GASTROINTESTINAL BLEEDING

GASTROINTESTINAL BLEEDING – Etiology, Types, Signs and Symptoms, Diagnostic Evaluation and Management

Gastrointestinal bleeding or gastrointestinal hemorrhage is a form of hemorrhage in the gastrointestinal tract, from the pharynx to the rectum. The degree of bleeding can range from nearly undetectable to acute or massive, life-threatening bleeding

ETIOLOGY

• Peptic ulcers: helicobacter pylori (H.pylori) infections and long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen, are common causes of peptic ulcers
• Esophageal varices: varices, or enlarged veins, located at the lower end of the esophagus may rupture and bleed massively. Cirrhosis is the most common cause of esophageal varices.
• Mallory-Weiss tears: these tears in the lining of the esophagus usually result from vomiting. Increased pressure in the abdomen from coughing, hiatal hernia or childbirth can also cause tears
• Gastritis: NSAIDs and other drugs, infections, Crohn’s disease, illnesses and injuries can cause gastritis, inflammation and ulcers in the lining of the stomach
• Esophagitis: gastroesophageal reflux disease (GERD) is the most common cause of esophagitis
• Benign tumors and cancer: a benign tumor is an abnormal tissue growth that is not cancerous. Benign tumors and cancer in the esophagus, stomach or duodenum may cause bleeding
• Diverticular disease: this disease is caused by diverticula, pouches in the colon wall
• Colitis: infections, diseases such as Crohn’s disease, lack of blood flow to the colon, and radiation can cause colitis
• Hemorrhoids or fissures: hemorrhoids are enlarged veins in the anus or rectum that can rupture and bleed. Fissures, or ulcers are cuts or tears in the anal area
• Angiodysplasia: aging causing angiodysplasia, abnormalities in the blood vessels of the intestine

TYPES OF GI BLEEDING

• Upper GI bleeding: bleeding in the esophagus, stomach, or the beginning of small intestine
• Lower GI bleeding: bleeding in the small intestine, large intestine, rectum or anus
• Frank (obvious) bleeding: active bleeding that can easily see. For example, vomit blood
• Occult (hidden) bleeding: slow bleeding that cannot be seen easily. Tests may be needed to find occult bleeding
• Acute GI bleeding: blood loss that is new or sudden, and lasts for only a short time
• Chronic GI bleeding: blood loss that has been going on for a long time, or that comes back often

SIGN OF BLEEDING IN THE UPPER DIGESTIVE TRACT

• Bright red blood in vomit
• Vomit that looks like coffee grounds
• Black or tarry stool
• Dark blood mixed with stool
• Stool mixed or coated with bright red blood

SIGNS OF BLEEDING IN THE LOWER DIGESTIVE TRACT

• Black or tarry stool
• Dark blood mixed with stool
• Stool mixed or coated with bright red blood

Sudden, severe bleeding is called acute bleeding. If acute bleeding occurs, symptoms may include

• Weakness
• Dizziness or faintness
• Shortness of breath
• Crampy abdominal pain
• Diarrhea
• Paleness

Signs and symptoms of losing too much blood may include:

• Chest pain, or a feeling like heart is beating too fast
• Extreme tiredness
• Dizziness or fainting, especially after moving from a sitting or lying position
• Pale skin or gums, and sweaty or clammy skin
• Dry mouth, increased thirst, or passing less urine
• Feeling confused or short of breath

DIAGNOSTIC EVALUATION

1. Endoscopy

Endoscopy is the most common method for finding the source of bleeding in the digestive tract. An endoscope is a flexible tube with a small camera on the end. The doctor inserts the endoscope through the patient’s mouth to view the esophagus, stomach and duodenum. This examination is called esophagogastroduodenoscopy (EGD). An endoscope can also be inserted through the rectum to view the colon. This procedure is called colonoscopy

• Enteroscopy

Enteroscopy is an examination of the small intestine. Because traditional endoscopes cannot reach the small intestine, special endoscopes are used for enteroscopy

Enteroscopy Procedures Include:

