1. Gastrointestinal Bleeding

2. Case…  Hassan is 45 y/o saudi gentleman, presents to ED at KKUH early morning, C/O vomiting blood.  How would you approach?  How would you manage?

3. Gastrointestinal Bleeding PERSPECTIVE Epidemiology o Gastrointestinal (GI) bleeding is a relatively common problem countered in emergency medicine that often requires early consultation and hospital admission.

4. Gastrointestinal Bleeding o The overall mortality rate for GI bleeding is approximately 10% and has not changed significantly since the 1960s. o Diagnostic modalities have improved much more than therapeutic techniques.

5. Gastrointestinal Bleeding o GI bleeding is often easy to identify when there is clear evidence of vomiting blood or passing blood in the stool, but the clinical presentation may be subtle, with signs and symptoms of hypovolemia, such as dizziness, weakness, or syncope.

6. Gastrointestinal Bleeding o The approach to GI bleeding depends on whether the hemorrhage is located in the proximal or the distal segment of the GI tract (i.e., upper or lower GI bleeding). o These segments are anatomically defined by the ligament of Treitz in the duodenum.

8. Gastrointestinal Bleeding o Lower GI bleeding (LGIB) affects a smaller portion of patients and results in proportionally fewer hospital admissions than UGIB.

9. Gastrointestinal Bleeding o GI bleeding can occur in persons of any age but most commonly affects people in their 40s through 70s (mean age, 59 years). o Most deaths caused by GI bleeding occur in patients older than 60 years. UGIB is more common in men than in women (in a 2 : 1 ratio), whereas LGIB is more common in women.

10. Gastrointestinal Bleeding o Significant UGIB requiring admission is more common in adults, whereas LGIB requiring admission is more common in children.

11. Gastrointestinal Bleeding DIAGNOSTIC APPROACH Differential Considerations o Peptic ulcer disease, gastric erosions, and varices account for approximately three fourths of adult patients with UGIB.

12. Gastrointestinal Bleeding o Diverticulosis and angiodysplasia account for approximately 80% of adults with LGIB. In children, esophagitis, gastritis, and peptic ulcer disease are the most common causes of UGIB, and infectious colitis and inflammatory bowel disease are the most common causes of LGIB.

13. Gastrointestinal Bleeding o In children younger than 2 years of age, massive LGIB is most often a result of Meckel’s diverticulum or intussusception. o At all ages, anorectal abnormalities are the most common cause of minor LGIB.

16. Gastrointestinal Bleeding o Despite improved diagnostic techniques, no source of bleeding is identified in approximately 10% of patients with GI bleeding. o In patients with abdominal aortic grafts who present to the emergency department (ED) with GI bleeding, the possibility of aortoenteric fistula should be considered.

17. Gastrointestinal Bleeding o Prompt surgical consultation in the ED should be obtained if this is suspected, because bleeding can be massive and fatal.

18. Gastrointestinal Bleeding Rapid Assessment and Stabilization o Most patients with GI bleeding are easy to diagnose because they present to the ED complaining of vomiting blood or passing black or bloody stool. o The diagnosis is confirmed quickly by examination of the stool for the presence of blood.

19. Gastrointestinal Bleeding o Patients with suspected GI bleeding who are hemodynamically unstable should undergo rapid evaluation and resuscitation. o They should be undressed quickly to permit placement of cardiac and oxygen saturation monitors, and supplemental oxygen should be given as needed.

20. Gastrointestinal Bleeding o At least two large-bore peripheral intravenous lines should be placed (minimum 18-gauge); blood should be drawn for hemoglobin or hematocrit, platelet count, prothrombin time (PT), and type and screen or type and crossmatch studies; and crystalloid resuscitation should be initiated.

21. Gastrointestinal Bleeding o Intravenous crystalloid fluid should be given as a 2-L bolus in adults or 20 mL/kg in children until the patient’s vital signs have stabilized or the patient has received 40 mL/kg of crystalloid in an adult or 60 mL/kg as a child.

