GASTROINTESTINAL BLEEDING • Small and large intestines have no nerve endings

• can come from any of the areas in the digestive for us to determine kung nagkakaroon na ng
tract. pagkabulok.
• from the mouth to the anus • Compression/alteration in surrounding
• signs of bleeding in the digestive tract depend structures/blood vessels will give a hint to the px.
where it is and how much bleeding there is. • Possibility of pagkabulok of bowel.
• malaking factor sa amount of bleeding is kung • Ischemic portion can slough off and can cause
anong blood vessel yung affected. bleeding.
• Artery - more massive bleeding
• Manifestations will depend here Intussusception
• GI bleeding is a symptom of a disease or a • Telescoping of the small intestine into another part
condition, rather than a disease or condition itself. of the small intestine.
• When pxs come into the hospital with GI bleeding • Literally like a telescope.
assessment is important. Determine the root cause • Area na nagtelescope will be compressed and in
why the px is bleeding internally. the long run can necrotise and can slough off to
• Overt cause bleeding; or it can also cause an obstruction.

Meckel diverticulum
• Diverticula - out pouching
• Meckel diverticulum - occurs in the large intestine.
• Diverticulosis - small intestine
Increase build up of intraluminal pressure.
• Congenital defect that is said na karugtong ng
umbilcal cord ng isang neonate.
• Diverticulum can rupture and can cause bleeding
lalo na kapag may increaseed build up of pressure.
• Food particles na Hindi na-absorb or fecal material
can accumulate sa out pouches > can cause
inflammation > can cause rupture > can cause
bleeding

Angiodysplasia
bleeding can be recognized immediately unlike • Angio - blood vessel
occult bleeding. • Dysplasia - alteration of normal characteristic and
• the amount of bleeding can be so small that only a appearance of blood vessel
laboratory test can find it. • Increased BP can cause rupture.

Esophageal Varices Colonic cancer and rectosigmoid carcinoma

• varicosities/dilation ng mga blood vessels in the • Can cause lower GI bleeding.
esophageal are. Associated with portal • Cancer cell - needs blood supply. They create their
hypertension secondary to liver cirrhosis. own blood vessel (angiogenesis) - they branch it off
• A result of backflow of blood from hepatic the original blood vessel of the host. These vessels
circulation backward to the GI system because of are thin and can easily rupture > can cause
obstruction or inflammation or cirrhosis. bleeding.

Malory-Wise tear Inflammatory bowel disease

• Minute tear in the esophagaus • Classified into 2 diseases.
• Commonly associated with strenuous coughing or • 1. Regional enteritis - affects the small intestine
vomiting episodes (induced vomiting) • 2. Ulcerative colitis - affects primarily the colon
• Condition that promotes excessive diarrhea - some
Gastritis pxs can manifest bloody diarrhea.
• Inflammation of the lining of the gastric mucosa • Exact cause is unknown.
• Continuous exposure to insult will lead to ulcer >
perforation > tendency for bleeding episodes > Hemorrhoids
hemorrhagic gastritis - namumula lang muna but • Most common factor for lower Gi bleeding.
later on can cause bleeding. • Like outpouching pero kasama blood vessels.
• Secondary to constipation
Ischemic bowel disease • Px can also suffer from anal fissures.
• Ischemia in the bowel.
GI BLEEDING CLASSIFICATION
A. Visibility of bleeding:
 • Occult bleeding: ulcerative colitis
Bleeding in quantities too small to be (UC) & Crohn
macroscopically observable (requires chemical disease (CD)
- Invasive or
tests or microscopic examination to be detected). inflammatory
Maaring capillaries lang diarrhea -
• Overt (visible) GI bleeding: bacterial
Macroscopically observable bleeding with gastroenteritis,
due to e.g.,
accompanying clinical symptoms. (e.g., anemia, shigella,
tachycardia) enterohemorrha
gic escherichia
B. Degree of bleeding: coli (EHEC)
• Acute GI bleeding: VASCULAR - esophageal varices - Hemorrhoids
Sudden and sever (sometimes) or gastric varices - Ischemia (e.g.,
Acute, massive bleeding - can lead to - Gastric antral ischemic colitis,
hypovolemic shock, and even death; vascular ectasia mesenteric
(“watermelon ischemia)
- Can occur at any age from birth. stomach”) - Arteriovenous
- Mas nakakatakot kapag very young or very - Dieulafoy lesion: malformation
old ang px. minor mucosal - Rectal varices
• Chronic GI bleeding: trauma to an
abnormal
Slight bleeding that can last a long time or may submucosal artery -
come and go aneurysm (usually
Minute GI bleeding; mahirap madetect located in the
Kapag may manifestations na like anemia tsaka proximal stomach)
leads to major
lang mas napapansin bleeding (acute
Prolonged microscopic bleeding - can lead to UGIB)
loss of iron, causing anemia.
- anglodysplasia: a
common
C. Site of bleeding is divided into: degenerative
• Upper GI bleeding - located between the mouth disorder of GI
and the upper part of the small intestine. vessels (mostly
venous) that can
~70% - 80% of GI hemorrhages
cause GI bleeding
The source of the bleeding is proximal to the in the stomach,
ligament of Treitz (suspensory muscle of the duodenum,
duodenum). jejunum, and colon.
• Associated with
It is characterized by hematemesis and melena.
age >60 years, von
Hematemesis - pagsuka ng dugo Willebrand disease,
Kapag hindi nasuka it can go down further sa GI aortic stenosis, and
tract and then lumabas as melena (or black tarry ESRD
• Manifests with
stools) because na-digest na yung blood along
episodic bleeding
the GI tract. (hemtochezia) that
About half of cases are due to PUD ceases
Esophagitis and erosive disease is the next most spontaneously
(>90% of cases)
common causes (also ulcers)
• Diagnosis usually
• Lower GI bleeding - located between the upper part requires
of the small intestine and the anus. anglography.
