] - Gastrointestinal Bleeding: NIH Institute and Center Resources [3]
- National Guideline Clearinghouse
- Management of acute upper and lower gastrointestinal bleeding. A national clinical guideline. Scottish Intercollegiate Guidelines Network (SIGN). ngc-guideline: [4]