22. Gastrointestinal Bleeding o Patients who remain unstable after 40 to 60 mL/kg of crystalloid should be given type O, type-specific, or cross matched blood, depending on availability. o Persistently unstable patients should receive immediate consultation with a gastroenterologist for UGIB and with a surgeon for LGIB.

23. Gastrointestinal Bleeding o History, physical examination, testing a stool sample for blood, and measuring hemoglobin or hematocrit are the keys to diagnosing GI bleeding in most patients.

24. Gastrointestinal Bleeding History o Patients typically complain of vomiting red blood or coffee grounds–like material, or passing black or bloody stool. o Hematemesis (vomiting blood) occurs with bleeding of the esophagus, stomach, or proximal small bowel.

25. Gastrointestinal Bleeding History o Approximately 50% of patients with UGIB present with this complaint. o Hematemesis may be bright red or darker (i.e., coffee grounds–like) as a result of the conversion of hemoglobin to hematin or other pigments by hydrochloric acid in the stomach.

26. Gastrointestinal Bleeding o The color of vomited or aspirated blood from the stomach does not differentiate between arterial and venous bleeding. o Melena, or black tarry stool, will result from the presence of approximately 150 to 200 mL of blood in the GI tract for a prolonged period.

27. Gastrointestinal Bleeding o Melena is seen in approximately 70% of patients with UGIB and in one third of patients with LGIB. o Black stool that is not tarlike may result from presence of 60 mL of blood from the upper GI tract. Blood from the duodenum or jejunum must remain in the GI tract for approximately 8 hours before turning black.

29. Gastrointestinal Bleeding o Occasionally, black stool may follow bleeding into the lower portion of the small bowel and ascending colon. o Stool may remain black and tarry for several days, even though bleeding has stopped.

30. Gastrointestinal Bleeding o Hematochezia, or bloody stool (bright red or maroon), most often signifies LGIB but may be due to a brisk UGIB with rapid transit time through the bowel in 10 to 15% of patients. o Because UGIB is much more common than LGIB, a more proximal source of significant bleeding must be excluded before assuming the bleeding is from the lower GI tract.

31. Gastrointestinal Bleeding o Approximately two thirds of patients with LGIB present with red blood from bleeding per rectum. o Small amounts of red blood (e.g., 5 mL) from rectal bleeding, such as bleeding due to hemorrhoids, may cause the water in the toilet bowl to appear bright red.

32. Gastrointestinal Bleeding o Bright red stools also can be seen after ingestion of a large quantity of beets; in this case, Hemoccult testing would be negative and the patient also will report pink colored water in the toilet bowl.

33. Gastrointestinal Bleeding o In taking the history, specific questions should address the duration and quantity of bleeding, associated symptoms, previous history of bleeding, current medications, alcohol, nonsteroidal anti-inflammatory drug use and long-term aspirin ingestion, allergies, associated medical illnesses, previous surgery, treatment by nonhospital personnel, and the response to that treatment.

34. Gastrointestinal Bleeding o Patients with GI bleeding may report symptoms of hypovolemia, such as dizziness, weakness, or loss of consciousness, most often after standing up. o Other nonspecific complaints include dyspnea, confusion, and abdominal pain.

35. Gastrointestinal Bleeding o Rarely an elderly patient may present with ischemic chest pain precipitated by significant anemia due to a GI bleed. o One in five patients with GI bleeding may have only nonspecific complaints.

36. Gastrointestinal Bleeding o The history is of limited help in predicting the site or quantity of bleeding. o Patients with a previously documented GI lesion bleed from the same site in only 60% of cases.

37. Gastrointestinal Bleeding o Gross estimates of blood loss based on the volume and color of the vomitus or stool (e.g., brown or black, pink or red) or the number of episodes of hemorrhage are notoriously inaccurate.

38. Gastrointestinal Bleeding Physical Examination o Vital Signs Vital signs and postural changes in heart rate and blood pressure have been used to assess the amount of blood loss in patients with GI bleeding but are insensitive and nonspecific, with the exception of significant, sustained heart rate increase and hypotension.

