Management of Gastrointestinal Bleeding

Abstract

The urgency with which gastrointestinal (GI) bleeding is managed is dictated by the rate of bleeding. The patient with trace heme-positive stools and without severe anemia can be managed as an outpatient. Visible blood requires hospitalization and inpatient evaluation. Persistent bleeding or rebleeding with hemodynamic instability necessitates ICU admission. Massive bleeding is defined as loss of ≥30% of estimated blood volume or bleeding requiring blood transfusion of ≥6 U/24 hours. Hemodynamic assessment: blood pressure, pulse, postural changes and assessment of peripheral perfusion. The presence of comorbid disease must be determined. Estimating blood loss. This can be estimated by measuring the return from a nasogastric (NG) tube. An approximate estimate of blood loss can be made by the hemodynamic response to a 2- L crystalloid fluid challenge: If blood pressure (BP) returns to normal and stabilizes, blood loss of 15% to 30% has occurred. If BP rises but falls again, blood volume loss of 30% to 40% has occurred. If BP continues to fall, blood volume loss of >40% has probably occurred. History and examination: Attempt to localize most likely source of bleeding. The presence of melena indicates upper GI bleeding. Hematemesis indicates upper GI bleeding. When small amounts of bright red blood are passed per rectum, the lower GI tract can be assumed to be the source. In patients with large-volume maroon stools, NG tube aspiration should be performed to exclude upper GI hemorrhage. It should be noted that in about 15% of patients with upper GI bleeding, NG aspirate will fail to obtain blood or “coffeeground” material. In most cases, concerns that placement of an NG tube may induce bleeding in patients with coagulopathies are outweighed by the benefits of the information obtained. An NG tube should be inserted in all patients with upper GI bleeding to decompress the stomach. No data suggest that NG tube placement may initiate or potentiate bleeding in patients with esophageal varices. NG tube placement is essential to monitor ongoing bleeding and to decompress the stomach.