Introduction
Gastrointestinal bleeding refers to any bleeding that originates in the gastrointestinal tract. The amount of bleeding can range from microscopic to acute, massive, and life threatening.
What are the causes of GI bleeding?
Eighty-five to ninety percent of all GI bleeding occurs in the upper GI tract, between the mouth and the duudenum. Listed below are the problems that can result in upper GI bleeding.
• Gastritis: inflammation of the gastric mucosa
• Gastric or duodenal peptic ulcer: erosion in the lining of the stomach or duodenum
• Esophageal varices: dilated veins in the walls of the lower part of the esophagus or the upper part of the stomach
• Mallory Weiss Tear: a tear that occurs between the esophagus and stomach after persistent or violent vomiting
The remaining percentage of GI bleeding occurs in the lower GI tract from the end of the duodenum to the anus. Problems resulting in lower GI bleeding are:
• Bleeding diverticulum/diverticulosis
• Neoplasm: carcinoma, polyp
• Inflammatory bowel disease such as ulcerative colitis or Crohn’s disease
• Ischemic colitis
• Angiodysplasia or Arterio-Venous malformation
• Meckel’s diverticulum: a congenital pouch on the wall of the small intestine
How should I assess a patient with GI Bleeding?
1. Estimate blood loss
• Mild blood loss: 10 – 15% loss of patient’s total blood volume. The patient is usually hemodynamically stable.
• Moderate blood loss: 15- 30% loss. The patient may experience bradycardia, tachycardia or orthostasis.
• Severe blood loss: more than 30% blood loss. The patient will experience hypotension, tachycardia and will be in shock.
2. Patient history
• Inquire about onset and quantity of blood loss and any associated symptoms.
• Symptoms may include nausea, epigastric pain, weakness, anorexia, weight loss or dyspnea.
• Symptoms in the elderly adult may be vague, non-specific or even non-existent.
• Ask about all medications and alcohol use.
3. Physical exam:
Evaluate vital signs, mental status, skin, circulation, and characteristics of the emesis and stool. Is the stool tarry in color? Does the emesis look like coffee grounds?
4. Laboratory tests:
The hemoglobin and hematocrit are important laboratory tests to perform; however, they may not reflect the true blood loss for at least 6 hours
How can I figure out the source of the bleeding?
Bleeding manifests itself in different ways related to the physiologic processes the blood undergoes.
1. Bright red blood: has not undergone any chemical degradation. The site of bleeding is very close to the site of exit (hemorrhoids or esophageal varices), or the bleeding is very fast (i.e. arterial bleed).
2. Maroon/dark red blood: has been through at least one chemical process, such as degradation by hydrochloric acid in the stomach or enzymes in the intestine.
3. Maroon/dark red blood with clots: has been through a chemical process and has coagulated.
4. Black/tarry blood = has been through multiple chemical processes. Excreted as melena after passing through the large intestine where water is removed.
5. "Coffee ground" emesis: blood has been through at least one chemical process, such as degradation by hydrochloric acid in the stomach and usually indicates bleeding in the esophagus, stomach or duodenum.
How will a patient with GI Bleeding be managed?
GI Bleeding can be an emergency that necessitates immediate medical intervention. Interventions for a person with acute GI bleeding are:
• Immediate resuscitation and stabilization: insert two large bore IVs, and administer normal saline or lactated ringers.
• Oxygenation: protect the airway, elevate the head of the bed to prevent aspiration and initiate oxygen therapy. Intubation may be necessary.
• NG Lavage: If the source of the bleeding is believed to be upper GI, a nasogastric tube may be inserted and a tap water lavage initiated. This treatment is rarely used.
• Continued volume replacement and assessment: maintain normal vital signs and prevent hypovolemia and shock. Blood products will be administered if other IV fluids are ineffective in stabilizing the patient’s vital signs and hemoglobin/hematocrit. Blood loss should be replaced by blood products, not IV fluids.
• Medications: Depending on the source of the bleeding, medications may be of value. If the bleeding is due to esophageal varices, drugs such as vasopressin and somatostatin may be effective. Other medications that may be prescribed are H2 blockers and proton pump inhibitors to reduce gastric acid production. Stop any medications the patient may have been taking that could contribute to the bleeding. These medications include: Non-steroidal anti inflammatory drugs (NSAIDs) such as ibuprofen and aspirin, as well as corticosteroids.
• Other treatments: Finally, if the bleeding continues, endoscopy (with sclerotherapy to make the vessels shrink), colonoscopy, angiography, or surgery may be indicated to treat the cause of the bleeding. If helicobacter pylorii is found, therapy with antibiotics is also recommended.
What kind of diagnostic tests will be performed?
Diagnostic exams that may be performed include: CBC, abdominal x-ray or CT scan, colonoscopy/sigmoidoscopy, bleeding scan (tagged red blood cell scan), angiography or an abdominal MRI scan.
Is there anything special I should know about caring for an elderly person who is GI Bleeding?
In general, older adults are at an increased risk of developing acute upper and lower GI bleeding. The reasons for this include:
• Medications such as anticoagulants, which are used to treat systemic diseases
• Aspirin and NSAIDs are commonly used to treat arthritis and these medications increase the likelihood of developing peptic ulcer disease
• Increased occurrence of gastric and peptic ulcer disease in the elderly
• Increased incidence of diverticulitis in older adults, which can result in rapid and massive GI bleeding
Elderly persons are more likely to die from GI bleeding. They are also more likely to experience any number of life-threatening complications.
Complications that are more likely to occur in older adults are sepsis, hypoxia, and ischemic damage to the bowel, kidneys, liver, brain, and heart. Older persons are more likely to develop angina or have a myocardial infarction due to a low hemoglobin.
Even when GI bleeding is appropriately managed, the frail elderly person may develop congestive heart failure or pulmonary edema from the fluid resuscitation.
Although the elderly person may not be the ideal surgical candidate, they are also at a greater risk for developing severe complications when the bleeding is managed ineffectively.
Guaiac-positive stools in the elderly must be assumed to indicate pathology unless proven otherwise. However, medications commonly prescribed for older people can result in a false-positive guaiac test result. Those medications include: laxatives, iron supplements, cimetidine, anticoagulants, aspirin, and NSAIDs. Some foods may also cause a false-positive result including red meat, uncooked vegetables and fruits.
Summary
Caring for a patient with GI Bleeding is challenging. When bleeding occurs in the GI tract, it is a symptom and the cause could be the result of a number of different conditions. Most causes of bleeding are related to conditions that can be cured or controlled, such as ulcers or hemorrhoids. The cause of bleeding may not be serious, but locating the source of bleeding is important. Careful monitoring and management will increase the likelihood of a complete recovery.
References
http://www.nlm.nih.gov/medlineplus/ency/article/003133.htm accessed 07.24.08
http://en.wikipedia.org/wiki/Gastrointestinal_bleeding accessed 07.24.08
http://www.mayoclinic.org/gastrointestinal-bleeding/ accessed 07.24.08
http://digestive.niddk.nih.gov/ddiseases/pubs/bleeding/ accessed 07.24.08
Some of the material in this article was excerpted from the GI, Renal and Endocrine Critical Care Primer and Gastrointestinal Issues in Elder Care offered by TCHP. The TCHP Education Consortium offers homestudy education on a variety of health care topics on their website at www.tchpeducation.com. Homestudies are available to read free of charge on their website. If contact hours are desired, the processing
cost is $5 per contact hour.
