Lower gi bleed bright red blood4/22/2024 ![]() If patients are not able to protect their airways or have ongoing severe hematemesis, elective endotracheal intubation is advised.īlood transfusions should be given to target a hematocrit above 20%, with a hematocrit above 30% targeted in high-risk patients, such as the elderly and patients with coronary artery disease. Intravenous fluids should be administered to maintain adequate blood pressure and hemodynamic stability. Patients must have a minimum of two large-bore peripheral access catheters (at least 18-gauge). Per American College of Gastroenterology recommendations, endoscopy within 12 hours should be considered for all patients with higher risk clinical features (e.g., tachycardia, hypotension, bloody emesis or nasogastric aspirate in the hospital) to potentially improve clinical outcomes. The American College of Gastroenterology continues to recommend that all patients with UGIB should undergo endoscopy within 24 hours of admission, following resuscitative efforts to optimize hemodynamic parameters and other medical problems. Until now, there is no evidence that emergent EGD is superior to routine EGD (done in 24 to 48 hours). Multiple studies have tried to identify the best timing to perform endoscopy. If the patient is suspected of having UGIB, endoscopy (EGD) must be performed to identify the cause and potentially treat the source of bleeding. A score of six or higher is associated with a greater than 50% risk of needing an intervention. It includes hemoglobin levels, blood pressure, presentation of syncope, melena, liver disease, and heart failure. This scoring system was designed to predict the need for intervention. In contrast, patients with a score of six or more have a rebleeding rate of 15% and mortality of 39%.Īnother scoring system that is traditionally used in UGIB is the Blatchford Score. When the Rockall score is used, patients with two or fewer points are considered low risk and have a 4.3% probability of rebleeding and 0.1% mortality. A pre-endoscopic Rockall is also available and can be used to stratify patient's risk for rebleeding and mortality even before the endoscopic evaluation. The Rockall score was designed to predict rebleeding and mortality and includes age, comorbidities, the presence of shock, and endoscopic stigmata. There are few scoring systems designed to predict which patients will likely need intervention and also to predict rebleeding and mortality. Coagulation panel should also be checked. Elevated BUN or elevated BUN/Creatinine can also be indicative of UGIB. A low MCV can point towards chronic blood loss and iron deficiency anemia. Initial laboratory work must include a complete blood cell count (CBC) to look for current levels of hemoglobin, hematocrit, and platelets. These features may give clues to the etiology of the bleeding (i.e., variceal bleeding). In a comprehensive exam, search for evidence of chronic liver diseases such as palmar erythema, spider angiomas, gynecomastia, jaundice, and ascites. Orthostatic vital signs should also be documented. One should also pay attention to the patient's vital signs. Patients may also present with syncope or orthostatic hypotension if bleeding is severe enough to cause hemodynamic instability. The latter is usually a reflection of lower gastrointestinal bleeding (LGIB) but may be seen in patients with brisk UGIB. Hematochezia is the passage of fresh blood per rectum. The term "coffee-grounds" describes gastric aspirate or vomitus that contains dark specks of old blood. Melena refers to dark and tarry-appearing stools with a distinctive smell. Hematemesis is the overt bleeding with vomiting of fresh blood or clots. The clinical presentation can vary but should be well-characterized. ![]() Also, it is important to get a detailed social history regarding alcohol use. A detailed review of current medications should be performed, and patients should be directly asked about the use of NSAIDs, antiplatelet drugs, aspirin, or anticoagulants. ![]() During history taking, attention should be given to comorbidities. ![]()
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