Bleeding GIT

Stable: suspected of Melena/hematochezia/hematemesis

Hx:

• Hx of Bleeding GIT (Endoscopy/Colonoscopy)
• EtOH
• Meds: Aspirin/Plavix/Warfarin/other anticoagulants/NSAID/TCM/Steroid
• Cocaine/Sympathomimetics: ulcer
• Pain/No pain doesn't correlate with endoscope
• Hx of liver disease/heart failure

PE

• Abdominal exam
• Cirrhosis
• Rectal: look for fissures/hemorrhoids/anoscope

Labs

• ECG if anemic
• FBC/PT/Urea/Type and screen
• NG aspirate and lavage in ED: low sensitivity for hematochezia/melena (without hematemesis); Academic Emergency Medicine Feb 2010
• No imaging

*80% will need rebleed, only 20% needs to catch, but this patients are those with liver disease, on steroids, etc

Screening/Scoring = Non variceal bleeding: All common sense

- Blatchford score, Modified Glasgow Blatchford score, Rockall, Lee

* assume it's upper always: more common, more commonly fatal, you can do something

* assume it's variceal (not ulcer)

* if unstable, NG tube always! varices are not contraindicated

Corrected sodium underestimates sodium

Hyperglycemia lowers serum sodium levels; the degree to which has been updated from the previous dogma of:

Conventional Units: For each 100 mg/dL (over 100 mg/dL) the blood glucose rises; the measured serum sodium should have 1.6 mEq/L added to it in order to correct for the effect of the hyperglycemia.

SI Units: For each 5.6 mmol/L (over 5.6 mmol/L) the blood glucose rises; the measured serum sodium should have 1.6 mmol/L added to it in order to correct for the effect of the hyperglycemia.

In an interesting trial where the effects of hyperglycemia on sodium levels were actually measured, Hillier, et al. demonstrate that the correction factor of 1.6 is inaccurate and leads to serious underestimation of serum sodium levels; especially in those patients with blood glucose concentrations of >500 mg/dL. The clinical information from this; study, is that a factor of 2.4 is more appropriate.

We are now utilizing the 2.4 adjustment factor. The formulas for each are below:

Conventional Units:
Glucose = mg/dL Sodium = mEq/L For each 100 mg/dL (greater than 100 mg/dL) the blood glucose rises; the measured serum sodium should have 2.4 mEq/L added to it in order to correct for the effect of the hyperglycemia.

• Corrected Serum Sodium = Measured Serum Sodium + [(Glucose measured - 100)/100]x2.4

SI Units: For each 5.6 mmol/L (greater than 5.6 mmol/L) the blood glucose rises; the measured serum sodium should have 2.4 mmol/L added to it in order to correct for the effect of the hyperglycemia.

• Corrected Serum Sodium = Measured Serum Sodium + [(Glucose measured - 5.6)/5.6]x2.4

Reference:
Hillier TA, et al. Hyponatremia; evaluating the correction factor for hyperglycemia. Am J Med April 1999;106:399-403. Huffman, GB. Adjusting Sodium Levels in Patients with Hyperglycemia. Am Fam Phy. 15 October 1999;60(6):1798.

Bleeding GIT

• for suspected bleeding, can give 40mg IV omeprazole or esomeprazole while waiting for labs, confirming with rectal exam as long as hemodynamically stable
• For active bleeding: 80mg IV then 8mg/hr infusion
• Variceal bleed: Somatostatin 250mcg IV then 250mcg/hr infusion x 5 days -- inhibits vasodilatory hormone like glucagon, indirectly causing splanchnic vasoconstriction and decreased portal inflow.
• others: vasopressin (0.4 U bolus then 0.4 to 1 U/min infusion) or ocreotide - a long-acting somatostatin analog (50mcg then 50mcg/h). Somatostatin is the most superior among the three
• Antibiotics for variceal bleeding
• Maintain Hb to 8 g/dL

Unstable

• Airway: Supplemental oxygen, intubate early
• FFP: known liver disease, don't wait for PT/PTT
• Platelets if indicated
• DDAVP: if renal failure
• PCC:
• Factor VIIa:

Balloon Tamponade: another link

1. Sengstaken-Blakemore: gastric balloon, esophageal balloon, gastric suction port

2. Minnesota: plus esophageal suction port

3. Linton: single gastric balloon, most effective

Lower GI

- Diverticular bleeding, Angiodysplasia

- IR, GS