• ~20% - 30% of all GI hemorrhages • Lesions are usually
multiple tortuous
• The source of the bleeding is distal to the
dilated vessels
ligament of Treitz, usually in the colon. Most
• Hematochezia - passage of blood in the stool. commonly
• It may be indicated by passage of red blood located in the
discharge per rectum, especially in the absence right-sided colon
(~75%).
of hematemesis.
• The most common cause is hemorrhoids.

GI BLEEDING ETIOLOGIES • Crohn disease and inflammatory diarrhea - usually

ETIOLOGY UGIB LGIB
manifest bloody diarrhea.
• Ectasia - dilation of blood vessels
INFLAMMATO - PUD (`30% of - diverticulosis • Characteristic that signifies vascular ectasia is the
RY/ EROSIVE cases) (~30% of watermelon stomach (yung parang may stripes)
- Esophagitis cases)
- Erosive gastritis - Inflammatory Lining of the stomach is may parts na mapula tas
and/or duodenitis bowel disease may parts na pale.
(IBD) - i.e.,
• Dieulafoy lesion > aneurysm > can lead to mahor up in the relates to
bleeding stomach sexual acts
• Aneurysm - permanent dilation of an artery; arteries that involves
become weak. objects
• There are different types of aneurysm: inserted in the
Dissecting aneurysm - the different tunica’s ay na- anus)
infiltrate na **Following open or endoscopic surgery (e.g.,
Remember na arteries have high pressure so anastomotic bleeding following a gastric bypass)
kapag bumaba sya in areas na may dilation it can Other  Postal  Anal fissures
cause rupture Causes Hypersensitive
gastropathy –
 Ischemia - Kapag ang isang area ng bowel sa small gastric mucosa
or large intestine ay nabubulok, pwedeng mapull out is inflamed,
yung area na yon na pwedeng reason for bleeding becomes
 Arteriovenous malformation (AVM) edematous and
o Normally: Artery connects to a capillary then dilated blood
tsaka sa vein vessels
o In AVM, there is no capillary. Artery connects  Coagulopathies
directly to a vein,which causes the problem.
o Because the capillary functions as a gradient INCIDENCE
that decreases the pressure.  UGIB 100/100,000
o Therefore, kapag direct ang artery and vein,  LGIB 20/100,000
hinid kakayanin ng walls ng veins ang high o Both are more common in males and elderly.
pressure blood flow ng artery kaya there is  Bleeding from the upper respiratory tract (e.g.,
possibility of rupture, which is common sa mga nocturnal nosebleeds) can be mistaken for GI
may AVM. bleeding because the blood can be swallowed and
 AVM- a congenital defect na walang capillary ang vomited or appear in the stool as melena. Careful
isang patient. examination and history taking is the key to
 Von Willebrand – abnormal blood coagulation. differentiating respiratory sources of bleeding from
 Aortic stenosis – narrowed path/opening of aortic GI ones.
valve
 Angiography – visualization of the blood vessels
with the help of a contrast medium.
 Specifically located in the right-sided colon
PROBABLY, yun yung area ng colon natin na
nagrereceive ng flow ng digested and undigested
food from the ileum na highly fluid pa.

ETIOLOGY UGIB LGIB

Tumors  Esophageal  Colorectal
cancer and/or cancer and/or
gastric anal cancer
carcinoma  Colonic polyps
(grape-like
structures,
predispose to
colon cancer)
Traumatic  Hiatal Hernias  Lower
or  Mallory-Weiss abdominal
Iatrogenic Syndrome (tear trauma -
in the blood Hemorrhoids  Ligament of Treitz – the line to determine if it is an
vessel in the leading to upper or lower GI bleeding.
Esophagus) bleeding COMMON CAUSES OF GI BLEEDING
 Boerhaave  Anorectal Drug-Induced  Corticosteroid
Syndrome trauma (e.g.,
 NSAIDS
(Spontaneous anorectal
avulsion,  Salicylates
Esophageal
rupture) – this is impalement Esophagus  Esophageal varices
secondary to injuries)  Esophagitis
extreme  Anorectal  Mallory-Weiss tear
pressure build avulsion Stomach and Duodenum  Stomach Cancer
  Hemorrhagic gastritis
 PUD RISK ASSESSMENT
 Polyps  PRE-ENDOSCOPY
 Stress-related o All patients with GI bleeding should be risk-
mucosal disease stratified to guide the diagnostic and
Systemic Diseases  Blood dyscrasias therapeutic approach, timing of endoscopy,
(e.g., leukemia, and patient disposition.
aplastic anemia)  LOWER-RISK CLINICAL SCENARIOS
 Renal failure o Occult GI bleeding
- Hard to perform when patient experiences
RISK ASSESSMENT active massive bleeding.
 GI Bleeding is not merely the disease, this is the - Risky on the part of the client
manifestation of underlying conditions. - EGD is not a priority procedure to do.
 It is important to perform risk assessment to - We need to address the bleeding by giving
determine if the patient is at risk for GI bleeding. fluids to replenish or blood transfusion for
 This is usually done of physicians. low hemoglobin or hematocrit levels
ENDOSCOPY o Scant intermittent hematochezia due to
 The best determination of risks is through benign anorectal disease (e.g., hemorrhoid,
endoscopy anal fissure)
o Could be done in the Esophagus, gastro or  HIGHER-RISK CLINICAL SCENARIOS
duodenum. Or sigmoid, recto-sigmoid or o Overt GI bleeding with high-risk features
colonoscopy. - see table below
o Determine where is the source of bleeding, what o Esophageal variceal bleeding
type of bleeding, etc. - Esophageal varices: dilated blood vessels
 Pre-endoscopy on the esophagus. When you perform the
o All patients with GI bleeding should be risk- EGD procedure, there is an increase
stratified to guide the diagnostic and therapeutic likelihood to hit an area of dilated
approach, timing of endoscopy, and patient esophageal varices causing rupture and
disposition. bleeding. Ideally, this procedure is not done
 Lower-risk clinical scenarios when there is suspected esophageal
o Occult GI Bleeding varices.
