[Music] hi we're going to be talking about patients who present to the emergency department with concern for guests or intestinal bleeding so we can go ahead and start out with a case study so this is a 45 year old gentleman who presents to the emergency department with concern for two days of black stool and a lightheaded sensation when we're thinking about this we want to ask where is the patient bleeding from and also what are the key emergency department interventions for this patient so when we think about patients who present to the emergency department with GI bleed we oftentimes divide bleeding up into the upper GI tract or the lower GI tract the other thing that's important to remember is that we always start with our ABCs so in situations of GI bleeding the a and the B you want to make sure that the patient has a patent airway that they're breathing okay and then especially in a situation of bleeding focusing on that circulation component so again we're dividing our GI bleeding into upper GI bleeding and lower GI bleeding and where is the dividing line here for the most part upper GI bleeding is bleeding that takes place from the stomach or from the upper portions of the small intestine for lower GI bleeding that's leading that takes place in both the small the more distal small intestine as well as the entirety of the large intestine the most common causes for upper GI bleeding is peptic ulcer disease erosive gastritis or esophagitis esophageal varices and then mallory-weiss syndrome so peptic ulcer disease is when a patient has an ulcer in their stomach or in the beginning parts of their small intestine this is oftentimes a chronic problem where patients may experience painful abdominal pain potentially worse after eating sometimes better after eating depending on where that ulcer is located and at the base of that ulcer if there's a blood vessel and it gets eroded into the blood vessel that's what causes the bleeding esophageal varices are generally in patients who have liver disease and the liver diseases causes back up into the esophagus essentially and it makes those blood vessels there enlarged it's a variceal blood vessel so it's kind of like having a variceal blood vessel on your leg and it's just an abnormally friable blood vessel that's in the esophagus and then mallory-weiss syndrome is an element of small tears in the wall of the esophagus that cause patients to have bleeding it's most common in patients who have been vomiting a few times they may go ahead and get a mallory-weiss tear that's something that we see from time to time that's generally described as patient sees small kind of flecks of blood in their vomit now for lower GI bleed there's lots of different causes diverticulosis is one I just want to take a moment to remind everyone that diverticulosis is what bleeds diverticulitis generally is not associated with bleeding diverticulitis is when you have an infection in the area of the diverticulum which are little odd patching of the rest of the intestinal wall other prot things that can cause lower GI bleed are vascular ectasias ischemic colitis and that's due to the fact that there's damage to the wall of the of the intestines due to there not being enough blood flow and that can cause blood in the GI tract meckel's diverticulum infectious colitis so different bacteria can cause irritation and bleeding in the GI tract inflammatory bowel disease such as ulcerative colitis and Crohn's disease something simple like hemorrhoids can cause bleeding and then the most serious thing that can cause bleeding is in aortoenteric fistula which is basically when the aorta and the bowel wall and the bowel kind of become connected and as you can imagine that can cause a lot of bleeding so that's one of them a rare thing but very worrisome so the highest morbidity here for upper GI bleed it's those esophageal varices they can actually bleed quite a lot and for the lower GI bleed the aortoenteric fistula which is rare and then followed by the diverticular bleed so patients who have diverticulosis can have a lot of bleeding from their GI tract upper GI bleed is more common than lower GI bleed and the rates here are affected by H pylori prevalent prevalence h pylori is a bacteria that's very closely associated with the development of peptic ulcer disease so that's an additional test that sometimes it's done when patients are complaining of abdominal pain or in patients in whom there's concern for peptic ulcer disease they can get h pylori testing from the blood or from the stool potentially or also from biopsy samples from an endoscopy h pylori prevalence is affected by socioeconomic factors in places that are low have lower socioeconomic classes the rates of h pylori are actually higher so you want to keep that in mind when you're thinking about these patients now lower GI bleed like I said this less common than upper GI bleed and upper GI bleed is actually the most common cause for blood in the lower GI tract now if you think about it that actually makes sense right because what's happening is as you have blood in your stomach the blood in your stomach is then going down into your small intestines and then into your large intestines so the bleeding kind of trickles its way down now lower GI bleed is more common among female patients and there's an increase rates also in elderly patients you know the interesting thing about lower GI bleed is that a majority of them actually resolves spontaneously without a whole lot of intervention now that differs it from upper GI bleed upper GI bleeds do sometimes spot stop spontaneously but more likely than not that's gonna respond better to an intervention lower GI bleed is always one of those tricky things in the edie that the minute that you get a little more concerned or that you you know want to do additional work up oftentimes it'll stop on its own so it's one of those things where if you wait it out sometimes it'll it'll do its thing now it's not to say those people don't need more evaluation or to be admitted to the hospital but just it's an important thing for you to know now for those more serious causes like diverticular bleeds and for aortoenteric fistula that's generally not something that always stops on its own now let's think about the signs and the symptoms so first of all we want to start with the basics again going back to those ABCs I know it feels like we're kind of drilling it into you but we just really want to make sure that we're always focusing on these testing you also want to think about hemodynamic stability is your patient hypotensive is their blood pressure low are they tachycardic what is their skin are they cool and clammy or are they warm and well perfused definitely for those patients who are cool and clammy you want to start thinking about moving things along more urgently for them you want to ask some key historical points so you want to ask the patient's how many episodes have you had have you had one episode of bleeding have you had five episodes of bleeding and how much blood was present so did you throw up a small garbage can or a bowl full of blood or did