Acute Gastrointestinal Bleeding

• Gastrointestinal bleeding can manifest itself in various ways and it is important to be cognizant of the contributing causes and the signs/symptoms. 
• There are specific diagnostic tests that aid in proper diagnosing of gastrointestinal bleeding. 
• Gastrointestinal bleeding must be managed appropriately and one must be made aware of complications that may take place.  

A bleeding that occurs anywhere in the digestive tract is known as an acute gastrointestinal bleeding.  More than a disease, it is a symptom of an underlying condition.  

Gastrointestinal bleeding can take place in the upper or lower gastrointestinal area and it is important to determine the location of the blood in order for successful outcomes to be implemented.  

Gastrointestinal Bleeding Clinical Manifestations

Each individual may experience varying symptoms related to gastrointestinal bleeding and it is important to understand the differences between acute upper gastrointestinal bleeding versus lower gastrointestinal bleeding.   

Acute upper gastrointestinal bleeding can occur due to the following: 

• Gastric or duodenal ulcers, including stress-related ulceration 
• Nonsteroidal anti-inflammatory drugs (NSAIDs) – related to peptic ulcer disease 
• Erosive or hemorrhagic gastritis 
• Esophagitis  
• Esophagogastric varices 
• Mallory-Weiss tear that occurs due to increased abdominal pressure because of cough or vomiting.  It can also lead to esophageal wall rupture. 
• Liver disorders 
• Neoplasms  

Lower gastrointestinal bleeding can occur due to the following: 

• Diverticulitis 
• Infectious colitis or Crohn’s disease 
• Neoplasms 
• Polyps 
• Hemorrhoids or anorectal disorders 
• Bowel disease/trauma or ischemic bowel 
• Eroding aortic aneurysm 

The patient with acute gastrointestinal bleeding may present with the following signs and symptoms: 

• Hematemesis – red or brown-colored vomit  
• Melena- black and tarry stools  
• Hematochezia – the presence of fresh blood from the anus (with or without the stool)  
• Tachycardia with decreased pulse pressure  
• Mean arterial pressure less than 60 mm of  Hg 
• Cardiac dysrhythmias 
• Chest pain  
• Tachypnea – difficulty breathing  
• Confusion, lethargy, weakness, and pallor  
• Decreased urine output and increased urine concentration  
• Increased bowel sounds and diarrhea  
• Diaphoresis 
• Cool and clammy skin  
• Stupor and coma (if the bleeding is large enough) 
• Shock and multiple organ failure (severe blood loss) 

Gastrointestinal Bleeding & Diagnostic Tests

After history and examination, diagnostic testing should be ordered to determine specifics regarding the confirmation of a gastrointestinal bleed.  The following diagnostic parameters can be helpful in acute gastrointestinal bleeding: 

• Complete blood count  
• Platelets 
• Coagulation studies – PT and INR  
• Liver function tests 
• BUN and creatinine ratio 
• EKG to determine heart rhythm and if the patient has arrhythmias  
• ABGs or pulse oximetry 
• UGI series 
• Abdominal x-ray  
• CT scan of the abdomen 
• Barium enema 
• Endoscopy  
• Stool test for Helicobacter pylori 
• Colonoscopy or sigmoidoscopy 
• Mesenteric angiography

Nursing Management

Nurses need to be aware of how to effectively care for those with gastrointestinal bleeding.  The following management tips are helpful when caring for these individuals:  

• Monitor the vitals – check the heart rate and blood pressure.   
• Maintain an arterial line.  Note the decrease in blood pressure, increase in heart rate, decrease in cardiac venous output, and other symptoms of shock.  Treat them accordingly.  
•  Perform EKG and asses the patient for arrhythmias.  
• Assess the patient’s respiratory status by getting his/her pulse oximetry and ABGs.  Check for hypoxia.  Administer oxygen via cannula, mask, or mechanical ventilation.  
• Insert low bore NG tube and set to low intermittent suction.  Lavage with saline or water when needed.  Avoid doing iced lavage.  If the patient is actively bleeding, keep him/her with nothing by mouth.  Notice the draining fluid for blood or coffee ground items.  
• When the patient stops bleeding, give clear liquids.  Also, keep the head of the bed elevated.  To decrease the risk of aspiration in an actively bleeding patient, keep the patient in the left lateral decubitus position. 
• Assess the abdomen for pain, bowel sounds, and distension.  
• Administer IV fluids or colloids, crystalloids, blood, and blood products to prevent hypotension and dehydration via central access or two large-bore IV catheters.  
• Note the patient’s amount and color of the stool. 
• Monitor CBC, PT, PTT, and blood chemistries. 
• Insert Foley catheter and monitor the fluid intake and output.  Keep an eye on fluid and electrolyte balance.  
• Administer high-dose proton pump inhibitors to keep the pH of gastric fluid above 6.  
• If coagulopathy is present with increased PTT level, administer vitamin K 10 mg IV and fresh frozen plasma. 
• Calm the patient and family by offering emotional and mental support and relieving pain and anxiety.  

Gastrointestinal Bleeding Complications

Complications that can occur with acute gastrointestinal bleeding are: 

• Cardiac output is reduced, which can lead to hypovolemic shock. 
• Nausea, vomiting, and diarrhea can lead to pulmonary aspiration. 
• Altered nutritional status can lead to nutritional deficiencies. 
• Infection can lead to fever, increased heart rate, increased WBCs, and sepsis. 

The Bottom Line

Acute gastrointestinal bleeding can be life-threatening; therefore, it is important to complete accurate assessments and blood work in a timely manner in order for prompt treatment to be initiated. 

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