Often small-bowel source. Consider small-bowel enteroclysis x-ray (careful barium radiography via peroral intubation of small bowel), Meckel's scan, enteroscopy (small-bowel endoscopy), or exploratory laparotomy with intraoperative enteroscopy.
Treatment: Upper and Lower GI Bleeding - Venous access with large-bore IV (14-18 gauge); central venous line for major bleed and pts with cardiac disease; monitor vital signs, urine output, Hct (fall may lag). Gastric lavage of unproven benefit but clears stomach before endoscopy. Iced saline may lyse clots; room-temperature tap water may be preferable. Intubation may be required to protect airway.
- Type and cross-match blood (six units for major bleed).
- Surgical standby when bleeding is massive.
- Support blood pressure with isotonic fluids (normal saline); albumin and fresh frozen plasma in cirrhotics. Packed red blood cells when available (whole blood if massive bleeding); maintain Hct >25-30. Fresh frozen plasma and vitamin K (10 mg SC or IV) in cirrhotics with coagulopathy.
- IV calcium (e.g., up to 10-20 mL 10% calcium gluconate IV over 10-15 min) if serum calcium falls (due to transfusion of citrated blood). Empirical drug therapy (antacids, H2 receptor blockers, omeprazole) of unproven benefit.
- Specific measures: Varices: octreotide (50-µg bolus, 50-µg/h infusion for 2-5 days), Sengstaken-Blakemore tube tamponade, endoscopic sclerosis, or band ligation; propranolol or nadolol in doses sufficient to cause beta blockade reduces risk of recurrent or initial variceal bleeding (do not use in acute bleed) (Chap. 155. Portal Hypertension); ulcer with visible vessel or active bleeding: endoscopic bipolar, heater-probe, or laser coagulation or injection of epinephrine; gastritis: embolization or vasopressin infusion of left gastric artery; GI telangiectases: ethinylestradiol/norethisterone (0.05/1.0 mg PO qd) may prevent recurrent bleeding, particularly in pts with chronic renal failure; diverticulosis: mesenteric arteriography with intraarterial vasopressin; angiodysplasia: colonoscopic bipolar or laser coagulation, may regress with replacement of stenotic aortic valve.
- Indications for emergency surgery: Uncontrolled or prolonged bleeding, severe rebleeding, aortoenteric fistula. For intractable variceal bleeding, consider transjugular intrahepatic portosystemic shunt (TIPS).
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For a more detailed discussion, see Laine L: Gastro-intestinal Bleeding, Chap. 57, p. 276, in HPIM-19. |