Pocket Emergency Medicine (Pocket Notebook Series) 3rd Ed.

GASTROINTESTINAL BLEED

Definition

• Bleeding from the GI tract

Approach

• Hemodynamically unstable patients should get 2 large-bore IVs (14–18 gauge), early transfusion of PRBC as well as FFP & Vit K if impaired coagulation

• ROS, PMH, previous GIB, alcohol use, liver dz

• Labs: CBC, BMP, LFTs, lipase, coagulation studies, type & screen

UPPER GI BLEED

Approach

• Glasgow–Blatchford score was designed to predict need for transfusion or urgent endoscopy. A score of zero identifies low-risk pts who can safely be discharged w/ outpt f/u (JAMA 2012;307(10):1072; Lancet2000;356(9238):1318).

Bleeding Peptic Ulcer Disease (PUD) or Gastritis

Definition

• Inflammation or ulceration of the stomach or duodenal lining caused by H. pylori infection (80% of duodenal ulcers & 60% gastric ulcers), NSAIDs (15–30%), ASA, alcohol, malignancy, smoking, stress, gastrinoma, anticoagulants, other medications

History

• Epigastric abdominal pain worse w/ food (gastric ulcer) or relieved by food (duodenal ulcer). If bleeding ulcer/gastritis: Black tarry stool, coffee ground emesis

Physical Findings

• Epigastric tenderness, melena or heme-positive stools, peritonitis or back pain if perforated

Evaluation

• Upright CXR for free air if perforation suspected

• Labs: CBC, LFTs, coagulation panel, elevated BUN; H. pylori serology (90% sens)

• NG tube not routinely indicated; may help GI to determine emergent vs. delayed EGD

Treatment

• For nonbleeding gastritis/PUD: All patients should start PPI or H2B. May use antacids, Maalox for sx relief. Empiric H. pylori tx not recommended.

• For bleeding or e/o cx: IVF resuscitation, PRBC if indicated, start IV proton pump inhibitor empirically (omeprazole 80 mg IV bolus, then drip)

• Emergent EGD if hemodynamically unstable (vs. surgical intervention in severe cases)

Disposition

• If ongoing bleeding, Blatchford >0, high risk: Admit for EGD

Variceal Bleeds

Definition

• Bleeding from esophageal or gastric varices (present in 40–60% of cirrhotics) due portal HTN (10–30% of UGIB)

History

• Bright red hematemesis, diffuse abdominal pain, nausea

Physical Findings

• Stigmata of liver failure (jaundice, spider angiomas, ascites, caput medusae), Ill-appearing hypotension, tachycardia, melena

Evaluation

• Labs: CBC, LFTs, coagulation panel, type & cross

Treatment

• Place 2 large bore IVs, initiate IV fluid resuscitation, PRBC if anemic or active bleeding

• Octreotide bolus & drip; often start IV PPI empirically for PUD until EGD confirms etiology

• Antibiotic prophylaxis for SBP if ascites present (ceftriaxone or levofloxacin)

• Emergent EGD if hemodynamically unstable, may need emergent TIPS if still bleeding

• Balloon tamponade w/ Minnesota or Blakemore tube if exsanguinating (after intubation)

Disposition

• Usually ICU admission

Pearls

• 30% bleed rate in 1st year, 70% rebleed rate, 30% mortality from the 2nd bleed

• Do not underestimate history: May not appear sick initially but can decompensate quickly

Mallory–Weiss Tear

Definition

• Tears in the mucosal membrane of the distal esophagus caused by retching against a closed glottis (10% of UGIB)

History

• Specks of bright red blood in emesis or mild hematemesis after forceful retching

Physical Findings

• Most have no physical findings, mild tachycardia

Evaluation

• Upright CXR if hemodynamically unstable to evaluate for subcutaneous or mediastinal air for Boerhaave syndrome (complete esophageal rupture)

Treatment

• Antiemetics, PO challenge

Disposition

• D/c w/ outpt EGD

Pearl

• Boerhaave syndrome can result from forceful emesis but pts are usually ill-appearing w/ shock & require surgical management. Consider barium swallow if high suspicion.

Aortoenteric Fistula

Definition

• Fistula b/w the aorta & GI tract, most commonly in duodenum

History

• H/o AAA, aortic graft (usually >5 y), may have sentinel bleed or large-volume GIB

Physical Findings

• Rapid GIB, hemodynamic collapse

Evaluation

• CBC, type & cross, emergent surgical consult, CT scan if stable

Treatment

• IV fluid resuscitation, PRBC if indicated (use uncrossed blood if unstable)

• Surgical repair

Disposition

• Surgical ICU admission

Pearl

• Mortality directly related to time to the OR

LOWER GI BLEED

Bleeding Diverticulosis

Definition: Bleeding diverticula (33% of LGIB), 50% are from ascending colon

History: Sudden onset, painless bright red rectal bleeding initiated by urge to defecate

Physical Findings: nl abdominal exam, BRBPR, no etiology found on rectal exam

Evaluation: Labs: CBC, LFTs, coagulation panel, type & cross

Treatment: IV fluid resuscitation, PRBC if indicated

Disposition: Admit for colonoscopy

Colorectal Cancer

Definition

• Cancer of the colon or rectum (19% of LGIB)

History

• Chronic blood in stool, change in bowel habits, anorexia, weight loss, lightheaded

Physical Findings

• Pale, heme occult positive stools

Evaluation

• Labs: CBC, LFTs, coagulations; CT if concern for obstruction or significant bleeding

Treatment

• IV fluid resuscitation, PRBC if indicated

• Surgical consultation if significant bleeding (rare)

Disposition

• If stable, d/c for outpt colonoscopy/oncology w/u

Colonic Angiodysplasia

Definition: Enlarged, fragile blood vessels, usually in cecum or proximal ascending colon (8% of LGIB)

History: >60 y/o, small frequent bleeds

Physical Findings: nl abdominal exam, BRBPR or heme occult positive stools

Evaluation: CBC, coagulation panel

Treatment: IV fluid resuscitation, PRBC if indicated; endoscopic cautery or IR embolization

Disposition: Admit for observation & colonoscopy

Hemorrhoids

Definition

• Dilated or bulging veins of the rectum & anus. Internal hemorrhoids may prolapse & become incarcerated (irreducible) or strangulated (ischemic).

History

• Bright red coated stool/toilet paper/dripping into the bowl, pain w/ defecation (external hemorrhoids), h/o hard stools/constipation/prolonged sitting

Physical Findings

• External hemorrhoids are visible on eversion of the anal orifice, internal hemorrhoids are visible at 2-, 5-, & 9-o’clock (when prone) w/ anoscopy, unless prolapsed

Evaluation

• CBC only if significant blood loss suspected or concerning underlying condition

Management

• Generally outpt w/ stool softener (Colace, Senna), Sitz baths (15 min TID & after BMs), suppositories for symptomatic relief

• Acute thrombosis (<48 h since onset of pain) can be excised at bedside in ED

• If prolapsed hemorrhoid is incarcerated w/ signs of strangulation, consult surgery

• All patients over 40 should be referred for colonoscopy to exclude concurrent malignancy

Pearl

• Does not cause anemia