you throw up and there was a Fleck of blood in there and that really makes a difference so sometimes patients can potentially exaggerate the amount a little bit there are potentially patients you might under exaggerated a little bit but trying to get an idea as to how much blood is there this is one of those situations where I say our job is sometimes a little bit less glamorous but where patients bring in a picture a picture is actually very very helpful in this situation so if someone brings me in a picture as to what they threw up or what was in their toilet I know it doesn't sound super exciting it's a lot of people but for us in the emergency department he gives us an idea as to what we're dealing with so smartphones have actually really made a difference here and thinking about this another thing to think about our associated symptoms is the patient also having pain in their abdomen are they feeling light-headed are they dizzy or did they sink opai's feeling light-headed feeling dizzy definitely a sinkable episode may indicate that there's been more acute blood loss when you don't have those symptoms it might indicate the ER a little bit more hemodynamically stable belly pain can be associated with perforation one of those things so for an upper GI bleed peptic ulcer can actually perforate there can become a hole in the stomach and that can be associated with a lot of abdominal pain so asking about that can definitely help point you in one direction or the other it's also important to try and get some medical history from your patient so do they have a history of alcohol abuse do they have liver disease have they ever had any surgeries have they ever had this before that can be a very helpful question two now the other thing to know would be do they have any history of peptic ulcer disease getting a good medication list from your patient also will be of great benefit so things that can be associated with GI bleeding are nonsteroidal medications medications like ibuprofen can actually lead to GI bleeding due to your increased irritation in the abdominal and in the stomach so you want to ask about heavy and said use you'd be surprised how many patients will tell you that they've been taking increasing amount of NSAIDs for a period of time due to back pain or neck pain or headaches I had a very memorable young man when I was a resident who had been taking lots of ibuprofen and in the end had developed a very significant and severe GI bleed glucocorticoids are another thing that can lead to GI bleeding again they can have effects on the lining of the stomach and lead to bleeding and potentially ulcer disease especially for patients who are chronically on those medications and then very important to ask about anticoagulants is your patient on warfarin are they on one of the new oral anticoagulant medications are they on plavix very important to get this information from someone because especially if they're having a significant GI bleed you have to know what they're on so you can figure out how to reverse that anticoagulation and last but not least is food intake beets and food that has a lot of red dye in it can actually cause patients to look like they're having GI bleeding so again something that doesn't seem like a normal question to ask but to go ahead and ask a patient have you been eating a lot of beets red beets can cause it to look just like blood in the stool or a lot of red dye I actually had a patient when I was a resident who had had a GI illness like some vomiting and diarrhea and drank a lot of red Gatorade and then had a bowel movement and was very concerned that he was having a GI bleed so red dye from the red Gatorade made it look that way so asking about if the patient has eaten anything that could make the stool appear red now let's think about the differential here so could the blood be coming from elsewhere so let's say someone tells you that they threw up a large amount of blood where else could it be coming from now nosebleeds are a classic place that it could be coming from our nose posterior lis is connected to our oral pharynx so if someone is having a nosebleed that blood can get swallowed into the stomach and the stomach can get irritated when there's blood in it and the patient can in turn throw up something that looks like blood hemoptysis is another thing that can be confused for a GI bleed a mop is this is when you cough and you spit up blood sometimes that can be a massive amount of blood and sometimes it can be very hard to tell whether or not the blood is coming from the stomach or coming from the lungs dental bleeding is another concern especially if someone has had a dental procedure so someone who's had a tooth pulled or who has had trauma to their mouth potentially can have a lot of bleeding from those areas and again similar to the nose bleed if you go ahead and you swallow that blood it goes into your stomach the stomach can get irritated when there's blood in there and in turn the patient may in fact throw up and it may look like blood directly coming from the stomach other things are external hemorrhoids or an anal fissure can cause blood to be mixed in with the stool and then vaginal bleeding so for patients who have heavy vaginal bleeding sometimes it can be hard to tell if the bleeding is coming from the vaginal area or from the rectal area so you need to make sure you go ahead and keep that on your differential as well to see where the source of the bleeding is there are some keywords that are going to be important for you to know to help you communicate with people in the Eady so when hematemesis is one of them hematemesis is vomiting a bright red blood so that's when a patient throws up and it looks basically like completely undigested blood coffee ground emesis is vomiting of dark material it actually looks like the way it sounds so it looks like someone who took the coffee grounds from the filter and threw that up that's called coffee ground emesis patients sometimes voluntarily say my threw up and it looked like what comes from the coffee filter that's concerning for blood that has been somewhat partially digested melena is dark black or Tory stool what I'm trying to get this from patients I always try and find something black to point to as your stool bin black like this because it really is very noticeable melena is due to digested blood from the stomach that goes down through the intestines and gets digested and then comes out appearing in the stool that it's a dark or black Tory stool sometimes people describe it as like a little bit sticky this is something else once you've seen it you'll know what it is it's a kind of classic appearance for patients and Leslie is hematochezia and this is maroon blood with stool hematochezia is most commonly seen with a diverticular bleed or a more rapid lower GI bleed or even potentially a very rapid upper GI bleed so if someone is having bleeding very briskly from their stomach as it goes down through the intestines if it goes very very quickly it can come out and when it comes out in the stool it can look just like maroon blood mixed with stool [Music]