39. Gastrointestinal Bleeding o All patients with a history suggesting GI bleeding who are hypotensive, are tachycardic, or experience sustained posture-induced changes in heart rate of greater than 20 beats per minute should be assumed to have a significant hemorrhage.

40. Gastrointestinal Bleeding o Normal vital signs do not exclude a significant hemorrhage, and postural changes in heart rate and blood pressure may occur in individuals who are not bleeding (e.g., elderly patients, many normal individuals, individuals on certain medications such as beta-blockers, individuals with hypovolemia from other causes).

41. Gastrointestinal Bleeding o General Examination The physical examination is valuable in establishing a specific diagnosis and assessing the severity of blood loss and the physiologic response to that loss.

42. Gastrointestinal Bleeding o Careful attention is given to the patient’s general appearance, vital signs, mental status (including restlessness), skin signs (e.g., color, warmth, and moisture to assess for shock, or presence of lesions such as telangiectasia, bruises, or petechiae to assess for vascular diseases or hypocoagulable states), pulmonary and cardiac findings, abdominal examination, and rectal and stool examination.

43. Gastrointestinal Bleeding o Frequent reassessment is important because a patient’s status may change quickly.

44. Gastrointestinal Bleeding o Rectal Examination Rectal and stool examinations are often key to making or confirming the diagnosis of GI bleeding. o The finding of red, black, or melenic stool early in the assessment is helpful in prompting early recognition and management of patients with GI bleeding.

45. Gastrointestinal Bleeding o The absence of black or bloody stool, however, does not exclude the diagnosis of GI bleeding. o Regardless of the apparent character and color of the stool, occult blood testing is indicated.

46. Gastrointestinal Bleeding Ancillary Testing o Tests for Occult Blood The presence of hemoglobin in occult amounts in stool is confirmed by tests such as ( Hemoccult, HemaPrompt). o Stool tests for occult blood may have positive results 14 days after a single, major episode of UGIB.

47. Gastrointestinal Bleeding o False-positive results have been associated with the ingestion of certain fruits (e.g., cantaloupe, grapefruit, figs), uncooked vegetables (e.g., radish, cauliflower, broccoli) and red meat, methylene blue, chlorophyll, iodide, cupric sulfate, and bromide preparations.

48. Gastrointestinal Bleeding o False-negative results are uncommon but can be caused by bile or ingestion of magnesium containing antacids or ascorbic acid. o Tests to evaluate gastric contents for occult blood (e.g., Gastroccult) can be unreliable and should not be used for this purpose. o In newborns, maternal blood that is swallowed may cause bloody stools; the Apt test may show that it is maternal in origin.

49. Gastrointestinal Bleeding o Clinical Laboratory Tests Blood should be drawn for evaluation of baseline hematocrit or hemoglobin, coagulation studies (PT and platelet count), and type and crossmatch studies (or type and screen studies if the patient is stable). o The initial hematocrit may be misleading in patients with preexisting anemia or polycythemia.

50. Gastrointestinal Bleeding o Changes in the hematocrit may lag significantly behind actual blood loss. Infusion of normal saline speeds equilibration of the hematocrit; however, rapid infusion of crystalloid in nonbleeding patients also may cause a decrease in hematocrit by hemodilution.

51. Gastrointestinal Bleeding o In general, patients with a hemoglobin concentration of 8 g/dL or less (hematocrit <25%) from acute blood loss usually require blood therapy. o After transfusion and in the absence of ongoing blood loss, the hematocrit can be expected to increase approximately 3% for each unit of blood administered (hemoglobin level increases by 1 mg/dL).

52. Gastrointestinal Bleeding o The PT should be used to determine whether a patient has a preexisting coagulopathy. o An elevated PT may indicate vitamin K deficiency, liver dysfunction, warfarin therapy, or consumptive coagulopathy.

