Overview
This lecture reviews the evaluation and management of patients presenting to the emergency department with gastrointestinal (GI) bleeding, including common causes, symptom assessment, key history questions, and terminology.
Initial Assessment and Triage
- Assess Airway, Breathing, and Circulation (ABCs) first in any GI bleeding case.
- Evaluate hemodynamic stability: check for hypotension, tachycardia, and skin signs.
- Gather key symptoms: number of bleeding episodes, volume, and associated symptoms like lightheadedness or syncope.
Types and Common Causes of GI Bleeding
- GI bleeding is classified as upper (stomach and proximal small intestine) or lower (distal small intestine and large intestine).
- Upper GI bleeding is commonly caused by peptic ulcer disease, erosive gastritis/esophagitis, esophageal varices, and Mallory-Weiss tears.
- Lower GI bleeding causes include diverticulosis (most common), vascular ectasias, ischemic colitis, Meckel’s diverticulum, infectious/inflammatory bowel diseases, hemorrhoids, and aortoenteric fistula.
Risk Factors and Relevant History
- Ask about history of peptic ulcers, liver disease, alcohol abuse, and previous GI bleeding.
- Obtain medication history: NSAIDs, glucocorticoids, and anticoagulants increase GI bleed risk.
- Dietary history is important—foods like beets and red dyes can mimic GI bleeding visually.
Differential Diagnosis for GI Bleed Symptoms
- Bleeding may come from sources other than the GI tract: epistaxis (nosebleed), hemoptysis (coughing up blood), dental or oral bleeding, and vaginal bleeding.
- External sources like hemorrhoids or anal fissures may also present as blood in stool.
Key Signs, Symptoms, and Terminology
- Hematemesis: vomiting bright red blood, indicates upper GI source.
- Coffee ground emesis: vomiting dark, grainy material, suggesting partially digested blood.
- Melena: black, tarry stool from digested blood, often from upper GI bleeding.
- Hematochezia: maroon/red blood mixed with stool, usually from brisk lower or upper GI bleeding.
Key Terms & Definitions
- Upper GI bleed — Bleeding from stomach or proximal small intestine.
- Lower GI bleed — Bleeding from distal small intestine or large intestine.
- Hematemesis — Vomiting bright red blood.
- Coffee ground emesis — Vomiting dark, granular digested blood.
- Melena — Black, tarry stool due to digested blood.
- Hematochezia — Maroon/red blood with stool, indicating brisk GI bleeding.
- Diverticulosis — Outpouchings in colon wall, common cause of lower GI bleed.
- Peptic ulcer disease — Ulcers in stomach/duodenum, common upper GI bleed source.
Action Items / Next Steps
- Take a thorough history including symptoms, medications, and dietary habits.
- Assess and support ABCs immediately upon patient arrival.
- Order labs and consider H. pylori testing if upper GI bleeding is suspected.
- Distinguish GI bleeding from other potential sources.