 First address the bleeding. High-risk features of GI bleeding
o Scant intermittent hematochezia due to benign https://next.amboss.com/us/article/ZS0Zy2#Za9Ba909
anorectal disease (e.g., Hemorrhoids, anal ec46171fc7d61894f4c263065
fissure)
 Higher-risk clinical scenarios Patient Factors  Age >60 years
o Overt GI bleeding with high-risk feature - wala  Chronic comorbidities
kang makikita kapag may massive bleeding and  History of diverticulosis
mas risky or angioectasia (for
o Esophageal variceal bleeding. LGIB)
HIGH-RISK FEATURES OF GI BLEEDING -Ectasia: dilated blood
vessels
Patient factors  Age >60 y/o
- Especially in the GI
 Chronic comorbidities tract, there is a higher
 History of diverticulitis chance of bleeding
or angioectasia (for associated with
LGIB) colonoscopy procedure
 History of an AAA and enema (prior to
graft colonoscopy)
Features Presentation  Hemodynamic  History of an AAA graft
instability - Some patient
 Ongoing bleeding experience dilation of
 Anemia, HVT ≤ 355, abdominal aorta. Pag
coagulopathy, or tumaas/lumaki yung
elevated BUN dilation of blood vessel
 Need to transfuse ≥ 6 (above 5.5 or 6cm in
units of packed RBCs diameter), there is an
Interpretation: >1 feature is associated with a risk of increase likelihood of
severe or recurrent bleeding rupture that may cause
 massive bleeding. g/dL
Repair is necessary ≤ 10 ≤ 10 5
and patient is g/dL g/dL
candidate for AAA Clinical Systemic ≥ 110 mmHg 0
graft) Features Blood 100-109 mmHg 1
Features at  Hemodynamic Pressure 90-99 mmHg 2
presentation instability ≤ 90 mmHg 3
 Ongoing bleeding Additional Heart rate ≤ 1
 Anemia, HCT ≤ 35%, Criteria 200/min
coagulopathy, or Melena at 1
elevated BUN presentation
- in relation in BUN, Syncope at 2
elevation of it may be presentation
caused by active GI Liver disease 2
bleeding due to the - Liver:
blood present in the responsible for
stomach that is producing the
metabolized and clotting factors
digested into urea. - If patient is
 Need to transfuse ≥ 6 bleeding, and her
units of packed RBCs liver function is
Interpretation > 1 feature is associated with a risk of incapable to
severe or recurrent bleeding produce
UGIB scoring systems: coagulating
e.g., the Glasgow-Blatchford score (GBS) factor, further
 Used to guide patient disposition in bleeding episode
hemodynamically stable patients with UGIB. is possible.
 Along with other scoring system it helps estimate: Heart Failure 2
o The likelihood of rebleeding - Heart finds it
- Purpose of creating this scoring system is difficult to
compensate to
for proper categorization.
the decreasing
- GI bleeding is not the disease perse of the
fluid volume or
patient, it is more often a manifestation of an cardiac output
underlying gastrointestinal disorder. that is being
o The need for urgent hemostatic control circulated into the
o Mortality body.
 Scores are directly proportional with risk of Interpretation
rebleeding and need for urgent intervention.  Score 0 low-likelihood of rebleeding or need for
o Score ≥ 7 – associated with a higher urgent intervention.
likelihood of urgent endoscopic intervention  Score ≥ 1 higher likelihood of rebleeding and or
and mortality. need for urgent intervention.
- Urgent endoscopic intervention: kailangang
susunugin yung blood vessels to create a  Critical assessment is needed – who is more likely is
tamponade for the bleeding to stop. at risk to develop GI bleeding.
Glasgow-Blatchford score  Detailed History must also be done.
Parameters Findings  But if patient is suffering from massive bleeding,
Laboratory BUN ≤ 18.2 mg/dL 1 withhold the history taking, focus to the assessment
Features 18.2 mg/dL – 2 and address the current problem/physiological
22.3 g/dL status of the patient. Avoid the occurrence of
22.4 mg/dL – 3 hypovolemic shock.
27.9 mg/dL LGIB scoring systems:
28 mg/dL – 69.9 4 e.g., the Oakland score.
mg/dL  This externally validated risk score based on
5 o Age
Hemoglobin Male Female o Sex
≥ 13 ≥ 12 0 o Prior admissions for LGIB
g/dL g/dL
o Vital signs
12-13 10-12 1
o DRE findings
g/dL g/dL
10-12 N/A 3 o Hemoglobin at admission
 It can help identify patients at low risk of poor  Age
outcomes who can be safely managed as ≤ 40 0
outpatients. 40-69 1
Variables comprising the Oakland score ≥ 70 2
Predictor Score component value  Gender
 Age Female 0
≤ 40 0 Male 1
40-69 1  Previous LGIB
≥ 70 2 admission
 Gender No 0
Female 0 Yes 1
Male 1  DRE findings
 Previous LGIB No blood 0
admission Blood 1
No 0  Heart Rate
Yes 1 ≤ 70 0
 DRE findings 70-89 1
No blood 0 90-109 2
Blood 1 ≥ 110 3
 Heart Rate  Systolic blood
≤ 70 0 pressure
70-89 1 < 90 5
90-109 2 90-119 4
≥ 110 3 120-129 3
 Systolic blood 130-159 2
pressure ≥ 160 0
< 90 5  Hemoglobin
90-119 4 < 70 22
120-129 3 70-89 17
130-159 2 90-109 13
≥ 160 0 110-129 8
 Hemoglobin 130-159 4
< 70 22 ≥ 170 0
70-89 17 Patients scoring ≤ 8, with no other indications for
90-109 13 hospital admission are suitable for immediate
110-129 8 discharge from Accident and Emergency and
130-159 4 outpatient investigation. DRE, digital rectal
≥ 170 0 examination: LGIB, lower gastrointestinal bleeding.
