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“Resident Reminders”
Practice Guideline Highlights in Gastroenterology
q Estimation and replacement of blood loss is the single most important aspect of care
q Baseline evaluation
ü Question carefully about ASA and NSAIDs recognizing that use is often surreptitious and that complicated ulcer diatheses are invariably from NSAIDs
ü Orthostatic vital signs unless pulse >120
ü Rectal exam- Note: melena, hematochezia, color, or occult blood
ü Hemogram, metabolic profile, protime
ü All patients with GI bleeding should have a diagnostic nasogastric lavage, even if lower source suspected, even if varices are likely. Note: fresh or old (coffee grounds) blood
q Observation
ü Mortality remains 8-10% despite recent advances and patients should be admitted to an intensive care unit.
ü Consult Gastroenterology and Surgery
ü Serial exam and hematocrit even 4-6 hours. Call GI if condition changes
q Treatment
ü If likelihood of chronic liver disease, start octreotide 50ug IV bolus and 50ug IV infusion
ü Acid modulation with IV proton pump inhibitor
ü Endoscopic findings can be used to triage and plan care. If non-bleeding Mallory-Weiss tear or clean-based ulcer, re-bleeding rate is <3% and the patient can be discharged if eating and hemodynamically stable. If visible vessel, adherent clot, active bleeding or therapeutic endoscopy, the re-bleed rate is 50-75% and patients should be observed at least 72 hour
References:
DiPalma JA. Gastrointestinal Bleeding. In: Critical Care Medicine, J.M.
Civetta, R.W. Taylor, R.R. Kirby, eds., Philadelphia: J.B. Lippencott Co., 3rd
edition, 1997;pp 2033-2044.
Laine L, etal. Prospective Evaluation of Immediate vs. Delayed Refeeding and Prognostic Value of Endoscopy in Patients with Upper Gastrointestinal Hemorrhage. Gastroenterology 1992;102:314-316.
