Gastrointestinal Bleeding
Knowledge
Students should be able to define, describe and discuss:
- common causes for and symptoms of upper and lower gastrointestinal blood loss, including:
- esophagitis
- esophageal/gastric varices
- gastritis
- peptic ulcer disease
- gastric neoplasm
- Mallory-Weiss tear
- malignancy
- intestinal angiodysplasia
- diverticuli
- ischemic colitis
- Arterial-Venous Malformations (AVMs)
- hemorrhoids
- anal fissures.
- distinguishing features of upper versus lower GI bleeding.
- indications for inpatient versus outpatient evaluation and treatment.
- principles of stabilization and treatment of acute massive GI blood loss.
- the role of contributing factors in GI bleeding such as:
- H. pylori infection
- NSAIDs
- alcohol
- cigarette use
- coagulapathies
- chronic liver disease.
Skills
Students should demonstrate specific skills, including:
- History-Taking Skills: Students should be able to obtain, document, and present a medical history that distinguishes upper from lower GI bleeding and differentiates among the causes of and/or contributors for each as outlined above. The history should address whether the patient has:
- upper or lower abdominal pain, and pattern of relief or exacerbation
- rectal or anal pain
- diaphoresis, lightheadedness or syncope
- black or grossly bloody stools
- brown or grossly bloody emesis
- forceful retching (Mallory-Weiss tear)
- weight loss (carcinoma)
- painless hematochezia (angiodysplasia, tumor)
- painful hematochezia with or without tenesmus (colitis)
- history of liver disease or alcohol use (varices, mucosal bleeding)
- history of NSAID use
- previous history of peptic ulcer disease
- known colonic diverticula
- history of vascular disease (ischemic colitis or bowel infarction).
- Physical Exam Skills: Students should be able to perform a physical examination to aid in making a specific diagnosis of GI blood loss and to determine the acuity and severity of the blood loss, including:
- postural blood pressure and pulse and their interpretation
- abdominal palpation of organomegaly, masses and tenderness
- identification of the stigmata of chronic liver diseases
- anal and rectal examination.
- Differential Diagnosis: Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam which:
- distinguish an upper from lower GI bleed
- distinguish an acute severe bleed from a more mild and/or chronic GI bleed
- suggest a specific etiology.
- Laboratory Interpretation: Students should be able to interpret the results/findings of:
- stool and gastric fluid tests for occult blood
- hemoglobin and hematocrit
- platelet count
- protime and partial thromboplastin time
- liver function tests
- tests for H. pylori.
- Students should understand and be able to interpret with consultation the results of:
- upper GI endoscopy
- colonoscopy
- barium studies of the gastrointestinal tract.
- Students should be able to recommend when each of these tests should be ordered.
- Management Skills: Students should be able to outline the appropriate management for a patient with severe blood loss, including:
- establishing adequate venous access
- crystalloid fluid resuscitation
- blood and blood product transfusion
- appropriate utilization of consultative services:
- gastroenterology
- general surgery
- consideration of IV proton pump inhibitors, vasopressin, octreotide
- long term management where appropriate:
- H. pylori eradication
- antacids
- H-2 blocker or proton pump inhibitor therapy
- smoking/alcohol cessation
- sclerotherapy/banding of varices, TIPS, Portocaval shunts
- NSAID restriction
- dietary modification.
Resources
- Acute gastrointestinal bleeding. Fallah, MA, Prakash, C, Edmundowica, S. Med Clin North Am (2000 Sep). 84(5): 1183-208.
- Clerkship Seminar, “Peptic Ulcer Disease,” T. Engel, MD
- Clerkship Seminar, “Gastrointestinal Bleeding,” R. Farrell, MD
- Internal Medicine Clerkship Guide, Paauw et al, Mosby 2003, pp105-112, 126-131 and 487-491
- Acute Gastrointestinal Bleeding, Fallah, MA, Prakash, C, Edmundowica, S. Med Clin North Am (2000 Sep). 84(5): 1183-208.
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