In this episode of "IM Basics," Dr. Amulya Anumolu provides a comprehensive overview of managing GI bleeds.

Patients often present with signs of volume loss like hypotension, tachycardia, pallor, altered mental status, or dizziness. Common complaints include vomiting blood (hematochezia) or dark, sticky, foul-smelling stools (melena). Melena specifically indicates an upper GI bleed because blood darkens as it passes through the GI tract. A disproportionately high BUN (e.g., 30:1 ratio) on CMP can also suggest an upper GI bleed. Bright red blood per rectum can be a lower GI bleed or as simple as hemorrhoids.

Initial Assessment & Stabilization:

• Ensure the patient has two large-bore IVs (16 or 18 gauge) in both forearms for rapid fluid and blood product administration. Central lines are too thin for emergencies.
• Cross-matching and blood typing are essential.
• Transfuse blood for hemoglobin below seven or with active bleeding, as hemoglobin can appear normal due to hemoconcentration from significant volume loss.
• Provide supplemental oxygen to all GI bleed patients to enhance the oxygen-carrying capacity of blood.
• Intubate altered patients unable to protect their airway immediately.

Workup & Management:

• Initial workup includes CBC, CMP, and INR.
• History taking should cover NSAID use, history of ulcers, prior scopes, and anticoagulant use.
• The Glasgow-Blatchford score can help risk stratify patients to determine if ICU admission is needed.
• For upper GI bleeds, administer an initial bolus of 80 mg IV Protonix, followed by 40 mg BID; there's no evidence a drip is better.
• For suspected variceal bleeds (e.g., in cirrhosis), give octreotide (50-100 mcg bolus followed by 25-50 mcg/hour infusion for 3-5 days) to reduce portal pressures. Terlipressin can also be used.
• Administer ceftriaxone for SBP prophylaxis (1g) or treatment (2g) in cirrhotic patients with ascites.
• Erythromycin (150-200 mg IV) can aid gastric emptying for better scope visualization in upper GI bleeds, but monitor for QTC prolongation.
• Correct coagulopathies. Stop anticoagulants like Eliquis or Warfarin in severe bleeds.

Diagnostic & Interventional Procedures:

• An EGD is used for upper GI bleeds to band varices or cauterize ulcers. A colonoscopy is used for lower GI bleeds and requires bowel prep.
• If the source isn't found endoscopically, a CT angiography (CTA) during active bleeding can localize it for IR embolization. Ensure it's a three-phase CT angiography, not just a CT with contrast.
• A tagged RBC scan can also help locate blood pooling.
• In severe, unstable upper GI bleeds where endoscopy is not feasible, a Blakemore or Minnesota tube can be placed to tamponade varices.

Pearls & Pitfalls:

• Hemoglobin should be considered as a concentration, not just a volume.
• For cirrhotic patients, have a lower threshold to start lactulose and rifaximin if hepatic encephalopathy is suspected.
• Bright red blood per rectum could also indicate mesenteric ischemia.
• Test for H. pylori if ulcers are found, ideally after being off PPIs for two weeks.
• Be aware of atrial-esophageal fistulas as a rare, serious complication post-AFib ablation.
• Constantly monitor GI bleeders, even stable ones, as they can decompensate rapidly

Sources:

• Washington Manual
• Up-to-date