A step-by-step approach to managing gastrointestinal bleeding

Using a stepwise approach to diagnose and treat gastrointestinal bleeding can improve patient outcomes.
Using a stepwise approach to diagnose and treat gastrointestinal bleeding can improve patient outcomes.

SAN ANTONIO – Creating a step-by-step plan to assess and manage patients with gastrointestinal (GI) bleeding can improve outcomes, according to research presented at the American Association of Nurse Practitioners (AANP) 2016 National Conference.

The signs of acute GI bleeding include tachycardia, orthostatic changes in blood pressure/heart rate, blood or coffee-grounds-like material in nasogastric aspirate, hematochezia, perioral telangiectasia, and skin abnormalities. If a patient is suspected to have GI bleeding, clinicians should take steps to manage the condition. The study author, Leslie S. Arceneaux, DNP, FNP-BC, CDE, of the Department of Nursing at Georgetown University Hospital in Washington, D.C., provides the following guide for managing GI bleeding:

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1. Assess severity of GI bleeding and stabilize

2. Take a patient history

  • Has the patient had previous GI bleeding? Up to 60% of patients with a history of an upper GI bleed are bleeding from the same lesion.
  • Ask the patient about medications. Non-steroidal anti-inflammatory drugs and acetylsalicylic acid can predispose the patient to peptic ulcer disease; antiplatelets and anticoagulants can promote bleeding; and bismuth and iron can cause stool to appear black.
  • Liver cirrhosis can indicate varices.
  • Aortic stenosis and renal disease can indicate angioectasia.
  • Tobacco abuse, alcohol abuse, and Helicobacter pylori can indicate a malignancy.
  • Marginal anastomotic ulcers can indicate gastroenteric anastomosis.

3. Perform a physical exam

  • Signs of hypovolemia include tachycardia, orthostatic hypotension, and supine hypotension.
  • Examining stool color may provide a clue to the location of the bleeding.
  • Abdominal pain may be a sign of perforation.

4. Perform a risk assessment

  • Perform a complete blood count, comprehensive metabolic panel, and coagulation studies.
  • Cardiac enzymes and electrocardiogram can determine if a patient as a high risk of cardiovascular disease.
  • Use risk-stratification tools to facilitate triage, including the Rockall scoring system, the Glasgow-Blatchford Scale, and AIM 65.
  • Predict the need for hospitalization and intervention.

5. Treat the source of the bleeding

  • Determine the need for pre-endoscopy medications.
  • Perform endoscopy based on risk.
  • If a patient undergoes hemodynamic resuscitation, they may need to undergo endoscopy, computed tomography, angiography, or push enteroscopy.

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Reference

  1. Arceneaux LS. On call with a GI bleeder: what you need to know to quickly assess and treat the urgency! Poster 238. Presented at: the American Association of Nurse Practitioners (AANP) 2016 National Conference; June 21-26, 2016; San Antonio, TX.
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