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so now let's talk a little bit more
about gastrointestinal or GI bleeds the
difference anatomically between an upper
GI lead and a lower GI bleed is the
cutoff point of the ligament of treitz
this is in the fourth portion of the
duodenum so everything above that is an
upper GI bleed and everything below is a
lower GI bleed the reason why we care
about that is because upper GI bleeds
present differently from lower GI leads
so with an upper GI lead patients tend
to come in with melania which is dark or
black colored stools or they may have
hematemesis which is the vomiting of
bright red blood on the other hand lower
GI bleeds tend to present with Hamato
kita this is when there is bright red
blood that is passed from the rectum
keep in mind however that a very quick
upper GI bleed may also sometimes
present with hematochezia if the
bleeding is occurring fast enough so
when I see a patient complaining of any
one of these symptoms I always want to
make sure to ask about these important
risk factors so the patient's past
medical history have they ever had a GI
bleed before do they have a known
history of ulcers or a history of
infection with h pylori these are some
of the things I want to ask you also
want to make sure to ask about their
medications so do they use NSAIDs
frequently are they on any
anticoagulants or antiplatelet agents
like aspirin or clopidogrel and
importantly do they take iron
supplements this is because iron pills
can actually turn the stool a dark color
and may obscure the clinical picture of
a GI bleed you also want to ask about
their social history so are they a
smoker or do they use heavy alcohol and
in their history you'll want to get at
any comorbid conditions such as
cirrhosis any renal disease or cancers
other associated symptoms such as
dysphasia or difficulty swallowing any
unintentional
less were they vomiting frequently prior
to the episode and have they had any
other changes in their bowel habits so
that brings us to the differential
diagnosis for GI bleeds it is quite a
broad differential so we'll break it
down first and to upper and then lower
GI bleeds your historical risk factors
can help you narrow down your
differential diagnosis so if your
patient comes in complaining of bleeding
with heavy and said use or alcohol use
your differential might include gastric
or duodenal ulcers or erosive
esophagitis gastritis or duo tinnitus if
they have a known history of liver
disease or cirrhosis then your
differential should include esophageal
or gastric varices and portal
hypertensive gas drop a--they the next
thing on your differential is the
arterial venous malformation or AVM this
is a rare cause of GI bleeding but
should always be on the differential
since it is always a present risk next
if your patient has describes a history
of frequent vomiting prior to presenting
with bleeding then you could suspect a
mallory-weiss tear and the last thing
that should always be on your
differential is cancer now let's move to
lower GI bleeds in patients describe a
history of chronic constipation you
should be more concerned about
diverticulosis and hemorrhoids those who
have a long-standing history of diarrhea
along with bloody bowel movements might
be concerned for inflammatory bowel
disease those who describe abdominal
pain along with their bleeding may have
a schema colitis just as with upper GI
leads you should always be concerned for
an AVM and in the right patient who just
a Scott describes a history of
infectious symptoms along with their
bloody bowel movements you might think
of infectious colitis and lastly cancer
as always should be on your differential
for all GI bleeds so now let's move to
the physical exam there are some
important physical exam findings that
can help you stratify whether your
patient is sick or not sick so
first thing to look at is their heart
rate if their patient has resting
tachycardia so a heart rate greater than
90 at rest this implies that they have
already lost about less than 15% of
their total blood volume keep in mind
here though that if your patient is
taking a medication that can slow down
the heart rate like a beta blocker or a
calcium channel blocker then this
finding may not be present and you might
be falsely reassured the next thing you
can check is orthostatic hypotension if
your patient meets these parameters in
the drop of their blood pressure from a
supine to a standing position this
indicates they have already lost greater
than 15 percent of their total blood
volume so this is already a concerning
finding next if your patient is already
hypotensive while lying flat in general
we consider this a blood pressure less
than 90 over 60
however keep in mind that your patient's
baseline blood pressure may be a bit
lower so you always want to compare to
their no and baseline if they're
hypotensive just lying flat this
indicates to us that they have already
lost greater than 40 percent of their
total blood volume and this is one of
your sicker patients the next you want
to do is a focused abdominal exam this
can be helpful to look for things like
rebound tenderness involuntary guarding
or extreme pain when you palpate the
abdomen these things can be helpful to
look for signs of peritonitis
peritonitis occurs when there is a
perforated organ or the patient has
developed bowel ischemia and lastly the
most important thing you should always
remember to do when seeing a patient
with a GI bleed is a rectal exam you
want to look for either grossly bloody
stool or black colored melon otic stool
in addition you can also check for
things like an anal fissure or
hemorrhoids or any masses in the rectum
that might help you focus your
differential diagnosis a bit more so now
let's move to laboratory studies there
are several lab studies that you should
always make sure to get
in a patient presenting with a GI bleed
the first is a complete blood count or
CBC here you're looking specifically for
a drop in the hemoglobin or low
platelets keep in mind here though that
a drop in the hemoglobin may not be
immediately apparent because the loss of
whole blood after the loss of whole
blood it takes time for the body to
re-equilibrate and that drop in
hemoglobin may be delayed by about a day
or so the next thing you want to check
is your basic metabolic panel or BMP you
can look specifically here for Abe UN to
creatinine ratio when the b12 creatinine
ratio is greater than 30 to one this has
been shown to correlate well with the
presence of an upper GI lead keep in
mind though that this isn't only helpful
for upper GI bleeds and not lower GI
bleeds the next thing you can look at is
your liver panel here you're looking
specifically for signs of impaired liver
synthetic dysfunction so in this case a
low albumin may be helpful
next you always want to check
coagulation factors to look for any
coagulopathy that might exist for your
patient and make it more difficult to
control bleeding and the last thing you
could check is an is a lactate here if
you find an elevated lactate this may be
a sign that your patient has developed
signs of end organ dysfunction and needs
to be more aggressively resuscitated so
let's take a brief moment to talk a
little bit about further tests you might
do for GI bleeds there is a test called
an fobt or fecal occult blood testing as
a high-value care tip this is not a test
that you should use to look for active
GI bleeding it has a very poor
sensitivity and specificity for active
GI bleeds and really should only be used
in the screening for colorectal cancer
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