53. Gastrointestinal Bleeding o Patients receiving therapeutic anticoagulants or patients with an elevated PT and evidence of active bleeding should receive sufficient fresh frozen plasma to correct the PT. o Serial platelet counts are used to determine the need for platelet transfusions (i.e., less than 50,000/mm3).

54. Gastrointestinal Bleeding o Blood Bank Blood should be sent for “type and hold” or type and crossmatch studies early in the patient’s care. o Immediate transfusion needs in unstable patients can be met with O-positive packed red blood cells (O-negative packed red blood cells in women of childbearing age whose Rh status is unknown).

55. Gastrointestinal Bleeding o Type-specific blood is usually available within 10 to 15 minutes. o Group O blood and type-specific blood are safe for patients and cause few transfusion reactions.

56. Gastrointestinal Bleeding o Fully crossmatched blood may take 60 minutes to prepare. o Stable patients can be managed more cost- effectively by ordering “type and hold” without crossmatching for units of blood.

57. Gastrointestinal Bleeding o Other Laboratory Tests Electrolytes usually are normal in patients with GI bleeding. o However, determination of electrolytes, blood urea nitrogen, and creatinine may be useful in a small percentage of patients with GI bleeding when indicated.

58. Gastrointestinal Bleeding o For example, in patients with repeated vomiting, hypokalemia, hyponatremia, and metabolic alkalosis may develop, which usually correct with adequate hydration and the resolution of vomiting.

59. Gastrointestinal Bleeding o Patients with shock often have metabolic acidosis from lactate accumulation. The blood urea nitrogen is elevated in many patients with UGIB as a result of the absorption of blood from the GI tract and hypovolemia causing prerenal azotemia.

60. Gastrointestinal Bleeding o Electrocardiogram An electrocardiogram (ECG) should be obtained in all patients with a GI bleed who are older than 50 years of age or have preexisting ischemic cardiac disease, significant anemia, or chest pain, shortness of breath, or persistent hypotension.

61. Gastrointestinal Bleeding o Asymptomatic myocardial ischemia (ST segment depression greater than 1 mm) or injury (ST segment elevation greater than 1 mm) may develop in the setting of GI bleeding.

62. Gastrointestinal Bleeding o Patients with GI bleeding and clinical or ECG evidence of myocardial ischemia should receive packed red blood cells as soon as possible, as well as appropriate treatment for myocardial ischemia.

63. Gastrointestinal Bleeding o Imaging GI hemorrhage is not an indication for plain abdominal radiography. o An upright chest radiograph should be obtained in patients with UGIB suspected of aspiration or with signs and symptoms of bowel perforation (shock with significant abdominal or peritoneal tenderness).

64. Gastrointestinal Bleeding o Subdiaphragmatic air consistent with bowel perforation is a rare finding with UGIB, but it is an indication for immediate surgical consultation and operative repair.

65. Gastrointestinal Bleeding DIFFERENTIAL DIAGNOSIS o Not all patients complaining of vomiting blood or passing blood in the stool have GI bleeding. o Swallowing blood during epistaxis or from the oral cavity may cause hematemesis or melena.

66. Gastrointestinal Bleeding o Red vomitus may be due to food products (e.g., Jell-O, tomato sauce, wine), and black stool may be due to iron therapy or bismuth (e.g., Pepto-Bismol).

67. Gastrointestinal Bleeding o Hypovolemia (and its symptoms) may be due to vomiting and diarrhea without bleeding. o Poor oral intake with or without fever also may result in hypovolemia. o Usually the patient’s hemoglobin or hematocrit is normal or elevated until hemodilution can occur.

68. Gastrointestinal Bleeding o There are many causes of anemia other than GI bleeding. o In the absence of suggestive symptoms or blood in the stool, GI bleeding is less likely to be the cause of observed anemia.

69. Gastrointestinal Bleeding MANAGEMENT o Quick identification, aggressive resuscitation, risk stratification, and prompt consultation are the keys to appropriate emergency management. o When the diagnosis of GI bleeding is made, emergency management of patients can proceed.

