GI bleed

[Age]-yo [M/F] with PMH of..., presenting with
days constant/intermitent *** progressively worsening/improving

  • CC:
    large volume = diverticulosis or varices
    small volume = Hemorrhoids, fissure, Mild gastritis / ulcers
    melena → UGIB (PUD, gastritis, varices)
    hematemesis → UGIB
    hematochezia → LGIB

  • PN

    • Melena (black, tarry stools → UGIB)

    • Hematochezia (bright red blood → LGIB or brisk UGIB)

    • Hematemesis / coffee-ground emesis (UGIB)

    • Dizziness / syncope / weakness (volume loss)

    • Abdominal pain (ulcer, ischemia, colitis)

    • History of liver disease / cirrhosis (→ varices)

    • NSAID / anticoagulant use

    • Alcohol use

    • Prior GI bleed or known ulcers/diverticulosis

  • PN:

    • Pertinent Negatives (PN)

    • No hematemesis

    • No melena or hematochezia (if occult suspected)

    • No abdominal pain (suggests painless bleed → diverticulosis, varices)

    • No NSAID / anticoagulant use

    • No history of liver disease (↓ suspicion for varices)

    • No recent vomiting/retching (↓ Mallory-Weiss)

    • No weight loss or change in bowel habits (↓ malignancy)

    • No fever (↓ infectious colitis)

  • pertinent SHx: tobacco, EtOH, drug use

  • Etiology:
    (UGIB))
    NSAIDs + Epigastric Pain,Better/worsen with food?(duodena/gastric) → PUD
    Alcohol / ICU / NSAIDs → Gastritis
    liver disease?”alcohol use?Prior variceal bleed? →  Varices
    Vomiting BEFORE bleed → Mallory-Weiss
    Pain with swallowing? Immunocompromised? → Esophagitis
    Weight loss → Gastric Cancer
    ((LGIB))
    Painless + large volume → Diverticulosis
    Recurrent intermittent → Angiodysplasia
    Blood on wiping → Hemorrhoids (Straining?)
    Pain BEFORE bleeding → Ischemic Colitis (Recent dehydration or low BP?)
    Chronic diarrhea → IBD (Mucus in stool?)
    Fever?, Recent travel or food? → Infectious Colitis
    Weight loss?Change in bowel habits?Family history?**→ Colorectal Cancer

  • risk factors: NSAID/anticoagulant use, alcohol use, cirrhosis, PUD,

  • initial W/U: CBC(Hgb), CMP(BUN/Cr ratio (>20 suggests UGIB), PT/INR, PTT, Type & Screen, Lactate, EGD vs colonoscopy, Unstable → CTA/P , active bleed CTA for IR embolization

  • pending DATA:

  • MEDS:

  • COURSE:

  • DDX- UGIB (PUD, Gastritis, Esophageal Varices, Mallory-Weiss Tear, Esophagitis, Gastric Cancer) LGIB (Diverticulosis, Angiodysplasia (AVMs), Hemorrhoids, Colorectal Cancer,Ischemic Colitis, Inflammatory Bowel Disease (UC/Crohn’s), Infectious Colitis

Plan 

  • GI consult

    • UGIB → EGD within 24 hrs

    • Emergent EGD if unstable/ongoing hematemesis/variceal concern

    • Stable LGIB → colonoscopy

    • Unstable brisk hematochezia → CTA ± IR

  • 2 large-bore IVs (16–18G)

  • Type & screen / type & cross

  • CBC/BMP/Mg/INR/LFTs

    • Trend CBC q6h initially, space out once stable

  • Transfuse PRBCs

    • Hgb <7

    • <8 if CAD/ACS/symptomatic

  • IV fluids as needed

    • Avoid over-resuscitation in suspected varices

  • Pantoprazole

    • 80 mg IV bolus → 8 mg/hr infusion

    • OR 40 mg IV BID if lower-risk/non-variceal suspected

  • Octreotide** (if variceal suspected or undifferentiated severe UGIB)

    • 50 mcg IV bolus → 50 mcg/hr infusion
      (Your infusion rate was low; standard is usually 50 mcg/hr.)**

  • Ceftriaxone 1 g IV daily x 7 days

    • ONLY if cirrhosis/variceal bleed suspected

  • Hold/reverse anticoagulation/antiplatelets as appropriate

    • Restart individualized after hemostasis (often ~3–7 days depending on indication/risk)

  • NPO

  • Telemetry if significant bleed/hemodynamic instability/anemia

  • Strict I&Os / monitor vitals closely

  • SCDs only initially

    • Hold chemoprophylaxis until bleeding controlled

  • Avoid NSAIDs/alcohol

NOTE:

UGIB. (Melena / hematemesis) ↑BUN/Cr ratio (>20 suggests UGIB)
— PUD (H. pylori, NSAIDs)
SX: epigastric pain, melena, 
HX: NSAIDs, H. pylori 
W/U: CBC,BMP,H. pylori testing, 
TX: IV PPI (pantoprazole)→ endoscopic clipping/cautery → treat H. pylori, Stop NSAIDs

NSAIDs?Burning epigastric pain?(ulcer), Pain better with food?(duodenal ulcer), Pain worse with food (gastric ulcer) melena? ± hematemesis?

