Gastrointestinal bleeding can be a serious medical emergency. Whether it's from the upper or lower GI tract, quick identification and treatment are crucial. Causes range from ulcers and varices to diverticulitis and cancer.

Assessing patients involves monitoring vital signs, checking lab values, and looking for signs of shock. Treatment focuses on stopping the bleed, replacing fluids and blood, and preventing complications. A team approach with doctors, nurses, and specialists is key to successful management.

Upper Gastrointestinal Bleeding

Causes of gastrointestinal bleeding

• Upper gastrointestinal bleeding (UGIB) occurs when the source of bleeding is above the ligament of Treitz (duodenojejunal flexure)
  • Peptic ulcer disease most common cause of UGIB results from erosion of the stomach or duodenal lining due to excessive acid secretion (Helicobacter pylori infection, NSAIDs)
  • Gastritis inflammation of the stomach lining caused by various factors (alcohol, stress, medications)
  • Esophageal varices dilated, fragile blood vessels in the esophagus resulting from portal hypertension (cirrhosis)
  • Mallory-Weiss tear longitudinal mucosal laceration at the gastroesophageal junction caused by severe vomiting or retching
  • Gastrointestinal malignancies tumors in the stomach or esophagus can ulcerate and bleed (adenocarcinoma, lymphoma)
• Lower gastrointestinal bleeding (LGIB) originates from a source below the ligament of Treitz
  • Diverticular disease most common cause of LGIB occurs when small pouches (diverticula) in the colon wall become inflamed or rupture
  • Angiodysplasia abnormal, fragile blood vessels in the colon that can bleed spontaneously (elderly patients)
  • Inflammatory bowel disease chronic inflammation of the gastrointestinal tract (Crohn's disease, ulcerative colitis) can lead to ulceration and bleeding
  • Colorectal cancer tumors in the colon or rectum can ulcerate and cause bleeding
  • Hemorrhoids swollen, inflamed veins in the rectum or anus that can bleed with straining or defecation
  • Ischemic colitis reduced blood flow to the colon leading to mucosal injury and bleeding (atherosclerosis, low-flow states)

Assessment of bleeding patients

• Vital signs provide crucial information about the patient's hemodynamic status and severity of bleeding
  • Monitor heart rate and blood pressure frequently to detect tachycardia and hypotension, which may indicate significant blood loss
  • Assess respiratory rate and oxygen saturation to evaluate for respiratory compromise secondary to anemia or aspiration
• Hemodynamic status assessment helps determine the extent of hypovolemia and guides fluid resuscitation
  • Assess for signs of hypovolemia decreased urine output, altered mental status, and cool extremities suggest significant blood loss
  • Monitor for signs of shock cool, clammy skin, delayed capillary refill, and altered mental status indicate severe hypovolemia and require immediate intervention
• Laboratory values provide objective data on the patient's hematologic and metabolic status
  • Monitor complete blood count (CBC) for decreasing hemoglobin and hematocrit, which indicate ongoing blood loss or inadequate resuscitation
  • Assess coagulation studies (PT, INR, aPTT) to evaluate for coagulopathy that may exacerbate bleeding
  • Monitor electrolytes and renal function tests to assess for metabolic derangements and guide fluid and electrolyte replacement
  • Obtain type and cross-match for potential blood transfusions in patients with severe bleeding or hemodynamic instability

Interventions for gastrointestinal bleeding

• Fluid resuscitation is essential to maintain hemodynamic stability and tissue perfusion in patients with gastrointestinal bleeding
  • Administer intravenous fluids (normal saline, lactated Ringer's) to replace volume deficits and maintain adequate blood pressure
  • Monitor fluid balance and urine output to assess the adequacy of resuscitation and prevent fluid overload
• Blood transfusions may be necessary to maintain adequate oxygen-carrying capacity in patients with severe anemia or ongoing bleeding
  • Administer packed red blood cells as ordered to maintain hemoglobin levels above a target threshold (typically 7-8 g/dL)
  • Monitor for transfusion reactions (fever, chills, urticaria) and report any adverse events promptly
• Medication administration plays a key role in reducing bleeding and preventing recurrence
  • Administer proton pump inhibitors (pantoprazole) to reduce gastric acid secretion and promote ulcer healing in patients with UGIB
  • Administer octreotide, a somatostatin analog, to reduce portal pressure and control variceal bleeding
  • Administer anticoagulation reversal agents (vitamin K, fresh frozen plasma) as needed in patients on anticoagulants who develop gastrointestinal bleeding
• Other interventions aim to minimize complications and promote patient comfort
  • Maintain NPO status until the bleeding source is identified and controlled to prevent aspiration and allow for diagnostic testing
  • Insert a nasogastric tube for gastric decompression and monitoring of bleeding in patients with UGIB
  • Provide comfort measures (pain control, positioning) and emotional support to alleviate anxiety and discomfort associated with gastrointestinal bleeding

Interprofessional management of bleeding

• Diagnostic testing is crucial for identifying the source of bleeding and guiding therapeutic interventions
  • Coordinate with gastroenterology for endoscopic procedures (esophagogastroduodenoscopy for UGIB, colonoscopy for LGIB) to visualize the bleeding source and perform hemostasis
  • Assist with radiographic studies (angiography, tagged red blood cell scan) to localize the bleeding site when endoscopy is unsuccessful or contraindicated
• Therapeutic interventions may involve endoscopic, radiologic, or surgical techniques depending on the cause and severity of bleeding
  • Collaborate with gastroenterology for endoscopic treatments (banding, sclerotherapy, cauterization) to achieve hemostasis and prevent recurrent bleeding
  • Assist with interventional radiology procedures (embolization) to control bleeding from arterial sources or when endoscopic therapy fails
  • Prepare patients for potential surgical interventions (partial gastrectomy, colectomy) when bleeding is refractory to less invasive measures
• Follow-up care ensures continuity of care and reduces the risk of recurrent bleeding
  • Coordinate with case management and social services for discharge planning to arrange for appropriate support services and follow-up appointments
  • Educate patients and families on preventive measures (avoiding NSAIDs, managing chronic conditions) and signs of recurrent bleeding to promote self-care and early intervention
  • Arrange for outpatient follow-up with gastroenterology and primary care providers to monitor for complications and adjust long-term management plans