Rosen & Barkin's 5-Minute Emergency Medicine Consult (294 page)

• 530.11 Reflux esophagitis
  
• 530.81 Esophageal reflux
  

BASICS

• Bleeding from GI tract:
  
  • Upper GI tract: Proximal to ligament of Treitz
    
  • Lower GI tract: Distal to ligament of Treitz to anus
    
• Mortality rate:
  
  • 10% overall; from <5% in children up to 25% for adults of age >70
    
  • Upper GI bleed (UGIB) 6–8%; variceal 30–50%
    
  • Lower GI bleed (LGIB) 2–4%
    

• Ulcerative disease of upper GI tract:
  
  • Peptic ulcer disease (40%):
    
    • Helicobacter pylori
      infection
      
    • Drug-induced (NSAIDs, aspirin, glucocorticoids, K
      ⁺
      supplements, Fe supplements)
      
  • Gastric or esophageal erosions (25%):
    
    • Reflux esophagitis
      
    • Infectious esophagitis (
      Candida
      , HSV, CMV)
      
    • Pill-induced esophagitis
      
    • Esophageal foreign body
      
  • Gastritis and stress ulcerations:
    
    • Toxic agents (NSAIDs, alcohol, bile)
      
    • Mucosal hypoxia (trauma, burns, sepsis)
      
    • Cushing ulcers from severe CNS damage
      
    • Chemotherapy
      
• Portal HTN:
  
  • Esophageal or gastric varices (10%)
    
  • Portal hypertensive gastropathy
    
• Arteriovenous malformations:
  
  • Aortoenteric fistula (s/p aortoiliac surgery)
    
  • Hereditary hemorrhagic telangiectasia (Osler—Weber–Rendu syndrome)
    
  • Dieulafoy vascular malformations
    
  • Gastric antral vascular ectasia (GAVE or watermelon stomach)
    
  • Idiopathic angiomas
    
• Mallory–Weiss tear (5%)
  
• Gastric and esophageal tumors
  
• Pancreatic hemorrhage
  
• Hemobilia
  
• Strongyloides stercoralis
  infection
  

• Diverticulosis (33%)
  
• Cancer or polyps (19%)
  
• Colitis (18%):
  
  • Ischemic, inflammatory, infectious, or radiation
    
• Vascular:
  
  • Angiodysplasia (8%)
    
  • Radiation telangiectasia
    
  • Aortocolonic fistula
    
• Inflammatory bowel disease:
  
  • Crohn's disease and ulcerative colitis
    
• Postpolypectomy
  
• Anorectal (4%):
  
  • Hemorrhoids (internal and external)
    
  • Anal fissures
    
  • Anorectal varices
    
  • Rectal ulcer
    
  • Foreign body
    

Meckel diverticulum and intussusception are the most common causes of LGIB in children.

DIAGNOSIS

• Both UGIB and LGIB may present with signs/symptoms of hypovolemia
  
• UGIB classic presentation:
  
  • Hematemesis or coffee ground emesis
    
  • Melena: Black tarry stool
    
• LGIB classic presentation:
  
  • Hematochezia: Bright red or maroon stool
    

• Hematemesis and melena most common
  
• Coffee ground emesis
  
• Black stools
  
• Bright red blood per rectum
  
• Abdominal pain
  
• Weakness or lightheadedness
  
• Dyspnea
  
• Confusion or agitation
  

• Tachycardia
  
• Hypotension
  
• Pale conjunctiva
  
• Dry mucous membranes
  
• Bloody, melanotic, or heme-positive stools
  
• Shock
  

• CBC, coagulation studies, electrolytes
  
• Perform ENT exam. Distinguish between hemoptysis and hematemesis:
  
  • Pulmonary source:
    
    • Bright red and frothy in appearance
      
    • Sputum mixed with blood is likely pulmonary
      
    • pH >7
      
  • GI source:
    
    • Dark red/brown blood, ± gastric contents
      
    • Associated with nausea/vomiting
      
    • pH <7
      
• Consider nasogastric lavage:
  
  • Might help determine if bleeding is ongoing and facilitate endoscopy
    
  • Controversialstudies have failed to demonstrate outcome benefit. False-negatives, if bleeding beyond pylorus.
    