70. Gastrointestinal Bleeding Reassurance o Patients who present to the ED with symptoms and signs of GI bleeding are often frightened by their symptoms. o They may be concerned about the possibility of painful procedures and of the real or perceived risk of death.

71. Gastrointestinal Bleeding o These patients and their families should be treated in a supportive and reassuring manner. o They should be provided with accurate information about their problem, and all aspects of the care they are receiving should be explained in a way that they understand.

72. Gastrointestinal Bleeding o After initial resuscitation of the patient, it is important to identify whether the hemorrhage is proximal or distal to the ligament of Treitz (i.e., UGIB or LGIB). o If the patient’s vomitus demonstrates blood, then the diagnosis of UGIB is confirmed.

73. Gastrointestinal Bleeding o If a patient reports bloody or “coffee grounds” emesis or if melenic stool is present, an upper GI bleed is more likely. o Placement of a nasogastric (NG) tube formerly was widely undertaken in the belief that it had both diagnostic and therapeutic benefit.

74. Emergency management of patients with gastrointestinal bleeding. ED, emergency department; IV, intravenous; LGIB, lower gastrointestinal bleeding; UGIB, upper gastrointestinal bleeding.

75. Gastrointestinal Bleeding o In patients who have hematochezia, an upper GI origin for the bleeding often is associated with signs and symptoms of shock, because rapid transit time of large quantities of blood is producing the hematochezia.

76. Gastrointestinal Bleeding o Because up to 10 to 15% of patients with hematochezia have UGIB, it has been recommended that an NG tube be inserted in most cases of LGIB, but there is no evidence to support an improved outcome related to this practice.

77. Gastrointestinal Bleeding o Typically, a clinical decision is made regarding the likelihood of an upper versus lower GI origin for the bleeding, and endoscopy is then performed based on that determination. o If the first endoscopy approach fails to identify the bleeding site, often endoscopy of the other end of the GI tract is necessary.

78. Gastrointestinal Bleeding Anoscopy/Proctosigmoidoscopy o Patients with mild rectal bleeding who do not have obviously bleeding hemorrhoids should undergo anoscopy or proctosigmoidoscopy. o If bleeding internal hemorrhoids are discovered, and the patient does not have portal hypertension, the patient may be discharged with appropriate treatment and follow-up evaluation for hemorrhoids.

79. Gastrointestinal Bleeding o If hemorrhoids are not detected, it is important to determine if the stool above the rectum contains blood. o The absence of blood above the rectum in a patient who is actively bleeding indicates that the source of bleeding is in the rectum.

80. Gastrointestinal Bleeding o The presence of blood above the anoscope or sigmoidoscope does not invariably indicate a proximal source of bleeding, because retrograde passage of blood into the more proximal colon commonly occurs. o Such patients need further evaluation.

81. Gastrointestinal Bleeding Endoscopy o Endoscopy is the most accurate diagnostic tool available for the evaluation of UGIB. o It identifies a lesion in 78% to 95% of patients with UGIB if it is performed within 12 to 24 hours of the hemorrhage. o Accurate identification of the bleeding site allows for risk stratification with respect to predicting rebleeding and mortality.

82. Gastrointestinal Bleeding o Endoscopy-based triage significantly reduces o hospitalization rates and costs of treating upper GI bleeding. o Significant advances in endoscopic hemostasis also make it of therapeutic value in select patients (e.g., for banding or sclerosing of varices). o Colonoscopy is an effective tool for diagnosis and selected treatment of LGIB.

83. Gastrointestinal Bleeding Angiography and Tagged Red Blood o Cell Scan Angiography can detect the location of UGIB in two thirds of patients studied. o Since the advent of endoscopy, however, the use of angiography has decreased significantly, and today angiography is used in only 1% of patients with UGIB.

