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Upper Gastrointestinal Bleeding

Upper Gastrointestinal Bleeding. Chapter 42. Upper GI (UGI) Bleeding. Each year, 300,000 hospital admissions for UGI bleeding Approximately 60% of patients are older than 65 years Mortality rate has been 6% to 13% for past 45 years. Etiology and Pathophysiology.

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Upper Gastrointestinal Bleeding

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  1. Upper Gastrointestinal Bleeding Chapter 42

  2. Upper GI (UGI) Bleeding • Each year, 300,000 hospital admissions for UGI bleeding • Approximately 60% of patients are older than 65 years • Mortality rate has been 6% to 13% for past 45 years

  3. Etiology and Pathophysiology • Most serious loss of blood from UGI characterized by sudden onset • Insidious occult bleeding can also be a major problem • Severity depends on bleeding origin • Venous • Capillary • Arterial

  4. Etiology and Pathophysiology • Types of UGI bleeding • Obvious bleeding • Hematemesis • Bloody vomitus • Appears fresh, bright red blood or “coffee grounds” • Melena • Black, tarry stools • Caused by digestion of blood in GI tract • Black appearance—due to iron

  5. Etiology and Pathophysiology • Types of UGI bleeding • Occult bleeding • Small amounts of blood in gastric secretions, vomitus, or stools • Undetectable by appearance • Detectable by guaiac test

  6. Etiology and Pathophysiology • Bleeding from arterial source is profuse, and the blood is bright red • Bright red color indicates that blood has not been in contact with the stomach’s acid secretions

  7. Etiology and Pathophysiology • “Coffee ground” vomitus reveals • Blood has been in stomach for some time • Blood has been changed by gastric secretions

  8. Etiology and Pathophysiology • Melena (black, tarry stools) • The longer the passage of blood through intestines, the darker the stool color, caused by breakdown of Hgb and release of iron • Cause of bleeding is not always easy to determine

  9. Case Study • B.H., a 40-year-old woman, was previously admitted to the hospital for exacerbation of Cr0hn’s disease • After beginning high-dose IV corticosteroid treatment for Crohn’s disease, she develops massive upper GI bleeding • Bright red blood hematemesis and melena iStockphoto/Thinkstock

  10. Common Causes of UGI Bleeding • Esophageal origin • Stomach and duodenal origin • Drug-induced origin • Systemic disease origin

  11. Common Causes of BleedingEsophageal Origin • Chronic esophagitis • GERD • Mucosa-irritating drugs • Aspirin, NSAIDs, corticosteroids • Alcohol • Cigarettes

  12. Common Causes of BleedingStomach and Duodenal Origin • Peptic ulcer disease • Bleeding ulcers account for 40% of cases of UGI bleeding • Related to H. pylori or drug use (NSAIDs) • Gastric cancer • Hemorrhagic gastritis

  13. Common Causes of BleedingStomach and Duodenal Origin • Polyps • Stress-related mucosal disease (SRMD) • Also called physiologic stress ulcers • Occurs in patients with severe burns or trauma, or after major surgery

  14. Diagnostic Studies • Endoscopy • Primary tool for diagnosing source of bleeding • Before performing • Lavage may be needed for clearer view • NG or orogastric tube placed, and room-temperature water or saline used • Do not advance tube against resistance • Stomach contents aspirated through a large-bore (Ewald) tube to remove clots

  15. Diagnostic Studies • Angiography • Used to diagnose only when endoscopy cannot be done • Invasive procedure • May not be appropriate for high-risk or unstable patient • Catheter placed into left gastric or superior mesenteric artery until site of bleeding is discovered

  16. Case Study • B.H. has an upper GI endoscopy that reveals a peptic ulcer. • What other diagnostic tests would be helpful in evaluating her overall status? iStockphoto/Thinkstock

  17. Diagnostic Studies • Laboratory studies • Complete blood cell count (CBC) • Blood urea nitrogen (BUN) measurement • Serum electrolyte measurements • Prothrombin time, partial thromboplastin time • Liver enzyme measurements

  18. Diagnostic Studies • Laboratory tests • Liver enzyme measurements • ABG measurements • Typing/crossmatching for possible blood transfusions

  19. Diagnostic Studies • Other laboratory studies • Vomitus/stools • Tested for the presence of gross and occult blood • Urinalysis • Specific gravity: indication of patient’s hydration status

  20. Collaborative Care • Of patients who have massive hemorrhage, 80% to 85% spontaneously stop bleeding • Cause still must be identified and treatment initiated

  21. Case Study • B.H. stops vomiting for the present time. • She complains of fatigue, weakness, and continued nausea. iStockphoto/Thinkstock

  22. Emergency Assessment and Management • Immediate physical examination with emphasis on • BP • Rate and character of pulse • Peripheral perfusion with capillary refill • Observation for neck vein distention

  23. Emergency Assessment and Management • VS every 15–30 minutes • Signs and symptoms of shock evaluated • Treatment as soon as possible • Respiratory status assessed

  24. Emergency Assessment and Management • Abdominal examination • Presence or absence of bowel sounds • Tense, rigid abdomen: may indicate perforation and peritonitis

  25. Emergency Assessment and Management • Once immediate interventions have started • Document complete history of events leading to bleeding episode • Previous bleeding episodes • Weight loss • Receipt of blood transfusion

  26. Emergency Assessment and Management • Once immediate interventions have started • Document complete history of events leading to bleeding episode • Other illnesses (liver disease, cirrhosis) • Medication use • Religious preferences regarding blood or blood product usage