• Rectal exam:
  
  • Inspect for hemorrhoids and anal fissures
    
  • Examine stool color
    
  • False-positive Hemoccult result:
    
    • Raw red meat
      
    • Iron supplements
      
    • Fruits: Cantaloupe, grapefruit, figs
      
    • Vegetables: Raw broccoli, cauliflower, radish
      
    • Methylene blue, chlorophyll
      
    • Iodide, bromide
      
  • False-negative Hemoccult result:
    
    • Bile
      
    • Mg-containing antacids
      
    • Ascorbic acid
      
  • Agents causing black stools, but negative Hemoccult:
    
    • Iron
      
    • Charcoal
      
    • Bismuth (i.e., Pepto-Bismol)
      
    • Food dyes
      
    • Beets
      

Bloody stool in newborns may be caused by the infant swallowing maternal blood.

• CBC:
  
  • Anemia (low mean corpuscular volume seen with chronic blood loss)
    
  • Thrombocytopenia
    
• Electrolytes, BUN, creatinine, glucose
  
• Coagulation profile
  
• Lactate
  
• LFTs, if upper GI bleeding suspected
  
• Type and screen/cross for active bleeding or unstable vital signs
  
• BUN/Cr ratio >36 has a high sensitivity but low specificity for UGIB
  

• Upright CXR if concern for aspiration or perforation
  
• Angiography/arterial embolization:
  
  • Effective for identifying large, active bleeding
    
• Radionucleotide (tagged red blood cell) scan:
  
  • Effective for identifying slow, active bleeding
    

• Anoscopy:
  
  • For suspected internal hemorrhoids or fissures
    
• Esophagogastroduodenoscopy (EGD):
  
  • Diagnostic and possibly therapeutic
    
• Colonoscopy:
  
  • Diagnostic only
    
  • Best after adequate bowel prep
    
• Bowel resection:
  
  • Reserved for refractory bleeding
    

• Epistaxis
  
• Oropharyngeal bleeding
  
• Hemoptysis
  
• Hematuria
  
• Vaginal bleeding
  
• Visceral trauma
  

TREATMENT

• Stabilize airway
  
  • Intubate for massive UGIB, if patient unable to protect airway
    
• Establish access
  
  • Insert large-bore IV (16–18g) and administer crystalloid to keep SBP >90 mm Hg
    
  • Attempt 2nd IV line en route to hospital
    

• Assess airway, breathing, and circulation
  
• Control airway in unstable patients, with massive bleeding, or unable to protect airway
  
• Initiate 2 large-bore (16 g) IVs and place on cardiac monitor
  
• Provide volume:
  
  • Administer 1 L NS bolus (peds: 20 mL/kg) and repeat once, if necessary
    
  • Transfuse RBCs if significant anemia or unstable after crystalloid boluses
    
    • Cross-matched or type-specific blood, if available
      
    • Otherwise, O negative for premenopausal women, O positive for others
      
    • Provide fresh frozen plasma (FFP) along with RBC transfusion in ratio of 1:2–4. For patients requiring massive transfusion, consider adding FFP and platelets in 1:1:1 ratio with RBCs
      
  • For coagulopathy, administer FFP and vitamin K (if INR >1.5) and platelets (if platelets <50,000/uL)
    

• Consult gastroenterology for any significant GI bleeding
  
• Consider surgical consult and/or interventional radiology for massive active bleeding, unstable patient, or evidence of perforation
  
• Place Foley catheter to monitor urine output
  
• Consider nasogastric tube (NGT), as above
  
• Blood transfusion indications:
  
  • Significant anemia:
    
    • Hemoglobin <7 g/dL
      
    • Hemoglobin <10 g/dL when at increased risk of ischemia (e.g., CAD and CVA)
      
    • Evidence of end-organ ischemia
      
    • Ongoing chest pain/ischemic EKG changes
      
  • Unstable vital signs despite crystalloid bolus