Dr. Clever Presents: Gastro-Intestinal Bleeding
New Terminology:
Hematemesis: Vomiting blood
Hematochezia: Blood coming out of the rectum. Often abbreviated as BRBPR (bright
red blood per rectum).
Melena: Black stools, with a consistency of tar, and a horrible smell. Typical for
digested blood.
Guaiac: A test which helps check for the presence of blood in the stool. Reported as
positive (blood present) or negative (no blood present). Always document the control
was positive (a sign that the test is functioning properly).
Varices: Large veins in the esophagus that can cause severe bleeding. Most common in
patients with liver problems such as cirrhosis.
Cirrhosis: A hardened and shrunken liver. May be caused by certain types of hepatitis
or excess alcohol intake. Patients with cirrhosis are much more likely to have varices
and hemorrhoids.
Ascites: Fluid in the abdomen. Usually caused by cirrhosis.
Background
GI bleeding is a common presenting problem to the Emergency Department. Patients
will present across the spectrum of perfectly healthy and able to get an outpatient workup to
patients who will try very hard to die in front of you. The workup and treatment depends upon
whether the bleeding is coming from the upper part of the GI system (the esophagus, stomach
or 1st part of the small bowel), or the bleeding is coming from the bottom (pun intended) part
of the GI system (the colon and rectum).
Patients bleeding from an Upper GI bleed (UGIB) with usually have nausea and vomiting.
The emesis may be bright red blood or may look like coffee grounds (partially digested blood
from the stomach). These patients will usually have guaiac positive stools and will sometimes
have melena as well.
Patients bleeding from the lower GI system (LGIB) usually have bright red or maroon
colored stools. These stools will be guaiac positive. Patients who are vomiting bright red blood
or coffee grounds and having red or maroon stools are very sick. They are bleeding so fast that
the body does not have time to digest the blood to cause melena.
Important HPI Elements: Has this ever happened before? Any liver problems such as cirrhosis?
Any history of hemorrhoids? Any blood thinners such as Coumadin (Warfarin), Plavix, or
Aspirin? Any use of NSAIDS such as ibuprofen or steroids.
Important ROS Elements: Nausea and vomiting? Melena? Lightheaded or dizzy? Abdominal
pain? Hematemesis? Hematochezia?
Important Physical Exam Elements: General appearance: Does the patient appear in distress?
CV: Is the patient tachycardic? Abdominal exam: Any pain, Is ascites present? Rectal Exam: Is
the stool guaiac positive or negative. Is melena present?
Important Charting Considerations: Critical Care time: Many of these patients will meet the
criteria for critical care time. Timing of consultations with GI/Surgeons/ICU
hospitalists/Interventional radiology. Response to therapy. Was a Naso-gastric tube placed
and what did it show? Was the pt given a blood transfusion? Did the physician perform any
procedures?