Gastrointestinal (GI) bleeding is a common problem in emergency medicine and should be considered life-threatening until proven otherwise. Acute upper GI bleeding is more common than lower GI bleeding. Upper GI bleeding is defined as that originating proximal to the ligament of Treitz. Upper GI bleeds can result from peptic ulcer disease, erosive gastritis and esophagitis, esophageal and gastric varices, and Mallory–Weiss syndrome. Lower GI bleeds most commonly result from diverticular disease, followed by colitis, adenomatous polyps, and malignancies. What may initially appear to be lower GI bleeding may be upper GI bleeding in disguise.
Most patients complain of hematemesis, coffee-ground emesis, hematochezia, or melena. Others will present with hypotension, tachycardia, angina, syncope, weakness, and confusion. Hematemesis or coffee-ground emesis suggests an upper GI source. Melena suggests a source proximal to the right colon. Hematochezia (bright red or maroon-colored) indicates a more distal colorectal lesion; however, approximately 10% of hematochezia may be associated with upper GI bleeding. Weight loss and changes in bowel habits are classic symptoms of malignancy. Vomiting and retching, followed by hematemesis, is suggestive of a Mallory–Weiss tear. A history of medication or alcohol use should be sought. This history may suggest peptic ulcer disease, gastritis, or esophageal varices. Spider angiomata, palmar erythema, jaundice, and gynecomastia suggest underlying liver disease. Ingestion of iron or bismuth can simulate melena, and certain foods, such as beets, can simulate hematochezia. However, stool heme (guaiac) testing will be negative.
DIAGNOSIS AND DIFFERENTIAL
The diagnosis may be obvious with the finding of hematemesis, coffee ground emesis, hematochezia, or melena. A careful ear, nose, and throat (ENT) examination can exclude swallowed blood as a source. Nasogastric (NG) tube placement and aspiration may detect occult upper GI bleeding. A negative NG aspirate does not conclusively exclude an upper GI source. Guaiac testing of NG aspirate can yield both false-negative and false-positive results. Most reliable is gross inspection of the aspirate for a bloody, maroon, or coffee-ground appearance. A rectal examination can detect the presence of blood, its appearance (bright red, maroon, or melanotic), and the presence of masses. All patients with significant GI bleeding require type and crossmatch for blood. Other important tests include a complete blood count, electrolytes, blood urea nitrogen, creatinine, glucose, coagulation studies, and liver function tests. The initial hematocrit level may not reflect the actual amount of blood loss. Upper GI bleeding may elevate the blood urea nitrogen level. Routine plain radiographs are of limited value. The initial diagnostic procedure of choice for lower GI bleeds—angiography, scintigraphy, or endoscopy—depends on resource ability and consultant preference. In one study, a cause for lower GI bleeding was found in <50% of cases.
EMERGENCY DEPARTMENT CARE AND DISPOSITION
Emergency stabilization (airway, breathing, and circulation) takes priority. Administer oxygen, insert large-bore intravenous catheters, and institute continuous monitoring.
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