— Gastritis / Erosive Gastropathy (alcohol, NSAIDs, stress (ICU), steroids) 
SX: Diffuse epigastric discomfort or burning, mild hematemesis, nausea, dyspepsia 
HX: alcoholism , NSAIDs, ICU/stress 
W/U: CBC,BMP, 
Meds: Steroids, NSAIDs
TX: IV PPI (pantoprazole)→ endoscopic clipping/cautery, Remove offending agent

Alcohol use? Steroids NSAIDs?

— Esophageal Varices
SX: Usually NO pain, massive hematemesis, dizziness, Hypotension/tachycardia
HX: cirrhosis, alcohol use, hepatitis, previous varices bleed 
W/U: CBC, CMP, Coag 
MEDs: 
Tx: bolus of 50 mcg followed by continuous infusion at rate of 25 mcg/hr,IV ceftriaxone, EGD with band ligation, Volume resuscitation if needed 

Hx of cirrhosis , Hx varices bleed? 

— Mallory-Weiss Tear (retching → hematemesis) 
SX: Chest or epigastric pain after vomiting, hematemesis after vomiting/retching
HX:alcohol, forceful emesis
W/U: CBC, CMP,
MEDs: 
Tx: IV PPI ± endoscopic therapy if persistent→ linear tear

alcohol use? forceful emesis? vomiting before the bleeding?

— Esophagitis (GERD, infections (CMV, HSV in immunocompromised)),
SX:Retrosternal, odynophagia(chest pain with swallowing), mild bleeding
HX:Painful swallowing, GERD, immunocompromised (HIV, chemo, steroids?)
W/U:CBC, CMP,
MEDs: 
Tx:PPI-> EGD-> Treat cause (CMV → ganciclovir, HSV → acyclovir)

chest pain with swallowing?  Burning chest discomfort

— Gastric Cancer (malignancy ulceration, weight loss, anemia)
SX:Vague epigastric discomfort, Weight loss, Early satiety, occult bleeding, fatigue, IDA
HX:Iron deficiency anemia 
W/U: CBC,BMP, EGD + biopsy
MEDs: 
Tx: EGD + biopsy

Unintentional weight loss? Early satiety( mass effect),

LGIB  (Bright red blood)

— Diverticulosis (painless hematochezia, sudden) 
SX:sudden painless hematochezia
HX:older age
W/U: CBC,BMP,colonoscopy (after stabilization) ± CTA
MEDs: 
Tx:Often self-limited, Colonoscopic clipping, IR embolization if ongoing bleed

Large-volume bright red blood? prior similar episodes?( common)

— Angiodysplasia (AVMs) 
SX:intermittent painless bleeding
HX:elderly, CKD, aortic stenosis, colonoscopy?
W/U:CBC,BMP
MEDs: 
Tx:Stable → colonoscopy (APC (Argon Plasma Coagulation), Unstable/ongoing brisk bleed → CTA → IR

Recurrent bleeding episodes

— Hemorrhoids (bright red blood on toilet paper) 
SX:bright red blood on wiping, internal: no pain, External: perianal pain/itching
HX: constepation  
W/U:CBC,BMP
MEDs: 
Tx:Fiber, stool softeners , Banding if persistent

bright red blood on wiping? Straining? (cause)

— Colorectal Cancer (weight loss, iron deficiency anemia, occult bleed)
SX: vague abdominal discomfort, Weight loss?occult bleeding, fatigue
HX:CBC,BMP
W/U:colonoscopy + biopsy
MEDs: 
Tx:colonoscopy + biopsy

Change in bowel habits?Family history?Weight loss?

— Ischemic Colitis (painful hematochezia), hypoperfusion (shock, atherosclerosis)
SX:painful hematochezia + abdominal pain
HX: hypotension, vascular disease
W/U:CBC,CMP.latate 
MEDs: 
Tx:IV fluids, Bowel rest, Broad-spectrum antibiotics

painful hematochezia + abdominal pain? pain start BEFORE bleeding? Recent dehydration or low BP?

— Inflammatory Bowel Disease (UC/Crohn’s)
SX: UC: LLQ cramping, Crohn’s: RLQ pain , chronic diarrhea, blood, mucus
HX:
W/U:CBC,CMP,ESR/CRP,colonoscopy
MEDs: 
Tx:colonoscopy, (steroids ± biologics)

Mucus in stool?(UC), UC: LLQ cramping, Crohn’s: RLQ pain

— Infectious Colitis (fever, diarrhea, recent travel/food)
SX:Diffuse abdominal cramping, diarrhea + fever + blood
HX:
W/U:CBC, CMP , stool PCR/culture
MEDs: 
Tx:supportive ± antibiotics 

fever? Recent travel or food exposure? diarrhea? Bold? 

STICKY

  • CC:

  • days

  • constant/intermitent

  • progressively worsening/improving

  • Melena? → UGIB

  • Hematemesis? → UGIB

  • Hematochezia? → LGIB vs brisk UGIB

  • Small vs large volume?

    • Large → diverticulosis / varices

    • Small → hemorrhoids / fissure / mild gastritis

  • Dizziness / syncope / weakness

  • Abdominal pain? (painful vs painless)

  • Vomiting before bleed?

  • Dysphagia / odynophagia?

  • Diarrhea / mucus?

  • Fever?

  • NSAIDs / anticoagulants

  • Alcohol use

  • Liver disease / cirrhosis

  • Prior GI bleed / ulcers / diverticulosis