GI Bleed

Notify vomiting blood, possible to lavage coffee ground, black stool/blood present. First, assess ABC (do resuscitation as needed). Differentiate Upper GI bleed vs Lower GI bleed, don’t forget NG and PR + NPO.

Symptoms:

• Upper GI Bleed: Hematemesis, Coffee ground emesis, Melena (Slow Bleed)
• Lower GI Bleed: Hematochezia (heavy bleeding), Melena

*BUN/Cr>20 suggests UGB (some textbooks use 30).

#Upper GI bleed

• Differentiate Non-variceal bleeding vs Variceal bleeding (20%)
• Non-variceal bleeding: May have abdominal pain, symptoms of chronic dyspepsia, long NPO, stress, NSAIDs use.
• Variceal bleeding: Painless, often presents with hematemesis, usually large volume of blood.
• V/S depends on the severity; variceal often unstable.
• Clues: For non-variceal, consider chronic dyspepsia, stress, NSAIDs. For variceal, look for heavy alcohol use, chronic liver disease, signs of portal hypertension.
• Assess risk (of re-bleeding & mortality) using clinical or Blatchford score, Pre-endoscopic Rockall score.
• Pre-endoscopic Management:
• Assess ABC: if unstable, start 2 large bore IVs and fluid load +/- ETT.
• Reserve PRC, FFP, especially for liver disease patients.
• If hemodynamically unstable, administer blood immediately, no need to wait for complete fluid resuscitation.
• LAB: CBC, BUN, Cr, Electrolytes, Ca, Mg, P, Coag, LFT & Serial Hct.
• Administer PRC if Hb<7 g/dl in non-CAD patients (keep Hb 7-9 g%) and <9 g/dl in CAD patients (perform EKG for all patients as Secondary MI might occur).
• For alcohol history, don’t forget DTX and others.

For Non-variceal bleeding:

• Administer pantoprazole 80 mg then drip 8 mg/hr, order as “Pantoprazole 80 mg IV bolus then 80 mg in NSS 200 ml IV drip 20 ml/hr”

For Variceal bleeding, administer PPI (above) along with:

• Splanchnic blood flow lowering agent:
• Somatostatin 250 mcg IV bolus then 250 mcg/hr or
• Octreotide 50 mcg IV bolus then 50 mcg/hr.
• Antibiotic Prophylaxis (Prevent SBP from bacterial translocation):
• Norfloxacin 400 mg PO bid for 7 days or
• Ceftriaxone 1 gm IV OD for 7 days.
• Early EGD (within 24 hrs) in high-risk groups after stabilizing with aim for Hb > 7 g%, platelet > 50,000, Electrolytes normal, INR < 1.5.

#Lower GI bleed

• Assess ABC: if unstable, start 2 large bore IVs and fluid load.
• History taking, physical examination, PR and Proctoscope if possible:
• Consider internal hemorrhoid (if not severe, might do banding ligation as OPD case).
• If active bleed is significant and hemodynamically unstable:
• Consider Angiography + embolization OR consult surgery.
• If bleed stops or is minor and vital signs stable:
• Consider Colonoscopy OR Angiography.

#Stress-related Mucosal Disease (SRMD)

• Pathophysiology: Critical illness and physical stress induce pro-inflammatory cytokine and catecholamine release, combined with hypovolemia and hypotension causing splanchnic hypoperfusion.
• Indication for SRMD prevention: Critical patients with ≥ 1 risk factors like Respiratory failure (Need ventilator > 48 hr) or Coagulopathy (INR>1.5 or Plt <50,000).
• Prevention methods:
• Manage stress condition + early enteral feeding.
• PPI (note: increases risk of C.difficile infection and aspiration pneumonia).