SIU School of Medicine

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Department of Internal Medicine

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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