84. Gastrointestinal Bleeding o Angiography is used more commonly in patients with LGIB and usually in consultation with a general surgeon. o Although angiography rarely diagnoses the cause of bleeding, it does identify the site of bleeding in approximately 40% of patients who have LGIB and in 65% of patients who eventually require surgical intervention.

85. Gastrointestinal Bleeding o Angiography ideally is performed during active bleeding; this may be apparent from persistently unstable vital signs or continued transfusion requirements to establish or maintain an optimal hemoglobin or hematocrit level.

86. Gastrointestinal Bleeding o Arterial embolization can be used in selected cases of LGIB. o In some patients with more indolent or elusive bleeding, a nuclear isotope–tagged red blood cell scan, usually performed from the inpatient unit, may identify the bleeding site.

87. Gastrointestinal Bleeding Gastric Acid Secretion Inhibition o All patients with peptic ulcer disease documented by endoscopy should receive therapy with a proton-pump inhibitor (e.g., omeprazole). o There is no documented benefit to initiating this therapy or administering H2 antihistamines in the ED for patients with UGIB, however.

88. Gastrointestinal Bleeding Octreotide (Somatostatin Analogues) o Patients with documented esophageal varices and acute upper GI bleeding should receive an intravenous infusion of octreotide at 25–50 μg/hour for a minimum of 24 hours while being observed in the intensive care unit (ICU).

89. Gastrointestinal Bleeding o Octreotide is a useful addition to endoscopic sclerotherapy and decreases rebleeding occurrences. o Octreotide may also reduce the incidence of lower GI rebleeding secondary to angiodysplasia.

90. Gastrointestinal Bleeding Vasopressin o Intravenous vasopressin has been used in the treatment of UGIB, most commonly in patients with variceal hemorrhage. o Controlled studies have not shown a positive effect of vasopressin on overall mortality, however.

91. Gastrointestinal Bleeding o These results, combined with a relatively high rate of serious complications (9% major o and 3% fatal), suggest that use of vasopressin should be limited. o A trial of vasopressin may be warranted in an exsanguinating patient with suspected variceal bleeding, especially if endoscopy is not immediately available.

92. Gastrointestinal Bleeding o The recommended dose of vasopressin is 20 units given intravenously over 20 minutes and then 0.2 to 0.4 unit per minute. o Consultation with a gastroenterologist is advisable.

93. Gastrointestinal Bleeding Sengstaken-Blakemore Tube o Placement of a Sengstaken-Blakemore tube stops hemorrhage in approximately 80% of patients bleeding from esophageal varices. o The Linton tube may be superior to the Sengstaken-Blakemore tube in patients with bleeding gastric varices; however, either of these tubes is rarely used.

94. Gastrointestinal Bleeding o In general, these tubes should not be used without endoscopic documentation of the source of bleeding because complications are common and significant (14% major, 3% fatal).

95. Gastrointestinal Bleeding o A trial of balloon tamponade should be considered, however, in an exsanguinating patient with probable variceal bleeding in whom endoscopy is not immediately available and vasopressin has not slowed the hemorrhage. o Consultation with a surgeon or gastroenterologist is advisable.

96. Gastrointestinal Bleeding Surgery o Surgery is indicated for all hemodynamically unstable patients with active bleeding who do not respond to appropriate intravascular volume replacement, correction of any coagulopathy, and endoscopic intervention (if available). o The mortality rate for patients undergoing emergency procedures for GI bleeding is approximately 23%.

97. Gastrointestinal Bleeding o Generally, surgery is indicated whenever the risk of ineffective medical therapy and continued hemorrhage outweighs that of surgical morbidity and mortality.

98. Gastrointestinal Bleeding o Emergency surgical consultation should be considered when blood replacement exceeds 5 units within the first 4 to 6 hours or when 2 units of blood is needed every 4 hours (after replacement of initial losses) to maintain normal cardiac output.

99. Gastrointestinal Bleeding DISPOSITION Risk Stratification o Risk stratification involves combining historical, clinical, and laboratory data to determine the risk of death and rebleeding in patients presenting to an ED with GI bleeding.

