Gastrointestinal Bleeding
Gastrointestinal Bleeding: Excerpt from The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
Mark B. Stephens
Gastrointestinal (GI) bleeding is responsible for 1% to 2% of all hospital admissions in the United States (1). Bleeding can be either acute or chronic. The source can be upper or lower, overt or occult. The patient can be either hemodynamically stable or unstable on presentation. A systematic approach to the patient with GI bleeding is critical to an accurate diagnosis.
Approach
The key to successful evaluation of GI bleeding revolves around the following principles (2): (a) determine the hemodynamic stability of the patient; (b) determine the source of bleeding (Table 9.4); (c) stop the bleeding; (d) prevent recurrence.
History
Clinical history accurately points to the source of bleeding in only 40% of cases (3).
A. Upper GI bleeding. Hematemesis and melena are the most common presentations of acute upper GI bleeding. Important questions to ask: Is there a prior history of bleeding (60% rebleed from the same site) (3)? Is there any family history? Does the patient have any comorbid diseases (peptic ulcer disease, pancreatitis, cirrhosis, cancer)? Is the patient taking any medications (especially nonsteroidal antiinflammatory agents)? Does the patient use recreational drugs, cigarettes, or alcohol? What is the character of the pain? Peptic ulcer pain is epigastric, gnawing, rhythmic, and dull. GI cancers are associated with vague epigastric pain, dysphagia, or weight loss. Was there any retching (Mallory–Weiss tear)? Does the patient have a history of prior surgeries? Patients with a history of vascular grafting are at risk for aortoenteric fistulae, which is often associated with a “herald bleed.”
B. Lower GI bleeding. How old is the patient? Age is an important feature in discriminating the source of lower GI bleeding. Patients aged less than 50 years usually bleed from infectious causes, anorectal disease, or inflammatory bowel disease. For patients aged more than 50 years, diverticulosis, angiodysplasia, cancer, and ischemia are most common (4). Are there any associated symptoms? Diverticular disease presents as painless, high volume bleeding. Angiodysplasia and cancer present with symptoms of chronic blood loss (fatigue, dyspnea on exertion). Inflammatory bowel disease presents with bloody diarrhea, cramping, weight loss, and fever. A prior history of inflammatory bowel disease, cancer, or radiation to the abdomen is also important.
Physical examination
A. Vital signs. The single most important aspect of the initial physical examination is determining the patient’s hemodynamic stability. Unstable patients should be managed as trauma patients. Placement of a nasogastric (NG) tube is considered the “fifth vital sign” in patients with acute GI bleeding (2).
B. Focused physical examination. After ensuring hemodynamic stability, the initial physical examination should eliminate a nasal or oropharyngeal source of bleeding. Examine the skin and abdomen carefully for clues to an underlying cause. A rectal examination is mandatory.
1. Skin examination. Ecchymoses, petechiae, and varices should be noted. Conjunctival pallor is a sign of chronic anemia. Numerous mucosal telangiectasias can point to an underlying vascular abnormality.
2. Abdominal examination. Look for stigmata of chronic liver disease (hepatosplenomegaly, spider angiomata, ascites, palmar erythema, caput medusae, gynecomastia, and testicular atrophy) (Chapter 9.9).
3. Rectal examination. Rectal varices, hemorrhoids, and fissures should be noted.
Laboratory evaluation
A. Basic laboratory studies should include a complete blood count with particular attention to the hematocrit, coagulation studies [prothrombin time (PT) and partial thromboplastin time (PTT)], liver function tests (LFTs), serum chemistries (blood urea nitrogen is elevated disproportionately to creatinine in patients with GI blood loss), electrocardiogram (ECG), and NG aspirate analysis. Acutely, the hematocrit is a poor indicator of blood loss; however, serial hematocrits can be useful in assessing ongoing blood loss. A prolonged PT or PTT suggests an underlying coagulopathy. Elevated LFTs suggest underlying liver disease. An ECG is important, especially in elderly patients, to search for evidence of cardiac ischemia. Finally, the NG aspirate is essential. If the aspirate is bright red, or “coffee grounds” in appearance, an upper GI source is likely.
B. Endoscopy plays a central role in the diagnosis and management of GI bleeding. Fiberoptic endoscopy is 90% accurate in pinpointing the source of upper GI bleeding. In addition, the endoscope can also be used to deliver therapy directly.
C. Anoscopy can be used to identify the source of lower GI bleeding; however, the yield is poor (5). Often the site of bleeding cannot be directly visualized or the volume of bleeding is sufficiently heavy to obscure clear visualization.
D. Nuclear medicine studies are useful in grossly localizing bleeding sources to the small intestine, right colon, or left colon. Nuclear scanning is also useful in detecting Meckel’s diverticulae. These images can detect ongoing GI bleeding with a sensitivity of blood loss at 0.05 to 0.1 ml/minute.
E. Angiography can also identify the source of lower GI bleeding. It is not as sensitive as nuclear scanning, requiring a blood loss of more than 0.5 ml/minute.
Diagnostic assessment
The key to the successful approach to GI bleeding is ensuring the hemodynamic stability of the patient. Once done, a systematic search for the source of the bleeding should be undertaken. Although often unreliable, a careful patient history can provide valuable clues to factors that may predispose the patient to hemorrhage from a particular site within the GI tract. Physical examination (including placement of a NG tube) can further delineate whether an upper source or a lower source is most likely. The key diagnostic modality in GI bleeding is fiberoptic endoscopy. Following the clues provided by a careful history and physical examination, targeted endoscopy is then used to definitively identify the source of bleeding. In the rare cases where endoscopy is unable to adequately identify the source of GI bleeding, specialized nuclear medicine and angiographic studies can be used.
References
1. Zimmerman HM, Curfman K. Acute gastrointestinal bleeding. AACN Clin Issues 1997;8(3):449–458.
2. Laine L. Acute and chronic gastrointestinal bleeding. In: Feldman M, Sleisinger MH, Scharschmidt BF, eds: Gastrointestinal and liver disease: pathophysiology, diagnosis, and management. Philadelphia: WB Saunders, 1998:198–218.
3. McGuirk TD, Coyle WJ. Upper gastrointestinal tract bleeding. Emer Med Clin N Am 1996;14(3):523–545.
4. Zuccaro G. Management of the adult patient with acute lower gastrointestinal bleeding. Am J Gastroenterol 1998;93(8):1202–1208.
5. Bono MJ. Lower gastrointestinal bleeding. Emer Med Clin N Am 1996;14(3):547–556.
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Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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