1. Gastro Intestinal Bleeding By: Abdulrahman Sindi ED Resident

2. Case Scenario A 55-year-old male not known to have any medical illness, presented to the E.D. complaining of blood in his vomitus two times this day. HR:120 BP:95/60 RR:22 T:36.7

3. Is the patient stable? What should be done for this patient? What are initial steps in the management?

4. Epidemiology GI bleeding is relatively common problem encountered in ED The mortality rate is is approximately 10% UGIB affects 50-150 people per 100,000 each year Mean age of affected people with GIB is 59 years UGIB is more common in men, whereas LGIB is more common in women UGIB admission is more common in adults whereas LGIB admission is more common in children

5. Differential Considerations

6. UpperLower Peptic ulcer disease diverticulosis Gastric erosionsangiodysplasia varicesUGIB Mallory-Weiss tear Cancer/polyp esophagitisRectal disease duodenitisIBD UpperLower esophagitisAnal fissure gastritisInfectious colitis ulcerIBD Esophageal varices polyps Mallory-Weiss tear intussusception AdultChildren In children less than 2 years of age massive LGIB is most often due to Meckels diverticulum or intussusception

7. Rapid Assessment and Stabilization Patients with suspected GIB who are hemodynamically unstable should be stabilized and evaluated rapidly. Undress and place cardiac and oxygen saturation monitors. Give supplemental oxygen. 2 large bore peripheral intravenous lines. Take blood for (CBC, PT, type and screen or crossmatch). Give bolus crystalloid. Give type O, type specific or crossmatched blood. Consult the GE in UGIB or surgeon in LGIB if persistently unstable.

8. History Hematemesis:: vomiting of blood that occurs in bleeding of the esophagus, stomach, or proximal bowel (50% in UGIB). Melena: black tarry stool that results from the presence of 150-200 ml of blood for prolonged period (70% in UGIB and 33% in LGIB). Hematochezia:

9. History Hematemesis: vomiting of blood that occurs in bleeding of the esophagus, stomach, or proximal bowel (50% in UGIB). Melena: black tarry stool that results from the presence of 150-200 ml of blood for prolonged period (70% in UGIB and 33% in LGIB). Hematochezia: bright red blood in the stool that mostly occurs with LGIB but can occur in UGIB (66% in LGIB and 10-15% in UGIB).

10. History Duration, quantity, associated symptoms, previous history, medications, alcohol, and associated medical illness

11. Physical Examination Vitals: hypotension, tachycardia or postural change in heart rate. General exam: general appearance, mental status, skin signs and abdomin should be assessed carefully. Rectal exam: it’s the key to confirm the diagnosis, it does not exclude the diagnosis if negative

12. Ancillary Testing Occult blood test: it may have positive result 14 days after a major bleed, it has a false positive and negative results, Clinical labs: CBC, coagulation profile, type and screen and crossmatch ECG: should be done to all patients over 50, preexisting cardiac insult, anemia, chest pain, S.O.B., persistent Imaging: CXR if perforation is suspected

13. Management Reassurance N.G. tube and gastric lavage: Aspiration of bloody content diagnoses UGIB, but it does not determine if it is ogoing False negative results are possible if if bleeding is intermittent, in duodenal bleed, pyloric spasm. False positive occurs in nasal bleeding. The presence of bile in excludes the possibility of UGIB. Gastric lavage is helpful to prepare for endoscopy Lavage should not performed in pneumoperitoneum.

14. Management Anoscopy/proctosigmoidoscopy. Endoscopy: It identifies lesion in 78% to 95% if done within 12 to 24 hours. Angiography and tagged RBC scan: Angiography is commonly used in LGIB Detects 40% of LGIB site. It is performed ideally in active bleeding. In undetected bleeding tagged RBC scan is performed.

15. Management Proton pump inhibitors Octreotide Vasopressin Sengstaken-Blakmore Tube: Stops bleeding in 80% of esophageal varices. Indicated when endoscopy is not readily available and vasopressin has not slowed the bleeding. Surgery: Indicated in for all hemodynamically unstable with active bleeding unresponsive to resuscitation

16. Stengstaken-Blackmore Tube

17. Disposition Very low criteria for GIB patients No comorbid disease Normal vitals Negative guaiac test Negative gastric aspiration Normal hemoglobin/hematocrit Proper understanding for signs and symptoms Immediate access to ER Arranged follow up within 24 hours

18. Risk Stratification

19. L

20. Thank You By Dr. Abdulrahman Sindi