Patients scoring ≤ 8, with no other indications for
hospital admission are suitable for immediate  DRE – Digital Rectal Exam
discharge from Accident and Emergency and  Kapag lower ang risk ng patient, the Dr may perform
outpatient investigation. DRE, digital rectal further assessment like colonoscopy
examination: LGIB, lower gastrointestinal bleeding.
FORREST CLASSIFICATION OF BLEEDING PEPTIC
LGIB scoring systems: ULCERS
e.g., the Oakland score.
 This externally validated risk score based on
o Age
o Sex
o Prior admissions for LGIB
o Vital signs
o DRE findings
o Hemoglobin at admission
 It can help identify patients at low risk of poor
outcomes who can be safely managed as
outpatients.
Variables comprising the Oakland score
Predictor Score component value
 Ia – spurting arterial haemorrhage, damaged bleeding: of blood from
integrity of mucosal lining maroon, the upper GI
 Ib – mas malakas ang bleeding episode jelly-like tract may also
 IIa – may visible vessel na if exposed to higher traces of result in
blood in hematochezia
insult, pwedeng matuklap ang outermost layer ng
stools
blood vessel that may cause spurting arterial or
- Rectal
active oozing haemorrhage bleeding:
 IIb – Ulcer with an adherent clot, shows that streaks of
nagkaroon ng recent PUD fresh blood
 IIc – Flat ulcer with a dark base (covered with on stools
hematin) (hematin – greenish yellow covering on  Both melena and hematochezia can be caused by
top of ulcer) either UGIB or LGIB.
III – flat ulcer base (no active haemorrhage)  Unexplained iron deficiency anemia (in men or
postmenopausal women) should raise suspicion for
COLONOSCOPY GI bleeding.
 Inpatient treatment is recommended if there are
UPPER GI BLEEDING
features requiring intervention or associated with
rebleeding  Bright red or coffee ground vomitus (hematesis)
 Melena
UPPER ENDOSCOPY  Decreased BP
 The Forrest classification is commonly used to  Increased HR
determine the need for hemostatic interventions  Weak peripheral pulses
during the procedure and can help guide disposition  Acute confusion (in older adults)
by predicting the risk of rebleeding  Vertigo
 Dizziness or light-headedness
GASTROINTESTINAL BLEEDING MANIFESTATIONS  Syncope (loss of consciousness)
 Anemia due to chronic blood loss  Decreased haemoglobin and hematocrit
o Acute haemorrhage with significant blood loss
 Signs of circulatory insufficiency or hypovolemic GI BLEEDING MANIFESTATION
shock  Cannot be generalized kasi pwedeng ,magresult
o Tachycardia, hypotension (dizziness, collapse, from different area yung bleeding sa lower GI.
shock) LOWER GI BLEEDING
o Altered mental status IBD
Features of overt GI bleeding 
Young patients may not present with abdominal
Description Cause pain, rectal bleeding, diarrhea, and mucus
Hematemesis Vomiting blood, Most commonly discharge.
may be red or due to bleeding ANGIODYSPLASTIC LESIONS
coffee-ground in in the upper GI  Elderly patients with atherosclerotic heart
appearance tract disease may not present with intermittent LGIB
(esophagus, and syncope.
stomach)
 Blood vessels in the colon become tortuous.
Melena Black tarry Most commonly
ISCHEMIC COLITIS
stool, with due to bleeding
strong offensive in the upper GI  Elderly patients presenting with abdominal pain,
odor tract rectal bleeding and diarrhea.
PERIANAL PATHOLOGY (such as anal fissure or
Can also occur hemorrhoidal bleeding)
in bleeding from  Stools are streaked with blood.
the small bowel  Patients has perinatal pain and
or the right  (+) blood drops on the toilet paper or in the toilet
colon
bowl.
Hematochezia The passage of Most commonly
MASSIVE LGBI
bright red due to bleeding
(fresh) blood in the lower GI  A life-threatening condition in which patient
through the tract (distal present with:
anus (with or colon)  A SBP below 90 mm Hg and
without stool)  A Hgb level of 6 g/dl or less
- Colonic Rapid passage  Patient manifest signs of hypovolemic shock
  Affected patients are usually: palpitation ischemia
o 65 years and older Rectal exam Bloody or Check the anal
o w/ multiple medical problems &, melanotic stool fissure,
o are at risk of death from acute hemorrhoids,
masses and
hemorrhage or its complications.
gross blood on
 The passage of maroon stool or bright red blood stool exam
from the rectum is usually indicative of massive
lower GI hemorrhage. CHARACTERISTIC OF BLOOD
BRIGTH RED
PRESENTATION OF LGIB DEPENDING ON
 Vomited from high in esophagus (hematemesis):
ETIOLOGY
from rectum or distal colon (coating stool).
INFECTIOUS OR NONINFECTIOUS (IDIOPATHIC)
COLITIS Hematochezia
o Left -sided bleeding of the colon
 A young patient may present with fever,
dehydration, abdominal cramps, and o If the bleeding is brisk and massive – it
hematochezia. maybe evident also in patients with
 Common sa mga infectious conditions leading to UGIB and those with right-sided colonic
colitis ay mga inflammatory bowel diseases. bleeding.
MIXED WITH DARK RED
 Noninfectious have unknown cause.
 Signs and symptoms are secondary to  Higher up in colon and small intestine: mixed
excessive blood or stool excreted. with stool.
