UPPER GI BLEEDING 1 P a g e UPPER GI BLEEDING P 980 985 Etiology and Pathophysiology Sudden onset Insidious occult bleeding Bleed from arterial source profuse bright red no contact with HCl secretions Coffee ground emesis blood has been in the stomach for some time Massive upper GI bleed loss of more than 1500 mL of blood Melena black tarry stools slow bleed from an upper GI source Overt bleeding hematemesis gross blood or coffree ground material in NG aspirate Clinically important bleeding overt bleeding complicated by one of the following within 24 hours after onset Spontaneous decrease of more than 20 mm Hg in SBP o o Decrease of more than 10 mm Hg in the SBP when sitting up o o Decrease in hemoglobin level of more than 2 g dL Increase of more than 20 beats min in HR Occult bleed presence of guaiac positive stools or NG aspirates Common Causes of Upper GI Bleeding Drug Induced Corticosteroids NSAIDS Salicylates Esophagus Mallory Weiss tear Esophageal varices Esophagitis Stomach and Duodenum Stomach cancer Hematologic gastritis Peptic ulcer disease Polyps Stress related mucosal disease Systemic Disease Blood dyscrasias Renal failure Esophageal Origin Chronic esophagitis caused by GERD ingestion of drugs irritating to mucosa alcohol and cigarettes Mallory Weiss tear in mucosa near esophagogastric junction r t severe retching and vomiting Esophageal vaerices secondary to cirrhosis of the liver Stomach and Duodenal Origin Bleeding peptic ulcers 50 of upper GI bleeding cases Drugs major cause of upper GI bleed o NSAID s o o Corticosteroids Aspirin Stress related mucosal disease Physiologic stress ulcers Severe burns or trauma o o UPPER GI BLEEDING 2 P a g e o Major surgery Emergency Assessment and Management 80 85 spontaneously stop bleeding Complete history of events leading to the bleeding episode deferred until emergency care Immediate physical exam o o Systemic evaluation of patient s condition Emphasize BP HR character of pulse peripheral perfusion cap refil presence or absence of neck vein distention Check these vitals every 15 30 minutes Assess signs and symptoms of shock Assess RR and abdominal exam o o o Note presence of absence of bowel sounds o Tense rigid boardlike abdomen may indicate perforation and peritonitis Have patient or caregiver answer questions once immediate interventions have begun Is there a history of previous bleeding episodes o o Has weight loss been a recent problem o Has the patient received blood transfusions in the past o Were there any transfusion reactions o o Are there any other illnesses liver disease cirrhosis or medications contributing to bleeding or interfering the treatment Is there a religious preference that prohibits the use of blood or blood products Mayt be normal and not reflect until 4 6 hours after fluid replacement Order lab studies o CBC BUN o Serum electrolytes o Blood glucose o PT time o Liver enzymes o Arterial blood gases o Type and crossmatch for possible blood transfusions o Test all vomit and stool for occult blood o o Urinalysis SG and hydration status o H H guides further treatment Two IV tines with 16 18 gauge for fluid blood replacement Isotonic crystalloid solution o LR Whole blood Packed RBC s Fresh frozen plasma Isotonic saline solution if bleeding is less profuse Supplemental oxygen delivered by face mask to increase O2 saturation Indwelling urinary catheter inserted so output can be assessed hourly Central venous pressure line inserted for fluid volume status assessment PPI therapy with high dose bolus started before endoscopy Diagnostic Studies Endoscopy for diagnosis Angiography when endoscopy cannot be done Endoscopic Therapy UPPER GI BLEEDING 3 P a g e First line management of upper GI bleeds Within 24 hours of bleeding for diagnosis Before the endoscopy Lavage before endoscopy to provide clearer view o o Do not advance tubes if resistance is felt due to damaging mucosa or causing perforation o Erythromycin to promote gastric motility to empty stomach Used to stop bleeding for patients with severe gastritis Produces tissue edema and pressure on source of bleeding o o Combined with other therapies such as thermocoagulation or laser treatment to prevent rebleeding Surgical Therapy Indicated when bleeding continues Medical Therapy Decrease bleeding Decrease HCl acid secretion Neutralize HCl acid that is present Injection therapy with epinephrine PPI s o Protonix H2 antagonists o Cimetidine Antacids o Duodenal ulcers Acute gastritis o Nursing Management ASSESSMENT Low BP Rapid weak pulse Increased thirst Cold clammy skin Restlessness Appearance of neck veins o Skin color o o Cap refill o o o Abdomen distention Abdomen guarding Peristalsis NURSING DIAGNOSES Risk for aspiration r t active bleed and altered LOC Decreased cardiac output r t loss of blood Thorough and accurate nursing assessment Subjective and objective data Perform immediate nursing assessment while getting patient ready for initial treatment o o LOC Vital signs monitor every 15 minutes indicates shock from blood loss S S include o o o o o o o UPPER GI BLEEDING 4 P a g e Deficient fluid volume r t acute loss of blood and gastric secretions Ineffective peripheral tissue perfusion r t loss of circulatory volume Anxiety r t upper GI bleed hospitalization uncertain outcome source of bleed Ineffective coping HEALTH PROMOTION Chronic gastritis or peptic ulcer disease history high risk One major bleeding episode will most likely have another bleed Cirrhosis and upper GI bleed from varices at high risk Instruct high risk patients to avoid gastric irritants such as alcohol and smoking stress inducing situations at home and work only take prescribed meds Drugs can produce gastroduodenal toxicity Peptic ulcer formation Bleeding Aspirin o o o o Corticosteroids o NSAIDs administer with PPI misoprostol Cytotec or high dose H2 blocker to reduce bleeding risk Take these drugs with meals or snacks Stress importance of avoiding Alcohol Smoking Treating upper respiratory infections ACUTE INTERVENTION Approach patient in calm manner Start infusion and maintain IV line for fluid and blood replacement o Assess for fluid volume overload Auscultate breath sounds for respiratory effort EKG Accurate I O for hydration status Measure urine output hourly o Rate of at least 0 5 mL kg hr for adequate renal perfusion o Measure urine SG for hydration status greater than 1 025 Lavage 50 100 mL of fluid instilled at a time into the stomach o o Do not aspirate if resistance is felt