WELCOME

SUBJECT: D231: Medical & Surgical Nursing

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 Lecture On
GASTROINTESTINAL (GI) BLEEDING

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Outline
1. Meaning
2. Etiology
3. Diagnostic History
4. Physical Examination
5. Interpretation of Findings
6. Pathophysiology with symptoms
7. Diagnosis
8. Treatment
9. Nursing Management
10. Risk Stratification
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GastrointestinaI (GI) bleeding: Meaning-
Gastrointestinal (GI) bleeding refers to any bleeding that
starts in the gastrointestinal tract.

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Meaning… Cont..

Bleeding may come from any site along the GI tract, but is often
divided into:

• Upper GI bleeding: The upper GI tract includes the esophagus

(the tube from the mouth to the stomach), stomach, and first part
of the small intestine.

• Lower GI bleeding: The lower GI tract includes much of the

small intestine, large intestine or bowels, rectum, and anus.
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Etiology
GI bleeding may be due to conditions including:
• Anal fissure
• Hemorrhoids
• Cancer of the colon
• Cancer of the small intestine
• Cancer of the stomach
• Intestinal polyps (a pre-cancerous condition)
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Upper GI tract disorders
• Peptic Ulcer Disease
• Duodenal ulcer (20–30%)
• Gastric ulcer (10–20%)

• Gastric or duodenal erosions

(20–30%)

• Varices (15–20%)
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 Upper GI tract disorders… Cont..
• Mallory-Weiss tear (5–10%)
• Erosive esophagitis (5–10%)
• Hemangioma (5–10%)
• Arteriovenous
malformations (< 5%)

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 Lower GI tract disorders
• Anal fissures
• Angiodysplasia (vascular ectasia)
• Colitis: Radiation, ischemic, infectious
• Colonic carcinoma
• Colonic polyps

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 Lower GI tract disorders… Cont..
• Diverticular disease
• Inflammatory bowel diseases:
• Ulcerative proctitis/colitis, Crohn disease
•Internal hemorrhoids

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Diagnostic History
• History of present illness should attempt to ascertain
quantity and frequency of blood passage
• Quantity can be difficult to assess because even small
amounts (5 to 10 mL) of blood turn water in a toilet bowl
an opaque red, and modest amounts of vomited blood
appear huge to an anxious patient
• Patients with hematemesis should be asked whether blood
was passed with initial vomiting or only after an initial (or
several) non-bloody emesis.
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Diagnostic History Cont..

• Patients with rectal bleeding: whether pure blood was passed/

mixed with stool, pus, or mucus; or whether blood simply coated
the stool. Those with bloody diarrhea should be asked about travel
or other possible exposure to GI pathogens.

• Past medical history: previous GI bleeding (diagnosed or

undiagnosed); known inflammatory bowel disease, bleeding
diatheses, and liver disease; and use of any drugs that increase the
likelihood of bleeding or chronic liver disease (e.g, alcohol).
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Clinical features
Clinical features of Upper GI bleeding (Haematemasis)
1. If bleeding is less –no sign and symptoms
2. If bleeding is severe-
• Weakness, faintness
• Nausea, sweating
• Agitated ,restless
• Disorientation
• The blood appears brown and granular in vomit or gastric aspirate.
3. Signs
■ Patient is anxious and pale ■ Anemia-in severe case
■ Pulse –weak and rapid ■ Blood pressure –Greater than 10 mm of Hg
difference indicates loss of more than 20%
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blood volume.
Clinical features Cont..
Clinical features lower GI bleeding (Malena)

Symptoms
• Weakness
• Burning of vision
• Coldness of the body particularly limbs
• Fainting and syncope
• Latter black tarry stool or frank blood pus per rectum.
Signs
• Anxious, pale face
• Signs of dehydration
• Pulse: Increased
• Blood pressure :Low 14
 Red Flags

Several findings suggest hypovolemia or hemorrhagic shock:

• Syncope
• Hypotension
• Pallor
• Diaphoresis
• Tachycardia

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Interpretation of findings
• The history and physical examination suggest a diagnosis in about
50% of patients, but findings are rarely diagnostic and
confirmatory testing is required.
• Epigastric abdominal discomfort relieved by food or antacids
• peptic ulcer disease
• Weight loss and anorexia, with or without a change in stool
• GI cancer
• History of cirrhosis or chronic hepatitis :
• esophageal varices.
• Dysphagia suggests
• esophageal cancer or stricture 16
Pathophysiology

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Diagnostic investigations
• Abdominal X-ray, CT scan, MRI
• Angiography
• Bleeding scan (tagged red blood cell scan)
• Capsule endoscopy (camera pill that is swallowed to look at the
small intestine)
• Colonoscopy
• CBC, clotting tests, platelet count, and other laboratory tests
• Enteroscopy
• Sigmoidoscopy 18
Diagnostic investigations Cont..

• CBC, coagulation profile

• NGT

• Upper endoscopy for suspected upper GI bleeding

• Colonoscopy for lower GI bleeding (unless clearly

caused by hemorrhoids)

• Upper endoscopy 19
General Management & Treatment

Airway
A major cause of morbidity and mortality in patients with active
upper GI bleeding is aspiration of blood with subsequent
respiratory compromise.

• To prevent these problems, endotracheal intubation should be

considered in patients who have inadequate gag reflexes or are
obtunded or unconscious—particularly if they will be undergoing
upper endoscopy. 20
General Management & Treatment Cont..

• Hemostasis : GI bleeding stops spontaneously in about 80% of

patients. The remaining patients require some type of intervention.
Early intervention to control bleeding is important to minimize
mortality, particularly in elderly patients.
• Active variceal bleeding can be treated with endoscopic banding,
injection sclerotherapy, or a transjugular intrahepatic
portosystemic shunting (TIPS) procedure.

