1. Care of Patient With Acute Gastrointestinal Hemorrhage Dr. Belal Hijji, RN, PhD November 26, 2011

2. 2 Learning Outcomes At the end of this lecture, students will be able to: Discuss the main causes of gastrointestinal (GIT) hemorrhage that are seen in the intensive care unit (ICU). Briefly describe the pathophysiology, assessment and diagnosis, and medical management of GIT hemorrhage. Discuss the nursing management of a patient with GIT hemorrhage.

3. 3 Description And Etiology of GIT Hemorrhage GIT hemorrhage remains a common complication of critical illness and is a potentially life-threatening condition. Causes of GIT hemorrhage are peptic ulcer disease, stress- related mucosal disease, and esophagogastric varices. These are discussed next. Peptic Ulcer Disease (PUD) PUD which results from breakdown of the gastro-mucosal lining is the leading cause of the upper GIT hemorrhage. PUD occurs when the mechanisms to protect the gastric mucosa cease to function, allowing gastroduodenal mucosal breakdown. Protection of gastroduodenal mucosa from noxious substances (acid, pepsin) takes place via a glycoprotein mucus barrier, tight junctions that help prevent acid penetration, and prostaglandins & nitric oxide (by stimulating mucus and bicarbonate secretion and inhibition of acid secretion).

4. 4 Peptic Ulcer Disease (PUD) (Continued…) After mucosal penetration, gastric secretions autodigest the layers of stomach and duodenum, resulting in a damage in blood vessels and subsequent hemorrhage. Stress-Related Mucosal Disease (SRMD) SRMD occurs by means of the same pathophysiologic mechanism as PUD, but the main cause of disruption of gastric mucosal resistance is increased acid production and reduced blood flow resulting in ischemia and degeneration of the mucosal lining. Patients at risk of SRMD are those in situations of high physiologic stress as in extensive burns, major surgery, severe trauma, shock, and sepsis.

5. 5 Esophagogastric Varices. The portal vein carries blood from the small and large bowel, the spleen, and the stomach to the liver. Obstruction of portal venous flow results in a rise in portal hypertension. Esophagogastric varices are engorged and distended blood vessels of the esophagus and proximal stomach that result from portal hypertension. Esophagogastric varices are vulnerable to damage from gastric secretions and that may result in subsequent rupture and hemorrhage.

6. 6 Pathophysiology Gastrointestinal hemorrhage results in hypovolemic shock and development of multiple organ dysfunction if left untreated. Assessment & Diagnosis The initial clinical presentation of a patient with acute GIT hemorrhage is that of a patient with hypovolemic shock. The hallmarks of GIT hemorrhage are hematemesis, hematochezia (bright red stools), and melena (black, tarry, or dark red stools). Laboratory tests include hemoglobin and hematocrit levels can help to determine the extent of bleeding. Endoscopy, after stabilising the patient, is performed to isolate and treat the source of bleeding.

7. 7 Medical Management To reduce GIT hemorrhage-related mortality, patients at risk should be identified early and be managed through the prophylactic administration of antacids, histamine-2 (H 2 ) antagonists (cimetidine, famotidine, and ranitidine), cytoprotective agents (sucralfate, misoprostol, bismuth subsalicylate), and proton pump inhibitors (lansoprazole, omeprazole) that reduce acid production. Initially, the patient must be stabilised by restoration of adequate circulating blood volume to treat and prevent shock. Therefore, medical management may include: –Intravenous infusion of crystalloids, blood, and blood products. –Oxygenation. –Insertion of nasogastric tube to facilitate gastric lavage or to prevent risk of aspiration.

8. 8 Medical Management (Continued…) Bleeding needs to be controlled as a second priority. This is based on the cause of bleeding. –Peptic Ulcer Disease: Endoscopic thermal therapy uses heat to cauterise the bleeding vessel, and endoscopic injection therapy uses hypertonic saline, epinephrine, ethanol, and sclerosants to induce localised vasoconstriction of the bleeding vessel. –SRMD: Intraarterial infusion of vasopressin and intraarterial embolisation (Gelfoam, coiling). –Esophageal Varices: In acute variceal hemorrhage, intravenous vasopressin, somatostatin, and octreotide can reduce portal venous pressure and slow the hemorrhage.

9. 9 Medical Management (Continued…) Surgical intervention is indicated in patients who remain hemodynamically unstable despite fluid replacement. –PUD: Vagotomy is performed to reduce hydrochloric acid production along with pyloroplasty (surgical procedure to widen the opening in the lower part of the stomach (pylorus) so that the stomach contents can empty into the small intestine). –SRMD: Total gastrectomy is performed when bleeding is generalised. –Esophagogastric Varices: There are a number of surgical procedures that can be performed to control bleeding from gastroesophageal varices. An example is portacaval shunt (A connection is established between the portal vein and the inferior vena cava), to reduce blood pressure in the area and decreases the risk of liver vein rupture and bleeding.

10. 10 Nursing Management Patients with GIT hemorrhage may have a variety of nursing diagnoses including: –Deficient fluid volume. –Decreased cardiac output due to decreased pre-load. –Risk for aspiration. –Imbalanced nutrition. –Risk for infection. –Deficient knowledge related to lack of previous exposure of information. Nursing interventions include administering volume replacement, controlling bleeding, observing for complications, and educating the patient and family.

11. 11 Nursing Management (Continued…) Administering volume replacement. The nurse should: –Establish 2 intravenous access lines using large catheters. –Administer IV fluids and blood components as prescribed. Controlling bleeding. The nurse should: –Insert a large-bore nasogastric tube (Slide 12).12 –Irrigating the stomach using normal saline (Gastric lavage) until the returned fluid is clear. –Keep accurate record of the amount instilled and aspirated to ascertain the amount of bleeding.

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13. 13 Nursing Management (Continued…) Observing for complications. The nurse should: –Continuously observe the patient for signs of gastric perforation. Signs and symptoms include sudden, severe, generalised abdominal pain, with significant rebound tenderness (Pain felt when pressure is placed over the abdomen when the tissue that lines the abdominal cavity is irritated, inflamed, or infected) and rigidity. Educating the patient and family. The nurse should: –Teach the patient and family about acute GIT hemorrhage, its causes and treatments. –Teach the patient about interventions necessary for preventing the recurrence of precipitating disorder, such as stopping alcohol.