• Push enteroscopy: a long endoscope is used to examine the upper portion of the small intestine
• Double-balloon enteroscopy: balloons are mounted on the endoscope to help the endoscope move through the entire small intestine
• Capsule endoscopy: the person swallows a capsule containing a tiny camera. The camera transmits images to a video monitor as the capsule passes through the digestive tract. This procedures is designed to examine the small intestine
• Barium X-rays: barium is a contrast material that makes the digestive tract visible in an X-ray. Liquid containing barium is either swallowed or inserted into the rectum. Barium X-rays are less accurate than endoscopy and may interfere with other diagnostic techniques
• Radionuclide scanning: a small amount of radioactive material is injected into the person’s vein. A special camera, similar to an X-ray machine, can detect this radiation and create images of blood flow in the digestive tract. Radionuclide scanning is sensitive enough to detect very slow bleeding, but it is not as accurate as other procedures
• Angiography: a dye is injected into the person’s vein to make blood vessels visible in X-ray or computerized tomography (CT) scan. Dye leaks out of the blood vessels at the bleeding site

Management

Pharmacological Management

There are many medicines that may be given to treat bleeding. It includes:

• Antibiotics: this medicine is given to help treat or prevent an infection caused by bacteria
• Antinausea medicine: this medicine may be given to calm the stomach and prevents vomiting
• Antiulcer medicine: this medicine helps decrease the amount of acid that is normally made by the stomach
• Blood pressure medicine: this medicine may be given in an IV to help improve blood pressure
• Pain medicine: caregivers may give you medicine to take away or decrease your pain

NURSING MANAGEMENT

Nursing Diagnosis

• Nutrition: imbalanced, less than body requirements related to inadequate diet, inability to process, digest nutrients, anorexia, nausea, vomiting, indigestion
• Skin integrity, risk for impaired related to altered circulation, metabolic state and loss of blood
• Risk for injury (hemorrhage) related to internal bleeding secondary to other GI problems like portal hypertension, development of esophageal varices, etc

1. Nutrition: imbalanced, less than body requirements related to inadequate diet, inability to process, digest nutrients, anorexia, nausea, vomiting, indigestion

Interventions

• Measure dietary intake by calorie count
• Weigh as indicated. Compare changes in fluid status, recent weight history, and skinfold measurement
• Encourage patient to eat, explain reasons for the types of diet. Include patient in meal planning to consider his or her preferences in food choices
• Encourage patient to eat all meals including supplementary feedings unless contraindicated
• Give small, frequent meals
• Provide salt substitutes, if allowed, and avoid those containing ammonium
• Restrict intake of caffeine, gas-producing or spicy and excessively hot or cold foods
• Suggest soft foods, avoiding roughage, if indicated
• Encourage frequent mouth care, especially before meals
• Promote undisturbed rest periods, especially before meals
• Recommend cessation of smoking. Provide teaching on the possible negative effects of smoking
• Monitor laboratory studies: serum glucose, prealbumin and albumin, total protein, ammonia
• Maintain NPO status when indicated
• Provide tube feedings
• Refer to dietitian to provide diet high in calories and simple carbohydrates, low in fat, and moderate to high in protein, limit sodium and fluid as necessary. Provide liquid supplements as indicated

• Skin integrity, risk for impaired related to altered circulation, metabolic state and loss of blood

Interventions

• Inspect pressure points and skin surfaces closely and routinely. Gently massage bony prominences or areas of continued stress
• Use of emollient lotions and limiting use of soap for bathing may help
• Encourage and assist patient with reposition on a regular schedule. Assist with active and passive ROM exercises as appropriate
• Recommend elevating lower extremities
• Keep linens dry and free of wrinkles
• Suggest clipping fingernails short, provide mittens, gloves, if indicated
• Use calamine lotion and provide baking soda baths
• Use alternating pressure mattress, egg-crate mattress, waterbed, sheepskins, as indicated.
• Provide perineal care following urination and bowel movement

• Risk for injury (hemorrhage) related to internal bleeding secondary to other GI problems like portal hypertension, development of esophageal varices, etc

Interventions

• Closely assess for signs and symptoms of GI bleeding; check all secretions for frank or occult blood. Observe color and consistency of stools, NG drainage, or vomitus
• Observe for presence of petachiae, ecchymosis, bleeding from one or more sites
• Monitor pulse, BP (and CVP, if available)
• Avoid rectal temperature and be gentle with GI tube insertions
• Encourage use of soft toothbrush, electric razor, avoiding straining for stool, vigorous nose blowing, and so forth
• Use small needles for injections. Apply pressure to small bleeding and venipuncture sites for longer than usual
• Advise to avoid aspirin-containing products
• Monitor Hb/Hct and clotting factors
• Supplemental vitamins: vitamins K, D and C
• Administer stool softeners
• Assist with insertion and maintenance of GI tube
• Provide gastric lavage with room temperature and cool saline solution or water as indicated.