100. Gastrointestinal Bleeding o Patients can be sorted into four risk categories: very low, low, moderate, and high risk. o Some patients present to the ED with a vague complaint of vomiting blood or passing blood from the rectum in whom detailed history and examination allows a diagnosis of hemorrhoid, or anal fissure, or there may be little or no objective evidence of significant GI bleeding.

101. Gastrointestinal Bleeding o These patients can be categorized as very low risk and can be sent home without further diagnostic tests. o Before discharge, patients should be educated about the signs and symptoms of significant GI bleeding and when to return to the ED or when to call their primary care physician.

102. Gastrointestinal Bleeding o They should be given specific education about the possible or actual cause of the bleeding and specific treatment for that disorder. o They should be educated about the side effects of any medications.

103. Gastrointestinal Bleeding o Patents should undergo specific follow-up evaluation within 24 to 36 hours. o They should be instructed to avoid aspirin, nonsteroidal anti-inflammatory drugs, and alcohol.

104. Gastrointestinal Bleeding o Patients with low-risk, moderate-risk, and high-risk criteria are more complicated and require further assessment. o Historically, nearly all patients with significant GI bleeding were admitted to the hospital. As health care has changed, a greater emphasis has been placed on outpatient management of select

108. Gastrointestinal Bleeding o low-risk patients with GI bleeding. Studies have shown that combining clinical and endoscopic criteria provides an accurate estimation of the risk of rebleeding and mortality in patients with UGIB.

109. Gastrointestinal Bleeding o These combined criteria have been used to identify patients with UGIB at low risk, who can be discharged home, and patients at moderate or high risk, who need to be admitted to an appropriate care site in the hospital.

110. Gastrointestinal Bleeding o Patients with clinical evidence of GI bleeding should undergo endoscopy as soon as it is available for final risk stratification, inpatient triage, and determination of appropriate treatment.

111. Gastrointestinal Bleeding o If endoscopy is not immediately available, patients with low clinical risk may be admitted to an ED observation unit or short-stay hospital bed until endoscopy can be performed.

112. Gastrointestinal Bleeding o Patients with moderate clinical risk criteria may be admitted to an inpatient floor, intermediate care unit, or ICU, as indicated by specific patient management needs and depending on the capabilities of the institution.

113. Gastrointestinal Bleeding o Patients with high clinical risk should be admitted to a closely monitored step-down unit or an ICU.  The timing of endoscopy depends on availability, the acuity of the patient, the need for emergent therapy, the need to determine final care site, and the need to minimize length of stay.

114. Gastrointestinal Bleeding o Patients with LGIB that is not clearly due to hemorrhoids, fissure, or proctitis should be admitted to an inpatient bed. o Patients with low risk may be admitted to an inpatient floor bed and prepared for a nuclear medicine imaging study (e.g., red blood cell– labeled study) or colonoscopy.

115. Gastrointestinal Bleeding o Patients with high-risk criteria should be admitted to a step-down unit or ICU and considered for angiography to identify the site of LGIB.

116. Gastrointestinal Bleeding o Patients with moderate-risk criteria require individualized determination of the most appropriate inpatient care site (floor, intermediate care bed, or ICU) and the most useful diagnostic studies (nuclear imaging or angiography).

117. Gastrointestinal Bleeding o Consultation with a surgeon should be obtained if it appears that more than 5 units of blood is required to achieve hemodynamic stability or if there is reasonable suspicion that operative intervention may be needed.

118. Gastrointestinal Bleeding o This is especially true of patients older than 65 years of age. In general, the older the patient, the more aggressive the surgical management ought to be. o Patients with a history of varices, persistent postural changes in heart rate, or significant bleeding of bright red blood per rectum are more likely to require surgery than are patients without these findings.

119. Gastrointestinal Bleeding o Emergent vascular surgical consultation is needed for patients who have abdominal aortic grafts who present to the ED with GI bleeding, because of the possibility of an aortoenteric fistula.

120. THANK YOU