Now, when we’re doing our exam
we wanna make sure we're paying attention to the vital signs.
And that you're looking at the blood pressure and the heart rate
in making sure that the patient is hemodynamically stable.
Now, if they are not hemodynamically stable,
you wanna try and intervene on that.
Next, you wanna try and inspect the vomit or the stool.
This goes back to potentially having a patient
if they've brought in a picture
or they can show you a picture
or if they’ve thrown up in the Emergency Department
to kind of have that saved in some way
so you’re able to take a peek at it.
So you're able to see what exactly is going on.
Sometimes, and a patient tells me a story
and I'm kind of underwhelmed by what they’re describing
and then they show me a picture,
it can really, really change the way
that I'm viewing that patient.
You also wanna perform a good abdominal exam.
The abdominal exam can be used to assess for tenderness,
to look for rebound tenderness.
Again, the most worrisome thing that you could be looking for
would be a perforated viscus or a perforation in the stomach.
You wanna look for a mass
and also possibly for ascites in the abdomen.
Ascites can clue you in as to the fact
that the patient may have liver disease.
And then further on from that
liver disease can clue you in
and make you think about the fact
that the patient may have esophageal varices.
You also wanna look at the patient’s skin.
You wanna look for conjunctival pallor,
so you basically pull down the patient’s lower lid
and you look and see if that area
is pink or more of a pale whitish,
very light pink kind of a color.
You wanna look at the patient’s skin.
Is their skin pale?
Do they look like they have normal coloration?
Is there delayed capillary refill
and you can get that information
by kind of pinching their finger
and seeing how quickly it takes for the blood
to kinda fill back in there.
And ideally, in a patient who is well perfused,
that time will be less than two seconds.
Lastly, you wanna do a rectal exam.
The rectal exam can help you get a sample of stool
that you can do stool guaiac on.
We’ll talk about that in a moment.
But it can also might help you see if there’s any masses ,
if there is a fissure,
which is a small cut in that lining of the rectum,
and also if there’s a hemorrhoid there.
So all of that information can really help you.
Now what are the tests we wanna do?
So one of the first things we wanna do
is a stool guaiac test.
Again, we wanna make sure that there’s
really, truly blood in that GI tract.
Now, a stool guaiac test is performed
by taking a little bit of stool
that’s obtained on a rectal exam
and you put it in a small guaiac card
and you either send it to the lab
or you can sometimes go ahead
and do that testing at the bedside in the Emergency Department
if you're trained to do so.
Now, if that patient’s stool is positive,
the sample will turn blue on the slide,
and if it’s negative, it won’t turn blue.
Now again, this is important because who knows,
maybe someone is coming in
and they're telling you that their stool was very red.
Potentially, it’s due to the fact that they ate beets
or drank a lot of Gatorade.
So having that stool guaiac test further supports
or goes against the fact
that the patient is having a true GI bleeding.
Other blood test to gather.
CBC, that’s gonna tell you what your hemoglobin is,
what your hematocrit is
and give you an idea as to whether or not
that patient needs blood or doesn’t need blood.
Then you're gonna think about coagulation test.
You’re gonna wanna send in an INR
and a PTT to take a look and see if the patient is anticoagulated.
It’s important to remember
that in patients with liver disease
they may be innately anticoagulated.
So even if they're not on any medication,
their coagulation test, especially that INR may be abnormal
so you're gonna wanna think about that.
The other thing to think about is what the
newer oral anticoagulant medications,
or your coagulation test actually appear normal.
So if someone is on those,
you still wanna be thinking about the fact
that you may need to reverse their anticoagulation.
You also wanna send a type and crossmatch,
especially for that hemodynamically unstable patient.
You wanna go ahead and you wanna make sure that
if they need a blood transfusion
that they have that blood available to them.
For some patients,
the type and crossmatch process is very easy.
So it’s very easy to go ahead and get blood.
If you have a patient
whose been transfused a bunch of times in the past,
you may have a harder time finding blood for that patient.
So get that process started early for a majority of people.
And then your chemistry and liver function test
can also help you figure out
if the patient has underlying liver disease.
Now, there is a certain value in the chemistry panel
that you send that can give you vital information
on patients with the GI bleeds.
That lab value is the BUN.
So the BUN or the blood urea nitrogen becomes elevated
in patients who have an upper GI bleed.
And this is due to the fact
that there is digestion and absorption
of the hemoglobin causes the BUN to be elevated.
if someone comes in and they tell you that they’re having melena
and concern for GI bleed,
if you get that and the BUN alone is elevated
without an elevation in the creatinine level,
that is something that points you in the direction
that the patient is actually having this digestion
and absorption of the hemoglobin.
We also should talk about
whether or not to put an NG tube in a patient.
So an NG tube is a nasogastric tube.
It’s a tube that goes in the patient’s nose
and then into their stomach.
NG tube insertion used to be very common place in patients
who are presenting with a GI bleed.
And it used to be common place
because people used to use it for diagnostic purposes.
So they would put in a nasogastric tube,
and then they would suck stuff out, and they would see
if there was any blood in what was removed from the stomach.
Now, it’s no longer recommended
for the diagnosis of upper GI bleeds.
And there are a few reasons for that.
One is that it’s a very painful procedure for patients.
It’s actually been found or in certain studies
has been quoted being the most painful thing
that we do for patients in the Emergency Department.
And we do definitely a lot of painful things to patients.
So if this is the most uncomfortable,
we wanna make sure that it has real value,
that we’re actually gonna get something out of it.
There is also a risk of aspiration.
So when you're putting something down someone’s nose
into their stomach,
there’s a risk that they could aspirate
some of those gastric contents in the process.
You also run the risk sometimes of taking this tube
and accidentally putting it in a patient’s lung.
As you can imagine that’s not a great thing to do
and if you do it,
you could potentially cause the patient to get a pneumothorax.
So that’s a certain risk and a very real risk
that can be associated with NG tube placement.
Lastly, there’s also concern for risk of perforation
that the NG tube could potentially make a hole in something
that would be a friable area of the stomach or the esophagus.
So does imaging help us diagnose GI bleed?
Now, if you're worried about perforation,
you’re worried that someone had a peptic ulcer
that then in turn make a hole,
a CT scan is the best test to evaluate for this.
You know, if your patient is unstable
you might wanna consider getting an upright chest X-ray
to take a look and see
if there's any free air under the diaphragm .
For lower GI bleed,
you can consider angiography versus scintigraphy.
Angiography is when you go ahead
and you take a look at the patient’s blood vessels using contrast.
Scintigraphy is radio-labeled dye
that’s given to a patient that can help take a look
and identify the area of bleeding.
Angiography has a benefit in a sense
that you can treat the patient
and embolize a vessel if you see something that’s bleeding.
Again, these are patients
who we generally will send to this treatment
when you're worried about lower GI bleed
and oftentimes, when they get there,
the bleeding has stopped and no bleeding is found.
That’s really what happens most commonly for these patients.
But for sure,
angiography is a little bit more beneficial for patients
but a little bit more resource intensive
and potentially harder to get for a patient.