DIVERTICULAR BLEEDING OR ANGIODYSPLASIA o Right-sided bleeding of the colon
SHADES OF BLACK (COFFEE GROUND)
 Older patient may have minimal symptoms and
present with painless bleeding and  Esophagus, stomach, & duodenum; vomitus
o Mild and intermittent LGIB (if due to from these areas
angiodysplasia)  It represents that there is digestion of blood from
o Moderate or severe LGBI (if due to GI tract.
TARRY STOOL (MELENA)
diverticula-related bleeding)
IMPORTANT EXAM FINDING  Occurs in patients who accumulates excessive
blood in the stomach.
Physical exam Exam Finding Significance o Maybe present with cecal bleeding
component NO distinct method exists for determining the anatomic
Resting HR >90/min Loss of <15% source of bleeding based solely on stool color.
tachycardia total blood Stool color is not a confirmatory test that there is GI
volume bleeding. Therefore, still assess the patient because
Orthostatic Decrease in Loss of >15% signs and symptoms vary.
hypotension SBP ≥20 mm total blood
Hg or DPB ≥10 volume
mm Hg from
supine to
standing
position
Supine Supine BP ≤ Loss of ≥40%
hypotension 80/60 mm Hg total blood
volume
Abdominal Rebound Peritoneal signs
exam involuntary may indicate
guarding, perforated
extreme pain to viscus or bowel
ESOPHAGUS hemorrhoids, infectious diarrhea, inflammatory
 Bright red blood via vomitus and hematochezia in bowel disease, polyps, tumors, ulcers, Mallory-
stool if there is heavy bleeding. Weiss tears.
 Coffee ground vomitus and the stool is melena  These conditions are the possible etiology or risk
and positive fecal occult blood if light bleeding. factor for the development or manifestation that
STOMACH leads to GI bleeding.
 Blood clots and mixture of bright and dark red
blood vomitus, hematochezia may occur in stool GI BLEEDING DIAGNOSTIC/LABORATORY TEST
for heavy bleeding.
 The same with esophagus for light bleeding. BLOOD TEST – to detect whether you have anemia or
DUODENUM bleeding disorders
 More blood clots in the vomitus bright to dark red,  COMPLETE BLOOD COUNT – low Hgb
stool is a mixture of dark red and black blood for indicates anemia; Thrombocytopenia can cause
heavy bleeding. GI bleeding
 The same with esophagus for light bleeding. o To check if mababa na ang
COLON hemoglobin and platelet count.
 No vomitus, stool fluctuate from bright red to dark Normal response of our body kapag
red for heavy bleeding. may bleeding, may platelet
 No vomitus, on stool exam there are blood clots, aggregation so there is an increased
positive fecal occult blood for light bleeding. likelihood na bumaba ang platelet
SIGMOID count.
 No vomitus, bright red blood in the stool for heavy  COAGULATION STUDIES – a series of serum
bleeding. tests that evaluate for abnormal blood clotting
 No vomitus, on stool exam there are blood clots, o Specifically for patients having GI
positive fecal occult blood for light bleeding. bleeding caused by coagulopathy
RECTUM  BLOOD TYPE AND CROSSMATCHING –
 No vomitus, bright red blood in the stool for heavy should be obtained promptly in patients with
bleeding. ongoing GI bleeding and/or hemodynamic
 No vomitus, on stool exam there are streaks on instability at presentation
stool, positive fecal occult blood for light o In preparation for having blood
bleeding. transfusion, lalo na kapag may
Gastrointestinal bleeding Clinical features of massive bleeding
gastrointestinal (GI) bleeding, including hematemesis,  BUN LEVEL – extensive bleeding into the
melena, and hematochezia, vary depending on source gastrointestinal (GI) tract will also cause an
and volume bleeding. elevated BUN because digested blood is a
GI BLEEDING DIAGNOSTIC/LABORATORY TESTS source of urea.
 It is not difficult to diagnose bleeding, but it may o Tumataas ang BUN kasi nada-digest
be difficult to locate the source of bleeding. ng stomach yung blood accumulating
 It is easier to address the situation if the bleeding in the GI tract.
location or root cause is known, and this is a  LIVER FUNCTION TESTS (LIVER
challenge to the health practitioner to identify CHEMISTRIES) – a group of laboratory test that
where the bleeding is. serve as parameters of hepatocellular damage,
HISTORY cholestasis, and hepatic synthesis.
 Change in bowel pattern, presence of pain or o Liver is also functioning in
tenderness, recent intake of food and what kind, manufacturing the clotting factors
alcohol consumption, such as aspirin or steroids. o Impairment of the liver leads to
 Focus assessment ang ginagawa for emergency further bleeding episodes.
na dinudugo ang patient kapag dumating sa
- Anemia, low hematocrit, coagulopathy, and
hospital to prevent the patient from suffering sa
elevated BUN at presentation are signs of GI
hypovolemic shock
bleeding
STOOL EXAM
- An elevated BUN to creatinine ratio in a
 To detect occult bleeding patient with hematochezia suggests a brisk
 Occult blood: diverticular disease, esophagitis, UGIB
gastritis, esophageal varices, anal fissure,
 o Normally if there is an elevation of - Consider intubation prior to endoscopy if
metabolic waste, creatinine is being there is a high risk of aspiration
observed in relation with renal o It is important to subject the patient in an
functioning. endotracheal intubation to create
o But in this condition, ang tinitingnan ay GI tamponade and prevent regurgitation and
bleeding na cause ng digestion ng RBC aspiration since ET tube balloon will be
and na ang by product ay urea, hindi inflated.
creatinine, kaya BUN ang tataas.