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General Management & Treatment Cont..

• Triage — All patients with hemodynamic instability or active

bleeding should be admitted to an intensive care unit for
resuscitation and close observation with monitoring.

• Other patients can be admitted to a regular medical ward.

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General Management & Treatment Cont..

• Supplemental oxygen by nasal cannula

• Nothing by mouth
• PIVC(16G/18G) or a central venous line should be inserted
• Placement of a pulmonary artery catheter
• Elective endotracheal intubation in patients with ongoing hematemesis or
altered respiratory or mental status may facilitate endoscopy and decrease
the risk of aspiration.

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General Management & Treatment Cont..

• Patients with active bleeding should receive intravenous fluids

(eg, 500 mL of NS or RL over 30 minutes) while being cross-
matched for blood transfusion. Patients at risk of fluid overload
may require intensive monitoring with a pulmonary artery
catheter.
• If the blood pressure fails to respond to initial resuscitation efforts,
the rate of fluid administration should be increased.

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General Management & Treatment Cont..

• The decision to initiate blood transfusions must be individualized

• The approach is to initiate blood transfusions if the hemoglobin is
<7 g/dL (70 g/L) for most patients (including those with stable
coronary artery disease), with a goal of maintaining the
hemoglobin at a level ≥7 g/dL (70 g/L)
• We do not have an age cutoff for determining which patients
should have a goal hemoglobin of ≥9 g/dL (90 g/L), and instead
base the decision on the patient's comorbid conditions

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General Management & Treatment Cont..

• Avoid over transfusion in patients with suspected variceal

bleeding, as it can precipitate worsening of the bleeding.
Transfusing patients with suspected variceal bleeding to a
hemoglobin >10 g/dL (100 g/L) should be avoided

• A randomized trial suggests that using a lower hemoglobin

threshold for initiating transfusion improves outcomes.
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General Management & Treatment Cont..

Essential medications:
• Acid suppression —Proton pump inhibitor (PPI)
(eg, omeprazole 40 mg IV twice daily).
• Prokinetics: Both erythromycin and metoclopramide
• Somatostatin, or its analog octreotide
• Tranexamic acid : an anti-fibrinolytic agent that has been
studied in patients with upper GI bleeding.

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Surgical interventions

• Peptic Ulcer Disease: Vagotomy and pyloroplasty

to control bleeding

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Surgical interventions Cont..

• Esophago-gastric varices: Decompression procedures like

portacaval shunting,mesocaval shunting (only if medical treatment
is unsuccessful and angiographic interventional procedures are not
available)

• Hemorrhoidectomy

• Colon Surgery

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Nursing Management

All critically ill patients should be considered at risk for stress ulcers
and therefore GI hemorrhage.
Maintaining gastric fluid pH 3.5-4.5 is a goal of prophylactic therapy.
The major nursing interventions are
• Administering volume replacement
• Controlling the bleeding
• Maintaining surveillance for complications
• Educating the family and patient
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 RISK STRATIFICATION

Endoscopic, clinical, and laboratory features may be useful for risk

stratification of patients who present with acute upper GI bleeding.
Factors associated with re-bleeding identified in a meta-analysis included:

• Hemodynamic instability (systolic blood pressure less than 100

mmHg, heart rate greater than 100 beats per minute)
• Hemoglobin less than 10 g/L
• Active bleeding at the time of endoscopy
• Large ulcer size (greater than 1 to 3 cm in various studies)
• Ulcer location 32
Risk Scores

Two commonly cited scoring systems are the Rockall score and the
Blatchford score:

The Rockall score is based upon age, the presence of shock,

comorbidity, diagnosis, and endoscopic stigmata of recent
hemorrhage

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 Glasgow Blatchford score

The score is based upon the BUN, hemoglobin, systolic blood

pressure, pulse, and the presence of melena, syncope, hepatic
disease, and/or cardiac failure
The score ranges from zero to 23 and the risk of requiring
endoscopic intervention increases with increasing score.
One meta-analysis found that a Blatchford score of zero was
associated with a low likelihood of the need for urgent endoscopic
intervention
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REFERENCES
• Black, J.M. & Hawks, J.H. (2009). Medical Surgical Nursing: Clinical Management for Positive Outcomes. 8th ed. : Elsevier
• Ignatavicius, D.D. and Workman, M.L. (2003). Medical Surgical Nursing: Patient Centered Collaborative Care. 7th ed. : Elsevier
• Linda D. [Link] M. [Link] E. Lough. Critical Care Nursing: Diagnosis and Management, Thelans Critical Care Nursing
Diagnosis. 7th Edition
• Jarvis,C. (2008). Physical Examination and Health Assessment. 5th ed. : Saunder, an imprint of Elsevier Inc.
• Lewis, S.L et. al., (2009). Medical Surgical Nursing: Assessment and Management of Clinical Problems. 7th ed. : Mosby Elsevier
• Barkun A, Bardou M, Marshall JK.(2013). Nonvariceal Upper GI Bleeding Consensus Conference Group. Consensus
recommendations for managing patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med
• Laine L, Jensen DM.(2012) Management of patients with ulcer bleeding. Ameriacan J Gastroenterology; 107:345.
• Srygley FD, Gerardo CJ, Tran T, Fisher DA. Does this patient have a severe upper gastrointestinal bleed? JAMA 2012; 307:1072.
• Cappell MS, Friedel D. Initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal
endoscopy. Med Clin North Am 2008; 92:491.

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