  27. Emergency Assessment and Management • Fluid replacement • IV lines • Should be established for fluid and blood replacement • Preferably two IV lines • 16- or 18-gauge catheter • Generally best to begin with an isotonic crystalloid solution (lactated Ringer’s solution)

  28. Emergency Assessment and Management • Blood replacement • Whole blood, packed RBCs, and fresh frozen plasma • Used for replacement of lost volume in massive hemorrhage • Packed RBCs are preferred over whole blood because of fluid overload and immune reactions

  29. Emergency Assessment and Management • Blood replacement • Hgb and Hct provide baseline for further treatment • Initial Hct may be normal and may not reflect loss until 4–6 hours after fluid replacement • Initially, losses of plasma and RBC are equal

  30. Case Study • B.H.’s Hgb is 9.2 g/dL, Hct is 33%. • A 16-gauge IV line is placed in her right hand. • Lactated Ringer’s solution, 1 L, is administered over the next 2 hours. • In addition, 1 unit of packed RBCs is infused. iStockphoto/Thinkstock

  31. Emergency Assessment and Management • Use of supplemental O2 helps increase blood O2 saturation • Indwelling urinary catheter • Accurate urine volume assessment • CVP line to monitor patient’s fluid volume status

  32. Collaborative Care • Endoscopic hemostasis therapy • Goal: to achieve coagulation or thrombosis in bleeding artery • Useful for gastritis, Mallory-Weiss tear, esophageal and gastric varices, bleeding peptic ulcers, and polyps

  33. Collaborative Care • Several endoscopic hemostasis techniques are used, including • Thermal (heat) probe • Coagulates tissue by directly applying heat to site • Electrocoagulation probe (multipolar and bipolar) • Argon plasma coagulation (APC) • Neodymium yttrium-aluminum-garnet (Nd-YAG) laser

  34. Collaborative Care • Surgical therapy • Indicated when bleeding continues • Regardless of therapy provided • Site of bleeding identified • Some physicians regard surgery as necessary when patient continues to bleed after rapid transfusion of up to 2000 mL of whole blood or remains in shock after 24 hours

  35. Collaborative Care • Surgical therapy • Site of hemorrhage determines choice of operation • Surgeon must consider age of patient • Mortality rates increase considerably in patients older than 60 years

  36. Collaborative Care • Drug therapy • During acute phase, used to • ↓ Bleeding • ↓ HCl acid secretion • Neutralize HCl acid that is present

  37. Collaborative Care • Drug therapy • Injection therapy with epinephrine during endoscopy for acute hemostasis • For bleeding due to ulceration • Epinephrine • Produces tissue edema → pressure on bleeding source • Usually combined with other therapies

  38. Case Study • B.H. undergoes endoscopy for epinephrine injection therapy. • This successfully stops her bleeding. • What medication might be prescribed for maintenance therapy? iStockphoto/Thinkstock

  39. Collaborative Care • Drug therapy • Acid reducers • Acidic environment can alter platelet function and clot stabilization • Histamine-2 receptor (H2R) blockers • Inhibit action of histamine at H2 receptors and decrease HCl acid secretion • Cimetidine (Tagamet) • Ranitidine (Zantac)

  40. Collaborative Care • Drug therapy • Acid reducers • Proton pump inhibitors (PPIs) • Suppresses gastric secretion by inhibiting H+, K+, ATPase enzyme system • Inhibits gastric acid pump • Pantoprazole (Protonix) • Esomeprazole (Nexium) • No proven ability to control active bleeding

  41. Collaborative Care • Drug therapy • Somatostatin or somatostatin analog octreotide (Sandostatin) • Used for upper GI bleeding • Reduces blood flow to the GI organs and acid secretion • Given in IV boluses for 3–7 days after onset of bleeding

  42. Case Study • In addition to administering IV cimetidine and pantoprazole, what nursing assessment is important during the initial phase of her care? • What complication would be of most concern? iStockphoto/Thinkstock

  43. Nursing Management • Nursing assessment • LOC • VS • Orthostatic • Every 15–30 minutes

  44. Nursing Management • Nursing assessment • Appearance of neck veins • Skin color • Capillary refill • Abdominal distention, guarding, peristalsis

  45. Nursing Management • Nursing assessment • Signs/symptoms of shock • Low BP • Rapid, weak pulse • Increased thirst • Cold, clammy skin • Restlessness

  46. Nursing Management • Nursing diagnoses • Decreased cardiac output • Deficient fluid volume • Ineffective peripheral tissue perfusion • Anxiety

  47. Nursing Management • Planning: overall goals • No further GI bleeding • Cause of the bleeding identified and treated • Return to normal hemodynamic state • Minimal or no symptoms of pain or anxiety

  48. Nursing Management • Health promotion • Patient with a history of chronic gastritis or peptic ulcer disease is at high risk • Patient who has had one major bleeding episode is more likely to have another • Patient with cirrhosis or previous UGI bleed is also at high risk

  49. Case Study • B.H. and her husband are asking about what caused this bleeding episode. • She also expresses anxiety about the possibility that it could happen again. iStockphoto/Thinkstock

  50. Nursing Management • Health promotion • Patient teaching • Disease process and drug therapy • Avoidance of gastric irritants • Alcohol • Smoking • Stress-inducing situations • Take only prescribed medications • Methods of testing vomitus/stools for occult blood

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