 Colonoscopy (assess the lower GI tract)
o Source of GI bleeding identified:
NASOGASTRIC ASPIRATES (NG ASPIRATE) – this test Attempt endoscopic hemostasis.
is not routinely recommended other than as adjunct in  Through an endoscope mag-create ng
patients with hematochezia with only moderate probability stasis para mahinto yung bleeding.
of UGIB as the source o Negative (nondiagnostic) colonoscopy
It is not routinely recommended because it will further  Hemodynamically stable patients:
create trauma in the lining of the mucus membrane  Evaluate for small bowel bleeding
further bleeding episode. Mas preferred ang EGD  Hemodynamically unstable patients
 Procedure: Instill 200-300 mL of warm with ongoing bleeding: Consult
isotonic saline via NG tube, then aspirate surgery or angioembolization
gastric contents for inspection - Lower endoscopy without bowel preparation
 Findings: (including sigmoidoscopy) is not
o Positive: Bright red blood or coffee- recommended in the workup of acute LGIB.
grounds output; active UGIB confirmed
o Inconclusive: Non-bloody and non- VIDEO CAPSULE ENDOSCOPY (VCE)
bilious
o Negative: Non-bloody and bilious; active  A diagnostic procedure using a tiny wireless
UGIB less likely camera fitted inside a capsule that is swallowed
- In patients with suspected UGIB, nasogastric by the patient to take pictures of the mucosa in
aspiration is poorly sensitive as ~15% of the GI tract
patients with active UGIB can have a false  Pictures are analyzed after the capsule is
negative excreted 24-48 hours later.
- VCE is preferred in hemodynamically stable
ENDOSCOPY – to detect and see if and where you have patients with negative EGD and colonoscopy.
GI bleeding and the cause of the bleeding Hemodynamically unstable patients with
Cannot be performed kapag may massive bleeding ang suspected small bowel bleeding should
patient, it should be addressed first by giving undergo angiography.
vasoconstrictors, fluid resuscitation or blood transfusion to
stabilize the hemodynamic status before performing any IMAGING TESTS – may detect etiology of bleeding
diagnostic procedure.  Angiogram – to help visualize abnormalities blood
 EGD (assess the upper GI tract) vessels supplying the GI tract
o Source of GI bleeding identified (positive  Computed Tomography Angiography (CTA)
EGD): Attempt endoscopic hemostasis. o A diagnostic imaging technique that uses
o Source of GI bleeding not identified computerized tomography, intravenous
(negative or nondiagnostic EGD) administration of a radiocontrast agent
 Hemodynamically stable patients and specific timing to visualize blood
with hematochezia or melena: vessels of interest
Perform colonoscopy (if not performed o Also used to localize the source of GI
as the first-line intervention); consider bleed
evaluation for small bowel bleeding o Can detect bleeds as slow as 0.3-
 Hemodynamically unstable patients 0.5mL/minute
with ongoing bleeding: Consider  After ma-inject and contrast
angioembolization medium, magkakaroon ng series
Angioembolization – nagiinject ng pang- of images para makita ang status
block or emboli to stop the bleeding sa ng blood vessels.
vessels.
  Abdominal CT Scan – help detect gastric or o Oliguria suggests that there is a
duodenal ulcers or lesions that may cause or decreased perfusion
predisposes the client to develop GI bleeding  Central Venous Pressure (CVP) may need to be
inserted
o Also called Right Atrial Pressure usually
measures 0-8mmHg
o Blood is received by the IVC/SVC and it
will be drained at the right atrium. The
MEDICAL-SURGICAL MANAGEMENT FOR PATIENTS CVP catheter ay iniisert sa may arms and
WITH GI BLEEDING ithe-thread sa veins. Ang tip ng catheter
Management of GI Bleeding is based on etiology: ay nasa junction ng SVC ang RA para
 If aspirin or NSAIDs are the cause  ma-measure ang fluid.
discontinue medication and treat bleeding o Kung ang patient ay magma-manifest ng
 If ulcer is the cause  medication, dietary and 8mmHg and above, it represents that
lifestyle modifications he/she is experiencing overhydration or
 Therapeutic endoscopic procedure (cautery, fluid overload.
injection) o CVP/RAP represents the hydration status
o Yung blood vessel na nagkakaroon ng of the patient. If 0 or negative ang CVP
oozing of blood, that is the one being measurement, it is an indication na
cauterized or injected ng schelorsal agent hypovolemic or decreased venous return.
 Surgery may be indicated for cancers,  Conduct a focused history and examination
inflammatory diseases and vascular disorder (including DRE)
 Risk stratify to guide further management
The following recommendations are consistent with the  Prior to endoscopic hemostatic procedures: (see
2019 International Consensus Group (ICG) Nonvariceal “Empiric Pharmacotherapeutic Interventions for GI
UGIB guidelines, the 2016 American College of bleeding” for details) (PPI, Antibiotic,
Gastroenterology (ACG) LGIB guidelines, the 2014 Vasopressin, Analogs)
American Society for Gastrointestinal Endoscopy (AGSE)
 Administer pre-treatment (e.g., IV PPI) as needed
LGIB guidelines
ALL PATIENTS  Administer anticoagulant reversal if INR > 2.5
 Ensure patient is NPO o Antidote for Heparin: Protamine Sulfate
 Early identification of signs and symptoms of o Antidote for Warfarin: Vitamin K
Hypovolemic Shock and monitor vital signs every o Sa mga patient na may bleeding and
15 to 30 minutes nagtake previously ng warfarin and
o We need to assess the history but heparin, kailangan ng antidote para
address first the physiological needs of bumalik sa normal functioning ang blood
patient for us to know if may signs clotting mechanism since na-alter noong
indicating hypovolemic shock may anticoagulant therapy.
