For the majority of patients presenting with gastrointestinal (GI) bleeding, hematemesis, hematochezia, or melena will be the chief complaint. Occasionally, patients may present with only dizziness, weakness, lethargy, angina, or syncope. Upper GI bleeding often presents with vomiting fresh blood (hematemesis), vomiting of dark-colored, granular material (“coffee-ground” emesis), and/or black tarry stools (melena). The passing of blood from rectum (hematochezia) usually indicates bleeding from the lower GI tract. The severity of blood loss must be assessed quickly so that lifesaving therapeutic interventions can be instituted. Factors that increase morbidity and mortality include hemodynamic instability, ongoing symptoms suggesting active bleeding, low initial hemoglobin, age over 65, abnormalities in renal, hepatic, and cardiac function, and other comorbidities.
IMMEDIATE MANAGEMENT OF LIFE-THREATENING BLEEDING
Immediate management of life-threatening bleeding. BUN, blood urea nitrogen; FFP, fresh frozen plasma; PT, prothrombin time; PTT, partial thromboplastin time.
ASSESS THE RATE AND VOLUME OF BLEEDING
Any patient presenting to the emergency department with ongoing hematemesis or hematochezia is at significant risk of exsanguination, and prompt volume resuscitation must begin at once. Proceed with initial stabilization procedures as described below.
CONDUCT INITIAL ASSESSMENT
Place the patient in a monitored bed and obtain a full set of vital signs including oxygen saturation. If the initial systolic blood pressure is greater than 100, and the pulse is less than 100 beats/min in the supine position, consider obtaining orthostatic blood pressure and pulse rate measurements.
Recognize Risk Factors for Severe Gastrointestinal Bleeding
Signs, symptoms, or history that may indicate ongoing hemorrhage are as follows:
Profuse hematemesis or hematochezia
Hypotension, tachycardia, or signs of shock
Postural hypotension, tachycardia, or light-headedness
Possible aortoenteric fistula (history of abdominal aortic aneurysm repair or palpable pulsating abdominal mass)
Known or suspected esophageal varices
Previous history of GI bleeding
History of diverticulosis
Initial Stabilization Procedures
As with any emergency, always address your patient’s ABCs first.
A. Assess Need for Airway Management
Consider endotracheal intubation for patients with ongoing massive hematemesis or if signs and symptoms of shock are present. Patients with massive hematemesis may aspirate blood leading to respiratory compromise or may present with altered mental status from hypovolemic shock. If immediate airway control is not needed, provide supplemental oxygen as needed to maintain oxygen saturation at greater than 93%.
Insert two large-bore intravenous (IV) catheters (18 gauge or larger) into peripheral veins. If peripheral access cannot be obtained, consider placement of a central venous catheter or an intraosseous line.
C. Begin Fluid Resuscitation