So now, let's talk about the
management of a GI bleed.
The first most important step is
to establish adequate IV access.
By this, we mean placing at least two large-bore
peripheral IVs which are 18 gauge or larger
or placing a centrally
placed large-bore catheter.
The goal is to be able to rapidly
infuse blood products and fluids.
So to understand why this is important, we'll
have to go back to your physics knowledge.
So we recall from Poiseuille's law in
physics that flow or Q in this equation
is affected exponentially by the
radius and inversely by the length.
So, why we care about a large-bore
IV is because we want a short length
and a wide radius in our catheter to make sure
that we can maximize the flow through the catheter.
The next step in management
is fluid resuscitation.
We want to give crystalloid fluids such as
normal saline or lactated ringer's solution.
Next, you should consider transfusing
the patient with blood products.
So, we'll break it down by
each type of blood product.
First, you should consider
packed red blood cells or PRBCs.
In the general, we use a transfusion threshold
of a hemoglobin less than 7 for most patients.
However, you might consider a higher
transfusion threshold of less than 8
for patients who have coronary artery
disease or have active bleeding.
The next blood product you
should consider is platelets.
In general, we transfuse platelets for
patients who are actively bleeding
when their baseline platelets
are less than 50,000.
There are other blood products you can
consider such as fresh frozen plasma or FFP
to correct underlying
However, that is beyond the
scope of this lecture.
The next step in management is to give
medications to stabilize the bleeding.
So, all patient should receive
a proton pump inhibitor.
This is to reduce acid secretion in the
stomach and hopefully slow the rate of bleeding
if they have an upper GI bleed.
Next, you can consider giving
vasoactive medications such as octreotide
but this is only if you
suspect a variceal bleed.
The last thing you can consider is any reversal
agents for anticoagulants that your patient takes,
if they are available.
The last step in management after you
have fluid resuscitated and stabilized the patient
is to consult the GI specialist.
This is so that they can perform both diagnostic and
therapeutic interventions to control the bleeding.
So now let's move on to talk about the various
diagnostic and therapeutic studies we have available.
So the gold standard for diagnosing and controlling
a GI bleed is upper or lower endoscopy.
There are other options we have
available including push enteroscopy.
This is a more complicated type of endoscopy by
which we are able to visualize the small bowel
which is otherwise unable to be reached
by either upper or lower endoscopy.
The next test you may consider are nuclear
scintigraphy which is a tagged red blood cell scan
or CT angiography.
By either of these modalities, you can
detect slower rates of GI bleeding.
However, keep in mind that both of
these tests are imaging test only
and so you may find the location of the
bleeding but you will not be able to intervene.
The last test we have available
is standard angiography.
This is usually performed by interventional
radiologist who can thread the catheter
through the groin up into the vessels
that may be contributing to the bleeding.
This is also a therapeutic intervention if they are able to
find and embolize the vessel that is causing the bleeding.
So now that we've gone through all
of that, let's return to our case.
We have Mr. Gibb who is a 56-year-old man who's
coming in with some concerning GI symptoms.
He does have a history
of NSAID and alcohol use
and he has signs on exam of hypovolemia, anemia
and some localizing symptoms of epigastric pain.
He is also shown to be anemic.
So, now we know that his
symptoms of coffee ground emesis
and dull epigastric pain are
concerning for an upper GI bleed.
In addition, his risk factors of
heavy NSAID and alcohol use
place him at risk for a differential of peptic
ulcer disease, potentially gastritis or cancer.
So we are asked what is the
best next step in management?
Now we know that the first step is always
to establish adequate peripheral IV access
and note that he already
has supine hypotension
so he should be given
aggressive fluid resuscitation.
At this time, he currently does not meet the
threshold for our packed red blood cell transfusion
with a hemoglobin of 11
but he is presenting with general bleeding so
a proton pump inhibitor should be started.
Thank you very much
for your attention.