Virtual Rounds Session 1: GI Bleed (Premed Shadowing)

Case Highlights

A 44-year old female with a PMH of RA presents to the ED with two-day history of hematemesis. She notes that she has had 3 episodes of vomiting cupfulls of blood. Additionally, she states that her stools have been darker than usual but she thought it was due to taking Pepto ® over the course of the week. She notes she has been eating less due to a decreased appetite but generally eating makes her epigastric abdominal pain better. Daily medications include lisinopril and celecoxib PRN for pain. No dizziness, HA, weight loss, syncope, CP, or SOB. No surgeries in the past. No previous episodes of GIB.

Pathology

There are two ways we delineate gastrointestinal bleeding: upper GI bleeding (UGIB) and lower GI bleeding (LGIB). The point at which we separate these two is an anatomical structure known as the ligament of treitz. Therefore, bleeding proximal to the ligament of treitz is deemed an upper GI bleed (UGIB) while bleeding distal to the ligament of treitz is known as a lower GI bleed (LGIB). Image: https://healthjade.net/upper-gi-bleed/

When we discuss causes of GIB, we certainly want to consider the following:

• Peptic Ulcer Disease (PUD)

• This is often the product of chronic NSAID use in the way of ibuprofen or aspirin, for example, but can also be due to a gastric mucosal invader known as H.pylori. NSAIDs decrease the production of prostaglandins of which are essential for forming the mucosal layer that protects from the harsh acidic environment of the stomach. H.pylori is a bacteria of which often contributes to ulcers and occasionally GIB, so identification and eradication of it is paramount to decreasing associated morbidity.

• Gastritis

• Irritation to the stomach lining can come in the way of cocaine use of which can cause vasoconstriction of arteries supplying the stomach and correspondingly ischemia or bleeding. Zollinger-Ellison syndrome is a malignancy of gastrin cells producing excess amounts of gastrin leading to a vastly acidic pH and eventual gastritis and bleeding.

• Varices

• Increased pressure from a scarred (cirrhotic) liver can lead to engorged veins, particularly in the esophagus. These are prone to rupture and bleeding which certainly requires emergent treatment.

• Mallory-Weiss / Boerhaave Syndrome

• These conditions are commonly the result of chronic retching or vomiting. This causes tears in the mucosal lining of the esophagus leading to bleeding and potentially air in the mediastinum.

The diagnosis of GIB often starts with a good history and physical exam. On exam, we might find hypovolemia, hypotension, tachycardia, abdominal pain, or pallor. Using a technique known as nasogastric (NG) lavage, we will insert a tube into the stomach, flush with saline, and potentially recover what is known as coffee ground emesis. This sounds exactly like what it is, stomach contents of which resemble coffee grounds which is the product of GI bleeding. Labs can show anemia, elevated BUN/Cr, and potential electrolyte abnormalities.

To treat a GIB, consider the following in your assessment and plan:

• Transfuse if hgb <7 g/dL
• NG lavage
• EGD / colonoscopy
• Surgery if pneumoperitoneum, ongoing bleeding
• Minimize risk factors

Take home points

1. Gastrointestinal bleeding can be a significant cause of morbidity and mortality
2. An extensive history and physical can pinpoint signs of a GIB. Additional testing, labs, and diagnostic work-up can help us be sure that a GIB is what we are dealing with.
3. Ulcers and gastritis are common causes of GI bleeding; though other etiologies exist.
4. Swift action can reduce morbidity and complications associated with GIB.
5. Remember to transfuse if Hgb < 7 mg/dL and to reduce risk factors to prevent recurrence.

Watch the virtual shadowing session here:

Virtual Rounds Session 1: GI Bleed (Premed Shadowing)