CRACKCast E30 – GI Bleeding

In CRACKCast, Podcast by Adam Thomas1 Comment

This episode of CRACKCast covers Rosen’s Chapter 30, GI Bleeding. This episode gives us a solid approach to the workup and management for GI bleeds.

Showntoes – PDF Here

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Rosen’s in perspective:

Large burden of disease

  • More than 1 million admissions in US per year.

Risk factors:

  • Medication use:
    • Aspirin
    • NSAIDs
    • Steroids
    • Anticoagulants (warfarin, heparin)
    • Chemotherapeutic agents
  • History of PUD
  • Known liver disease
  • Cirrhosis
  • Advanced age >60
  • Alcoholism
  • Current Smoker
  • Chronic medical comorbidities
    • CHF
    • Diabetes
    • Renal Failure
    • Malignancy
    • CAD
  • History of AAA or graft

Anatomic classification: Upper versus Lower

Above ligament of treitz (distal duodenum) is upper gastrointestinal bleed (UGIB) mortality 12-14%

Below ligament of treitz is lower gastrointestinal bleed (LGIB) mortality 4%.

UGIB – think hematemesis and melena and HIGH BUN

LGIB – think hematochezia (BRPR versus maroon stools)

Two major but rare causes of severe, life threatening GIB: Variceal bleeds and Aortoenteric fistula.

Don’t forget about mimics:

UGIBLGIB
Epistaxis

Hemoptysis

Dental Bleeds

Red Food Colouring

Bismuth/Iron supplements

Vaginal Bleeding

Gross Hematuria

Red Foods (BEETS)

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1) List 5 causes of UGIB in adults and pediatrics

Rosen’s 8th Edition – Table 30 – 1.

AdultsPediatrics
Peptic ulcers (gastric more than duodenal)

Gastric erosion

Esophagogastric varices

Mallory-Weiss tears

Esophagitis

Gastric cancer

Duodenal ulcers

Gastric ulcers

Esophagitis

Gastric erosion

Esophageal varices

Mallory-Weiss tears

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 2) List 5 causes of LGIB in adults and pediatrics

Rosen’s 8th edition. Table 30 -2.

AdultPediatrics
Diverticular disease

Angiodysplasia

Colitis (inflammatory, infectious, ischemic)

Anorectal sources

Neoplasm

Upper GI bleeding

Anorectal fissure

Infectious colitis

Inflammatory bowel disease

Juvenile polyps

Intussusception

Meckel’s diverticulum

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3) Describe your management approach for severe UGIB

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4) List 6 low-risk criteria for safe discharge of GIB

Upper:

  • no comorbid diseases
  • normal vital signs
  • normal or trace positive result on stool guaiac testing
  • negative findings on gastric aspiration
  • normal hemoglobin and hematocrit
  • good support systems
  • proper understanding of signs and symptoms of significant bleeding
  • immediate access to emergent care
  • follow-up within 24 hours

Lower: ADMIT if not clearly hemorrhoids, fissure, or proctitis

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5) List components of the Rockall and Glasgow-Blatchford score

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Wisecracks:

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1) Describe the insertion of a Blakemore tube

See http://emcrit.org/procedures/blakemore-tube-placement/

How to Do it:

  1. Patient should be intubated and the head of the bed up at 45 degrees.
  2. Test balloons on Blakemore and fully deflate. Mark salem sump at the 50 cm mark of the Blakemore with the tip 2 cm above gastric balloon and then 2 cm above esophageal balloon.
  3. Insert the Blakemore tube through the mouth just like an NGT. You may need the aid of the laryngoscope and sometimes McGill forceps. Make sure the depth-marker numbers face the patient’s right-side.
  4. Stop at 50 cm. Test with slip syringe while auscultating over stomach and lungs. Inflate gastric port with 50 ml of air or saline.
  5. Get a chest x-ray to confirm placement of gastric balloon in stomach.
  6. Inflate with additional 200 ml of air (250 ml total)
  7. Apply 1 kg of traction using roller bandage and 1 liter IV fluid bag hung over IV pole. Mark the depth at the mouth. The tube will stretch slightly over the next 10 minutes as it warms to body temperature.
  8. After stretching, the tube may be secured to the ETAD tube holder.
  9. Insert the salem-sump until the depth marked gastric is at 50 cm on the Blakemore. Suction both Blakemore lavage port and salem sump. You may need to wash blood clots out of the stomach with sterile water or saline.
  10. If bleeding continues, you will need to inflate esophageal balloon.
  11. Pull salem sump back until the esoph. mark is at the 50 cm point of the Blakemore. Attach a manometer to the second 3-way stopcock on the esophageal port of the Blakemore. Inflate to 30 mm Hg. If bleeding continues, inflate to 45 mm Hg.
  12. Consider switching traction to Hollister ETAD Device.
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2) List 6 causes of false positive stool guaic

False positives can be triggered by ingestions of red meat, turnips, horseradish, vitamin C, methylene blue, and bromide preparations.

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 This post was edited and uploaded by Ross Prager (@ross_prager)

 

Adam Thomas

CRACKCast Co-founder and newly minted FRCPC emergency physician from the University of British Columbia. Currently spending his days between a fellowship in critical care and making sure his toddler survives past age 5.

Chris Lipp

Chris Lipp is one of the founding Fathers for CrackCast. He currently divides his time as an EM Physician in Calgary (SHC/FMC) and in Sports Medicine (Innovative Sport Medicine Calgary). His interests are in paediatrics, endurance sports, exercise as medicine, and wilderness medical education. When he isn’t outdoors with his family, he's brewing a coffee or dreaming up an adventure…..