Transcript GASTROINTESTINAL (G.I) BLEEDING

GASTROINTESTINAL (G.I) BLEEDING
Fadi J. Zaben RN MSN
Normal Anatomy:
The gastrointestinal tract starts
at the mouth, which leads to the
esophagus, stomach, small
intestine, colon, and finally, the
rectum and anus. The GI tract is
a long, hollow, muscular tube
through which food passes and
nutrients are absorbed.
Definition:
Gastrointestinal (GI) bleeding refers to any
bleeding that starts in the gastrointestinal tract.
GI bleeding is not just a gastroduodenal disorder
but may occur anywhere along the alimentary
tract.
Bleeding from the GI tract is a common medical
problem.
Bleeding is a symptom of an upper or lower GI
disorder.
It may be obvious in emesis or stool, or it may be
occult (hidden).
Types of G.I Bleeding:
Bleeding may come from any site along the GI tract,
but is often divided into:
1. Upper GI bleeding:
 The upper GI tract includes the esophagus (the
tube from the mouth to the stomach), stomach,
and first part of the small intestine.
 An upper source is characterized by hematemesis
and melena.
 About half of cases are due to peptic ulcer disease.
 Esophagitis and erosive disease is the next most
common causes.
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2. Lower GI Bleeding:
The lower GI tract includes much of the small
intestine, large intestine or bowels, rectum,
and anus.
It may be indicated by red blood per rectum,
especially in the absence of hematemesis.
The most common cause is hemorrhoids.
Incidence:
Upper GI bleed 100/100,000.
Lower GI Bleed 20/100,000.
Both are more common in males and elderly.
Etiology:
1. Trauma anywhere along the GI tract.
2. Erosions or ulcers.
3. Rupture of an enlarged vein such as a
varicosity (esophageal or gastric varices).
4. Inflammation, such as esophagitis (caused by
acid or bile), gastritis, inflammatory bowel
disease (chronic ulcerative colitis, Crohn's
disease), and bacterial infection.
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5. Alcohol and drugs (aspirin-containing
compounds, NSAIDs, anticoagulants,
corticosteroids).
6. Diverticular disease.
7. Cancers.
8. Vascular lesions or disorders, such as bowel
ischemia, aortoenteric fistula.
9. Mallory-Weiss tear.
10.Anal disorders, such as hemorrhoids or
fissures.
Clinical Manifestations:
• Characteristics of Blood:
Bright red: vomited from high in esophagus
(hematemesis): from rectum or distal colon
(coating stool).
Mixed with dark red: higher up in colon and small
intestine: mixed with stool.
Shades of black (coffee ground): esophagus,
stomach, and duodenum; vomitus from these
areas.
Tarry stool (melena): occurs in patient who
accumulates excessive blood in the stomach
Signs and Symptoms of Bleeding:
 Massive bleeding:
Acute, bright red hematemesis or large amount of
melena with clots in the stool.
Rapid pulse, drop in BP, hypovolemia, and shock.
 Subacute bleeding:
Intermittent melena or coffee-ground emesis.
Hypotension.
Weakness, dizziness.
 Chronic bleeding:
Intermittent appearance of blood.
Increased weakness, paleness, or shortness of breath.
Occult blood.
Diagnosis:
1. It is not difficult to diagnose bleeding, but it may
be difficult to locate the source of bleeding.
2. History: change in bowel pattern, presence of
pain or tenderness, recent intake of food and
what kind, alcohol consumption, such drugs as
aspirin or steroids.
3. Complete blood count (CBC) (hemoglobin,
hematocrit, platelets) and coagulation studies
(partial thromboplastin time, prothrombin time
with international normalized ratio) may show
abnormalities.
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4. Lower and Upper Endoscopy: identifies
source of bleeding, determines risk of rebleeding, and provides endoscopic therapy if
needed.
5. Imaging may detect etiology of bleeding.
6. Test of stool for occult blood.
Management:
• Based on Etiology.
• Emergency Intervention.
• Nasogastric Intubation.
• Other Measures.
Based on Etiology:
1. If aspirin or NSAIDs are the cause, discontinue
medication and treat bleeding.
2. If ulcer is the cause, medications, dietary and
lifestyle modifications.
3. Therapeutic endoscopic procedure (cautery,
injection).
4. Surgery may be indicated for cancers,
inflammatory diseases, and vascular disorders.
Emergency Intervention:
1. Patient remains on NPO status.
2. I.V. lines and oxygen therapy initiated.
3. If life-threatening bleeding occurs, treat
shock, administer blood replacement, intraarterial vasopressin or embolization.
4. Surgical therapy, if indicated.
Nasogastric Intubation:
1. An NG tube should be in place for most
patients with acute or upper GI bleeding.
2. If the aspirate continues to be bloody after 2
to 3 L of tap water lavage, the patient may
have an active bleed requiring more
emergent intervention or endoscopic
therapy.
Other Measures………
1. Electrocoagulation using a heater probe.
2. Injection of sclerosant or epinephrine.
3. Endoscopy used in conjunction with management
measures as well as in diagnostic evaluation.
4. Pharmacotherapy depends on cause; can include
histamine blockers as either continuous I.V.
(preferred) or bolus infusion to block the acidsecreting action of histamine. Intra-arterial
vasopressin can be used to slow or stop active
bleeding from diverticulum or vascular ectasia.
5. Surgery is indicated when more conservative
measures fail.
Complications:
1. Hemorrhage.
2. Shock.
3. Death.
Nursing Assessment:
• Obtain history regarding:
Change in bowel patterns or hemorrhoids.
Change in color of stools (dark black, red, or streaked with blood).
Alcohol consumption.
Medications, such as aspirin, NSAIDs, antibiotics, anticoagulants,
corticosteroids.
Hematemesis.
Other medical conditions.
• Evaluate for presence of abdominal pain or tenderness.
• Monitor vital signs and laboratory tests for changes
that indicate bleeding (hemoglobin, hematocrit,
platelet count, coagulation studies).
• Test for occult blood, if indicated.
Nursing Diagnoses:
1. Deficient Fluid Volume related to blood loss.
2. Imbalanced Nutrition: Less Than Body
Requirements related to nausea, vomiting,
diarrhea.
Nursing Interventions:
1. Attaining Normal Fluid Volume:
A. Maintain NG tube and NPO status to rest GI tract
and evaluate bleeding.
B. Monitor intake and output as ordered to
evaluate fluid status.
C. Monitor vital signs as ordered.
D. Observe for changes indicating shock, such as
tachycardia, hypotension, increased respirations,
decreased urine output, change in mental status.
E. Administer I.V. fluids and blood products as
ordered to maintain volume.
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2. Attaining Balanced Nutritional Status:
A. Weigh daily to monitor caloric status.
B. Administer I.V. fluids, TPN if ordered to promote
hydration and nutrition while on oral restrictions.
C. Begin liquids when patient is no longer NPO.
Advance diet as tolerated. Diet should be highcalorie, high-protein. Frequent, small feedings
may be indicated.
D. Offer snacks; high-protein supplements.
Patient Education and Health Maintenance:
Discuss the cause and treatment of GI bleeding
with patient.
Instruct patient regarding signs and symptoms
of GI bleeding: melena, emesis that is bright
red or coffee ground color, rectal bleeding,
weakness, fatigue, shortness of breath.
Instruct patient on how to test stool or emesis
for occult blood, if applicable.
QUESTIONS……..