 Insert two large-bore (a 16- or 18-gauge needle) o Kailangan i-reverse kasi patients are high
peripheral IV lines for: risk of massive bleeding.
o Fluid resuscitation (Isotonic) – e.g.,  Consider withholding antithrombotic agents
Lactated Ringers, and
 Isotonic to lessen the chances of NURSING MANAGEMENT
fluid shifting
 Plain LR – para mayroong fluid & NURSING ASSESSMENT
electrolytes
o Assessment for a description of pain
o Blood Transfusion (fresh whole blood,
o Assessment of relief measures to relieve the pain.
packed RBC, and fresh frozen plasma)
o Assessment of the characteristics of the vomitus.
 Obtain blood samples for laboratory studies (e.g., o Assessment of the patient’s usual food intake and
CBC, ABO typing and screening)
food habits
 Administer supplemental 02 delivered by
facemask or nasal cannula NURSING DIAGNOSIS
 Insert an indwelling catheter – monitor UO hourly o Acute pain related to the effect of gastric acid
o Urine output is an important indicator of secretion on damaged tissue.
fluid volume status of patient o Anxiety related to an acute illness.
o Imbalanced nutrition related to changes in the diet. stool for occult or gross blood; monitor
o Deficient knowledge about prevention of symptoms vital signs frequently (tachycardia,
and management of condition hypotension, and tachypnea).
 Insert an indwelling urinary catheter and
monitor intake and output; insert and
NURSING CARE PLANNING & GOALS maintain an IV line for infusing fluid and
o The goals for the patient may include: blood.
o Relief of pain  Replenish fluid losses, urine will signify
o Reduced anxiety the concentration and fluid status.
o Maintenance of nutritional requirements  Monitor laboratory values (hemoglobin
o Knowledge about the management and and hematocrit).
 Insert and maintain a nasogastric tube
prevention of ulcer recurrence
and monitor drainage; provide lavage as
o Absence of complications
ordered.
 Kailangan right pathway kung saan
NURSING INTERVENTIONS lalabas ang drainage since post-op.
o Nursing interventions for the patient may include:  Lavage = washing; intake=output,
o Relieving Pain and Improving Nutrition aspirate by gravity.
 The only way to stop lavage if ordered
 Administer prescribed medications.
by a doctor, kapag yung output is clear,
 Medications to relieve the pain as well as
no blood tinge or coffee ground.
to manage the cause of ulcer formation
 Monitor oxygen saturation and
 Avoid aspirin, which is an anticoagulant,
administering oxygen therapy.
and foods and beverages that contain
 Place the patient in the recumbent
acid-enhancing caffeine (colas, tea,
position with the legs elevated to prevent
coffee, chocolate), along with
hypotension or place the patient on the
decaffeinated coffee.
left side to prevent aspiration from
 Encourage patient to eat regularly
vomiting.
spaced meals in a relaxed atmosphere.
 Treat hypovolemic shock as indicated.
 Obtain regular weights and
encourage dietary modifications.
o Monitoring and Managing Complications: If
 Encourage relaxation techniques.
penetration are concerns.
o Reducing Anxiety  Note and report symptoms of penetration
(back and epigastric pain not relieved by
 Assess what patient wants to know about
medications that were effective in the
the disease and evaluate level of anxiety;
past).
encourage patient to express fears
 Penetration= nag through and through to
openly without criticism.
another organ and system. Ex: pancreas
 Explain diagnostic tests and
 Note and report symptoms of perforation
administering medications on schedule.
(sudden abdominal pain, referred pain to
 If PPI, or trying to eradicate the H. Pylori
shoulders, vomiting and collapse,
or antacids which should be take at least
extremely tender and rigid abdomen,
30 mins before meals
hypotension and tachycardia, or other
 To reduce anxiety and explain in a level
signs of shock).
that they understand.
 Perforation is napunit. Example may
 Interact in a relaxing manner, help in
gastric cancer so napunit tumagos yung
identifying stressors, and explain
laman sa peritonium and surrounding
effective coping techniques and
areas
relaxation methods.
 Encourage family to participate in care
and give emotional support. MANAGEMENT FOR PATEINTS WITH GI BLEEDING
 Nasogastric lavage
o Monitoring and Managing Complications: If o Its use before endoscopy in the ER remains
hemorrhage is a concern: controversial.
 Assess for faintness or dizziness and o Lavage is stomach wash
nausea, before or with bleeding; test  Benefits:
 o To confirm an UGI source of bleeding (can  Lower Gi tract, nireremove
still miss up to 15%) yung polyps na possible
o Prognostic index for identifying high-risk nagcacause ng bleeding,
lesions as presence of fresh red blood in the
NGT aspirate.  Interventional Radiology (Angiography)
o Presence of blood will confirm na  Acute bleeding tapos di possible yung
may bleeding. endoscopic procedure kasi unstable yung
o May exclude false hematemesis. patient.
o Respiratory tract sputum -> linunok o Indications:
yung dugo  Preferred therapy in patients with
o To facilitate lavage of the upper GI tract to ongoing GI bleeding and
improve mucosal views at subsequent hemodynamic instability refractory to
endoscopy. resuscitation.
o If cause of bleeding is esophageal  An alternative to colonoscopy in
varices, insertion of NGT may patients with acute LGIB who cannot
traumatizes and increase bleeding tolerate bowel preparation.
tendencies.  Consider in patients with rebleeding or
o Reason to stop: if the return flow is ongoing bleeding despite endoscopic
clear. hemostasis.
o Techniques:
 Approach to Overt GI bleeding
o Emergency resuscitation  Angioembolization
 A minimally invasive
o Choice of source control modality depends
procedure used to selectively
on multiple factors (e.g., suspected
occlude the arterial supply of
hemorrhage source, hemodynamic status,
target tissue.
available resources)
 Primarily used to achieve
 Endoscopy is indicated, feasible, and
hemostasis non-operatively
able to identify the source of
but can also be used as an
bleeding: Attempt endoscopic
adjunct to surgical
hemostasis.
hemostasis.
 Endoscopy not recommended or
 Pinasok na pang
unable to identify the source of
emboli is a coil or gel
bleeding: angioembolization of
foam para mag stop
surgery.
yung bleeding.
o Identify and treat the underlying cause.
