A nurse on your ward informs you that overnight a patient has had five bowel movements of what looks like melena stool.
- What symptoms and physical exam findings would suggest a dangerous GI bleed?
- Symptoms of a dangerous GI bleed – abdominal pain, chest pain, dyspnea, fever, presyncope/syncope, hematemesis, brisk bleeding, fatigue/altered LOC
- Physical exam findings – tachycardia, hypotension, postural hypotension/tachycardia, pallor
- Assuming the above physical exam findings are present in this patient, and you suspect an unstable patient, what is your immediate management at this time?
In the setting of an unstable patient with an acute GI bleed, immediate management is geared towards stabilizing the patient and identifying/treating the source of bleeding:
- Insert 2 large bore IVs – essential for rapid resuscitation with fluids and blood products
- Informed consent for blood products (in case the patient’s wishes are to withhold blood products – i.e. Jehovah’s Witness)
- CBC (haemoglobin levels may be normal initially), lytes, Cr, BUN, AST, ALT, ALP
- INR, PTT
- Blood cross + type
- Reticulocyte count, ferritin, TIBC, TFsat, and serum Fe (these tests are not immediately necessary, but may be helpful in the future, and cannot accurately be assessed once the patient receives exogenous blood products)
- Bolus normal saline
- Pantoprazole 80mg IV bolus, then 8mg/hr IV infusion
- Consult gastroenterology
- Keep patient NPO in preparation for presumed endoscopy
- Blood transfusion if haemoglobin <70g/L or patient is symptomatic from anemia
- Barkun AN et al. International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding. Ann Intern Med. 2010, 152:101-113.
- Gralnek IM, Barkun AN and Bardou M. Current Concepts: Management of Acute Bleeding from a Peptic Ulcer. N Engl J Med. 2008, 359:928-937.
- Mannin-Dimmitt LL, Dimmitt SG and Wilson GR. Diagnosis of Gastrointestinal Bleeding in Adults. Am Fam Physician. 2005, 71:1339-1346.