Gastrointestinal Bleed (GI Bleed) Case Study

Gastrointestinal Bleed: A Comprehensive Guide for Nurses

A gastrointestinal (GI) bleed refers to bleeding anywhere along the gastrointestinal tract, from the mouth to the rectum. It can range from mild and self-limiting to severe and life-threatening. Nurses play a crucial role in the early recognition, stabilization, and management of GI bleeds.

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Classification of GI Bleeds

1. By Location:

Upper GI Bleed (UGIB):

• Originates above the ligament of Treitz (esophagus, stomach, duodenum).
• Common causes: peptic ulcers, esophageal varices, Mallory-Weiss tears, and gastritis.

Lower GI Bleed (LGIB):

• Originates below the ligament of Treitz (jejunum, ileum, colon, rectum, anus).
• Common causes: diverticular disease, hemorrhoids, colorectal cancer, and inflammatory bowel disease.

2. By Duration:

Acute GI Bleed:

• Sudden onset; can lead to hypovolemic shock.

Chronic GI Bleed:

• Occurs over time; may cause anemia without overt bleeding.

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Pathophysiology

GI bleeds occur when there is:

Erosion of Blood Vessels:

• Due to ulcers, tumors, or inflammation.

Vascular Abnormalities:

• Angiodysplasia or varices.

Trauma or Injury:

• From procedures, foreign bodies, or severe vomiting (e.g., Mallory-Weiss tears).

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Risk Factors

Medications:

• NSAIDs, aspirin, and anticoagulants increase the risk of mucosal damage and bleeding.

Chronic Conditions:

• Cirrhosis, chronic kidney disease, or peptic ulcer disease.

Lifestyle Factors:

• Alcohol abuse and smoking.

Age:

• Elderly patients are at higher risk due to comorbidities and medication use.

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Clinical Presentation

Upper GI Bleed:

Symptoms:

• Hematemesis: Vomiting blood (bright red or coffee-ground appearance).
• Melena: Black, tarry stools due to digested blood.
• Epigastric Pain: Often seen with peptic ulcers.

Lower GI Bleed:

Symptoms:

• Hematochezia: Bright red or maroon blood in stool, indicative of colonic or rectal bleeding.
• Abdominal Pain: Common in inflammatory bowel disease or diverticulitis.

General Symptoms of Severe Bleeding:

• Fatigue, weakness, or dizziness.
• Tachycardia, hypotension, and syncope (signs of hypovolemia).
• Pale, cool, clammy skin.
• Decreased urine output (renal hypoperfusion).

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Diagnosis

1. History and Physical Exam:

• Assess for risk factors, medications, and associated symptoms.
• Perform a focused physical exam, including abdominal and rectal exams.

2. Laboratory Tests:

Complete Blood Count (CBC):

• Decreased hemoglobin and hematocrit.
• Elevated white blood cells (infection or inflammation).

Coagulation Profile:

• PT/INR, aPTT to assess clotting function.

Blood Chemistry:

• Elevated blood urea nitrogen (BUN) in UGIB due to digested blood.

Type and Crossmatch:

• Prepare for potential blood transfusion.

3. Imaging and Procedures:

• Upper Endoscopy (EGD): First-line for diagnosing and treating UGIB.
• Colonoscopy: Preferred for diagnosing LGIB.
• CT Angiography: Identifies active bleeding in unstable patients.
• Tagged Red Blood Cell Scan: Detects slow or intermittent bleeding.

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Management of GI Bleeds

Goals of Treatment:

• Stabilize the patient and restore hemodynamic stability.
• Identify and treat the source of bleeding.
• Prevent complications, such as rebleeding or hypovolemic shock.

1. Initial Stabilization:

Airway and Breathing:

• Ensure a patent airway, especially in hematemesis cases.
• Provide supplemental oxygen to maintain SpO₂ >94%.

Circulation:

• Establish two large-bore IV lines.
• Administer isotonic crystalloids (e.g., normal saline or lactated Ringer’s) for volume resuscitation.
• Transfuse packed red blood cells (PRBCs) if hemoglobin is <7 g/dL or the patient shows signs of shock.

2. Pharmacologic Therapy:

• Proton Pump Inhibitors (PPIs):
  • High-dose IV PPI (e.g., pantoprazole) for UGIB, especially peptic ulcers.
• Octreotide:
  • Reduces portal hypertension in variceal bleeding.
• Antibiotics:
  • Prophylactic antibiotics (e.g., ceftriaxone) in cirrhotic patients with variceal bleeding.
• Vasopressors:
  • Used for hemodynamic support in hypotensive patients.

3. Endoscopic Intervention:

• For Upper GI Bleeds:
  • Epinephrine injection, thermal coagulation, or mechanical clipping.
• For Lower GI Bleeds:
  • Endoscopic clipping or cauterization during colonoscopy.

4. Interventional Radiology:

• Angiographic Embolization:
  • Used for persistent bleeding when endoscopy is unsuccessful.

5. Surgical Intervention:

• Reserved for refractory or massive bleeding (e.g., partial gastrectomy, bowel resection).

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Nursing Interventions

1. Monitoring and Assessment:

• Assess vital signs frequently, including blood pressure, heart rate, and oxygen saturation.
• Monitor urine output as an indicator of perfusion.
• Check for ongoing bleeding in vomit or stool.

2. Fluid and Blood Product Administration:

• Administer IV fluids and transfusions as ordered.
• Monitor for signs of fluid overload or transfusion reactions.

3. Positioning and Airway Management:

• Elevate the head of the bed to prevent aspiration in hematemesis.
• Position the patient flat or in Trendelenburg if hypotensive.

4. Medication Administration:

• Administer PPIs, octreotide, or antibiotics promptly.
• Monitor for therapeutic and adverse effects of medications.

5. Education and Support:

• Reassure and educate the patient and family about the treatment plan.
• Provide information on avoiding NSAIDs, alcohol, and other factors that exacerbate bleeding risks.

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Complications of GI Bleeds

Hypovolemic Shock:

• Resulting from massive blood loss.

Rebleeding:

• Recurrence of bleeding after initial control.

Multi-Organ Dysfunction Syndrome (MODS):

• Due to prolonged hypoperfusion.

Death:

• High mortality rate in severe cases, especially in elderly or comorbid patients.

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Prevention of GI Bleeds

Peptic Ulcer Prevention:

• Avoid NSAIDs and use PPIs in at-risk patients.

Variceal Bleed Prevention:

• Beta-blockers (e.g., propranolol) for portal hypertension.

Lifestyle Modifications:

• Avoid alcohol and smoking.

Regular Screening:

• Endoscopy for patients with cirrhosis or a history of GI bleeds.

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Conclusion

Gastrointestinal bleeding is a medical emergency requiring prompt recognition, assessment, and intervention. Nurses play a critical role in stabilizing the patient, assisting in diagnostic and therapeutic procedures, and preventing complications. Through vigilant monitoring, timely action, and patient education, nurses can significantly improve outcomes for patients experiencing a GI bleed.