 Intraarterial vasopressin
 Approach to Occult GI bleeding  Vasopressin (Arginine
o Identify and treat underlying cause; correct vasopressin) (medication): a
anemia. synthetic ADH analog
 Used to treat vasodilatory
 Endoscopic Hemostasis shock, esophageal variceal
o Indications: any high-risk endoscopic findings hemorrhage, and control
 Signs of active bleeding diabetes insipidus.
 Nonbleeding visible vessel  Directly inject ng
 Adherent clot embolization particles
o Modalities  May cause emboli to
 Injection therapy (e.g., with diluted other area na
epinephrine, normal saline) madedeliver.
 Cauterization (e.g., heater probes,  Suspected LGIB
electrocauterization) o Stable patients: Refer for colonoscopy
 Sinusunog yung blood vessels o Perform EGD: done first for unstable patients
na nag open-up/ oozing blood with hematochezia and to any of the following:
 Mechanical therapy (e.g., band  High probability of UGIB
ligation, clips)  Moderate probability of UGIB with
 Polypectomy in the case of bleeding positive or inconclusive NG aspirate
polyp (e.g., in the colon)
 o Consider colonoscopy: first for unstable o Platelet count
patients with hematochezia and to all of the o Coagulation studies
following: o Test for occult blood if indicated
 Moderate probability of UGIB and
negative NG aspirate NURSING DIAGNOSES
 Able to tolerate rapid bowel prep. o Deficient Fluid Volume related to blood loss
o Consider angiography: for patients with o Imbalanced Nutrition: Less Than Body Requirements
refractory hemodynamic instability. related to nausea, vomiting and diarrhea
o Consider surgery: if other options have failed
NURSING INTERVENTIONS (ACTIVE BLEEDING)
o Monitor VS closely
o During the active bleeding, every 15-30 minutes
o Assess for signs of:
o Dehydration
LOWER GI BLEED TREATMENT  Fluid losses
 Management of Lower GIB is focused on colonoscopy o Hypovolemic shock
and mechanically treating bleeds with little  Blood loss
pharmacological intervention o Sepsis
o Look for the source & location of bleeding o Respiratory insufficiency
o Wala masyadong tulong ang pharmacological  Once hypovolemic shock occurs, the fluid
interventions when it comes to lower GI bleeding volume is decreased; the lungs would try to
 After the initial assessment and risk stratification, and compensate which results to rapid breathing
once the patient is hemodynamically stable: o Maintain NPO status and administer IV fluid
o Colonoscopy preceded by colon cleansing is the replacements as prescribed
initial diagnostic procedure for most patient o Lactated ringers, Plain LR (isotonic solution)
presenting with a LGIB o To minimize chances of fluid shifting
 Management of LGIB mostly includes non- o Insert another line for possible blood transfusion
pharmacologic interventions o Monitor intake & output
 PPI Application in LGIB o Foley catheter needs to be inserted
o Evidence suggests that patients with LGIB do not o Urine output reflects the fluid volume status of
benefit from PPI therapy the patient
o Monitor the urine output per hour
o Monitor hemoglobin and hematocrit
NURSING ASSESSMENT o Continuous bleeding = hemoglobin and
o Change in bowel patterns or hemorrhoids hematocrit will decrease in value
o Change in color of stools o Administer blood transfusions as prescribed
o Dark black o Determine if the patient needs fresh raw blood,
o Red RBC, platelet concentrate, or fresh frozen
o Streaked with blood plasma
o Alcohol consumption o Prepare to assist with administering medications as
o Medications such as: prescribed to induce vasoconstriction and reduce
o NSAIDs bleeding
o Antibiotics o Examples: Epinephrine, Vasopressin
o Anti-coagulants
o Attaining Normal Fluid Volume
o Corticosteroids
o Maintain NG tube and NPO status
o Hematemesis
 NGT will be inserted and connected to a
o Other medical conditions
drainage bottle, to allow for gastric
o Examples: Liver cirrhosis, Cancer, etc.
decompression; to drain secretion
o Evaluate for presence of abdominal pain or
 To allow the GI tract to rest
tenderness
 To evaluate bleeding
o Monitor VS
o Monitor intake & output as ordered
o Monitor laboratory tests that indicated bleeding:
 To evaluate fluid status
o Hemoglobin
 Determining the patient’s output allows you
o Hematocrit
to know how much to replenish in terms of
 fluids & electrolytes since the patient is at
risk for dehydration and electrolyte
imbalances
 Volume per volume replacement; Lactated
Ringer solution
o Monitor VS as ordered
 Every 15 to 30 minutes
o Observe for changes indicating shock, such as:
 Tachycardia
 Hypotension
 Increased respirations
 Decreased urine output
 Change in mental status
o Administer IV fluids and blood products as
ordered to maintain volume
o Attaining Balanced Nutritional Status
o Weigh daily to monitor caloric status
o Administer IV fluids, TPN if ordered
 Promotes hydration and nutrition while on
oral restrictions
 Examples for TPN: Ready for use glucose,
amino acids, fatty acids, etc. that our body
needs to replace enteral feeding
 Usually makes use of the central line
because if you utilize the peripheral line,
there’s a possibility of phlebitis because the
TPN solutions used are highly osmolar &
hypertonic.
 IV fluids – crystalloids only
 TPN – can really provide nutrition, but are
pricey for the patient
o Begin liquids when patient is no long NPO
o Advance diet as tolerated
 Should be high-calorie, high-protein
 Frequent, small feedings may be indicated
 Offer snacks, high-protein supplements
o 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 – bright red, or coffee grounds
in color
 Rectal bleeding
 Weakness
 Fatigue
 Shortness of breath
 Instruct patient on how to test stool or
emesis for occult blood, if applicable