Gastrointestinal Bleeding

The goal when evaluating gastrointestinal bleeding in the ED is to resuscitate and stabilize patients with an acute GI bleed. In addition, attempts are made to determine the nature and extent of the bleed, whether it is acute or chronic, and to identify the 10% to 20% of patients who may rebleed. Upper gastrointestinal bleeding (UGIB) is bleeding occurring proximal to the ligament of Treitz; lower gastrointestinal bleeding (LGIB), the less frequent of the two, is distal and usually is due to colonic bleeding.

The five most common causes of nonvariceal UGIB are duodenal and gastric ulcers (50%), gastric erosions (30%), Mallory-Weiss syndrome (10%), and esophagitis. Duodenal ulcers are more common than gastric ulcers. Gastric ulcers are more often associated with the use of nonsteroidal antiinflammatory drugs and aspirin. Esophageal varices account for a significant minority of UGIB admissions. Many patients with known esophageal varices have GI bleeding originating from other locations.

Perirectal disease, diverticulosis, and angiodysplasia account for the majority of significant LGIB. In patients with a history of AAA grafts or occlusive aortoiliac disease, aortoenteric fistulas, a condition with high mortality, should be considered. A decreased hematocrit can lead to cardiac ischemia, particularly in elderly patients with coronary artery disease.

Causes

Few medicines, and alcohol can damage tissue in the GI tract and creat the infections and produce bleeding. So can growths or the swollen pockets that sometimes form in the walls of the intestines. Blood vessels that are not formed correctly also can bleed.

Some of the most possible causes of gastrointestinal bleeding such as including, Gastric ulcer, Bleeding diverticulum, Ulcerative colitis, Crohn's disease, Mallory-Weiss tear, Esophagitis, Dysentery (bloody, infectious diarrhea), Ischemic bowel, Hemorrhoids and Duodenal ulcer.

Symptoms

• Red or coffee-ground hematemesis with or without melena indicates UGIB.
• Bright red rectal bleeding usually occurs with LGIB but can be seen with a vigorous UGIB.
• Hematochezia can be associated with either UGIB or LGIB.
• Patients with UGIB may have no symptoms other than hematemesis or melena +++.
• The volume of hematemesis is a poor guide for estimating volume loss.
• For Mallory-Weiss tears, patients have a history of hematemesis and alcohol consumption ++++; repetitive vomiting +++; and aspirin use, coughing, heavy lifting, and pregnancy +.
• Patients with simultaneous UGIB and acute myocardial infarction may report only dizziness, syncope, or acute confusion +++ and not chest pain.

Signs

• Hematemesis
• Gross or occult blood in stool
• Hypotension occurs late (typically with about 1500 ml blood loss).
• Tachycardia may appear earlier in hypovolemia.
• Cool, clammy extremities and altered mental status occur late (after significant volume loss).
• Hepatomegaly, ascites, palmar erythema, and spider nevi are suggestive of variceal disease.

Treatment

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• Patients with peptic ulcers: Protone pump inhibitors iv .They work much better if the ulcer has initially been treated locally with endoscope
• Patients with liver failure: treat the vitamine K
• The patient has anaemia: if moderate they should not be transfused before the bleeding has stopped for a day, as the lower blood pressure may be a benefit in allowing the bleeding to stop.
• If the patient has hypotension: it should be treated with fluids and blood, but a slightly lower blood pressure may be of benefit by allowing the bleeding to stop.