Although none of the editors of InsideSurgery.com are participating in his care, we have noted with interest that the Reverend Billy Graham was admitted to the Missions Hospital and Health Center in Asheville, North Carolina today for gastrointestinal bleeding. His condition has apparently stabilized as reported by a hospital spokesperson.
What exactly happens to a patient who is admitted for GI bleeding? Although there is some variation depending on how old the patient is and the previous
medical history, the diagnostic and treatment algorithm is fairly straightforward, depending on whether the bleeding is from the rectum or mouth. From the reports we read, it appears his bleeding was from the rectum of lower GI bleeding. Patients should always be evaluated in an emergency room for this.
The first thing that is done is to do a quick physicial assessment to insure the patient is not in shock from the bleeding. This includes vital signs (blood pressure, heart rate, temperature, respiratory rate), listening to the patients heart and lungs, examining the abdomen for tenderness and rebound and guarding, and checking for mental status changes.
A more detailed history is then taken to ascertain the following: previous bleeding episodes; what color the blood was (dark or brighter red) how long the bleeding has been going on for; presence of diverticuli (outpouchings in the bowel); history of ulcers; medication use (including NSAIDs, steroids, coumadin, or lovenox); history of liver disease; and history of alcohol and drug use.
While this is being done (assuming the patient is stable), blood samples are taken to send to the lab for a complete blood cell count, electrolytes, coagulation studies, and a hepatic panel. Blood is also sent to the blood bank for type and cross for at least 4 units of packed red blood cells, fresh frozen plasma, and platelets.
Two large bore intravenous lines are placed with IV fluid typically started. The patient usually receives oxygen (usually by nasal cannula). An EKG is obtained.
Since the most common cause of lower gastrointestinal bleeding is upper gastrointestinal bleeding a nasogastric tube is placed into the stomach through the nostril. Lavage (infusing saline and then withdrawing it with a syringe) is performed to see if there is any blood in the stomach. To insure that a post pylorus bleed is not missed the lavage should continue until bile (green color) is returned. If this is not done the lavage is considered inconclusive.
If blood is returned in the NG tube the patient is taken to the endoscopy suite for an upper endoscopy (a lighted camera placed into the mouth, esophagus, stomach, and first part of the duodenum) to rule out mucosal erosions and tears, ulcers, arterio-venous malformations, and masses.
If the lavage/upper endoscopy is negative, attention is then turned to the lower gastrointestinal tract. There are two ways to image this. If the bleeding is felt to be brisk enough, a bleeding scan can be performed. This consists of injecting the patient with a slightly radioactive dye that is taken up by red blood cells. The patient is then taken to nuclear medicine where they are placed under a camera and visualized for “pooling RBCs.” This technique will allow a diagnosis of where the bleeding is coming from but will not be able to diagnose why the bleeding is occuring.
The second method to evaluate bleeding in the lower gastrointestinal tract is a colonoscopy. There is sometimes a reluctance of gastroenterologists and colorectal surgeons to perform this test in patients with active GI bleeding because the blood can obscure the field of view often.
To combat this, if the patient is stable, a bowel prep can be used (typically one gallon of Golytelyover 12 hours or so) to evacuate the bowel. The colonoscopy is almost always done under sedation and is quite good at locating both the site of bleeding and the cause of bleeding (tumor, diverticuli, AV malformation.
Typically, patients who come into the ER for GI bleeding are placed in a monitored bed with hemoglobin land hematocrit evels checked every 4 hours. If their H and H levels have dropped pre-admission or during admission they should be transfused (usually with empiric calcium gluconate given as well.)
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