GI Bleed Case Study PDF

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A case study done for simulation on GI Bleed...

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Running head: GI BLEED CASE STUDY

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GI Bleed Case Study Janice A. Novak Husson University NU-322

GI BLEED CASE STUDY

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A gastrointestinal bleed is considered a symptom of the gastrointestinal tract. Gastrointestinal bleeds can be mild to very severe. Sometimes the bleeding is so minimal that patients don’t even realize they are bleeding. The way you would know that a person has a GI bleed in the very mild cases is through lab work, endoscopy, and colonoscopy. The gastrointestinal tract consists of the esophagus, stomach, large intestine, small intestine, colon, rectum, and anus ("GI Bleed | Gastrointestinal Bleeding", 2019). When referring to a gastrointestinal bleed, it could be coming from any of the areas mentioned above. Case Study Questions and Answers Question 1: What is the incidence of, and mortality associated with acute GI tract bleeding? Answer 1: The incidence of and mortality associated with acute GI tract bleeding is approximately 200,000 plus and the mortality rate consists of an estimated 5%-10%. yearly (Kim, et al., 2014). There is a greater chance of mortality in the elderly, patients that are in shock from the blood loss, or who have started to bleed again within 48 hours of the initial GI bleed (Lee, Costantini, & Coimbra, 2009). The GI bleeds can be an upper GI bleed, lower GI bleed, or both. Question 2: Identify common causes of GI tract bleeding and list predisposing factors specific to Mr. Mitchell. Answer 2: There are many causes for gastrointestinal bleeding, the two most common causes of the upper gastrointestinal area are Peptic ulcers and Gastric Varices. The other causes seen in the upper gastrointestinal area consist of esophageal varices, erosive esophagitis, infectious esophagitis, esophageal malignancy, Mallory-Weiss tear, Black esophagus (ischemia), gastric

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malignancy portal hypertensive gastropathy, gastric antral vascular ectasia, dieulafoy lesion, Duodenal ulcer, duodenal malignancy (Kamboj, Hoversten, & Leggett, 2019). Question 3: Discriminate between the characteristics of upper and lower GI tract bleeding. Answer 3: The characteristic changes between an upper and lower GI tract bleed can vary. In an upper GI tract bleed, the bleeding occurs above the duodenojejunal junction. A person may vomit blood or material that looks like coffee grounds. In a lower GI bleed, the bleeding is coming from the colon, rectum, or anus. The blood being passed is usually red and stool can have a black or tarry look. If a person has a severe upper GI bleed, it is possible for the patient to experience vomiting of blood or material resembling coffee grounds and having black or tarry stools (Whelen, et. al., 2010). Question 4: What complication did Mr. Mitchell experience? Answer 4: Mr. Mitchell most likely experience a hypovolemic issue due to the acute blood loss. Symptoms he was experiencing indicate that he is hemorrhaging. He had tachypnea, tachycardia, low CVP, hypotension, a decreased urine output, and his skin color changed. He is most likely experiencing a hemorrhagic stroke (Gutierrez, Reines, & Wulf-Gutierrez, 2004). Question 5: Which factors determine whether blood products will be administered to a patient with GI tract bleeding? Answer 5: Whether blood transfusions would be required rely on a multitude of events such as is the patient responding to IV fluids, how is the Hgb and Hct doing, what are his vital signs to name a few. A blood transfusion may be warranted in the Hgb drops below 9mg/hg; especially in the case of active bleeding. Also, if the Hct level is less than 25% this warrants a blood transfusion. If the patient has liquid stool that is maroon colored and occurring approximately every 30 minutes or has an NG tube with constant blood output; this would be another reason

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that a blood transfusion would occur. If a blood transfusion is needed, packed red blood cells are typically chosen due to decreased risk (Thompson, 2016). Question 6: Mr. Mitchell’s Hbg and Hct values dropped dramatically from admission to 7AM. Discuss the drop in Hgb and Hct values in relation to Mr. Mitchell’s blood loss. Answer 6: The Hgb and Hct levels are not a very good indicator of blood loss. The reason for this is because it takes approximately 48 hours or more for the shift of fluid to occur and create and equal state. With that being said; it is less likely that the drop was caused by a massive blood loss but more from hemodilution from the increase in fluids (Van, et al., 2011). Question 7: If a patient continues to have active bleeding from the GI tract despite conservative management, what other medical procedures might be implemented? Answer 7: Many different treatments and procedures can be implemented to treat an active GI bleed. Some of these include band ligation, medications, transcatheter embolization, and mechanical tamponade. Band ligation is done through endoscopy and can be useful if a person has esophageal varices. These bands strangle the varices and help to decrease chance of rebleeding. Medications such as octreotide can help vasoconstriction. Transcatheter embolization is used when there is a bleeding artery. Products such as coils, glue, and polyvinyl alcohol can be used. Mechanical tamponade uses Ewald, Cantor, or Linton-Nachlas tubes to put pressure and is typically considered a last resort method. It can cause major complications to the patient (Chen & Freeman, 2011). Question 8: Identify pharmacologic therapy commonly used in the treatment of GI tract bleeding. Answer 8: Pharmacological therapy may be used during an active GI bleed or to help prevent a bleed by treating any underlying conditions. Proton pump inhibitors are useful in help to prevent

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future bleeds. If a person has a stress ulcer, they may get treated with antacids or histaminereceptor antagonists. Histamine-receptor antagonists are used by decreasing erosion and damage to the stomach by gastric content. Long term use of antacids are discouraged due to the risk for metabolic alkalosis and serum sodium level increases (Lam, Wong, & Lau, 2015). Question 9: What are the indications and types of surgical procedures for upper GI tract bleeding? Answer 9: Surgery would be indicated in the event that the patient keeps bleeding after other medical treatments have been tried, cancer, perforations, obstructions, or in the case of ulcers that continue to reoccur. Surgical options can be fairly minor or severe. Some options include portosystemic shunts, vagotomy, or possibly a gastric resection (Kerlin & Tokar, 2013). Question 10: Identify six nursing diagnoses appropriate for Mr. Mitchell. Answer 10: Knowledge deficit related to smoking, alcohol use, and medication use; altered nutrition: less than body requirements related to NPO; impaired physical mobility related to hospitalization, anxiety related to hemorrhage; pain related to disruption of GI tract; altered tissue perfusion related to hypotension and metabolic acidosis; fluid volume deficit related to vomiting and bleeding status. Question 11: What is the incidence of H. Pylori infection in gastritis and duodenal ulcers? Answer 11: In 1984, H. Pylori was first identified. It was estimated that over 90% of all duodenal ulcers were caused by a H. Pylori infection. Over 70% of gastric ulcers were found to be a result from H. Pylori (Lee et. al,. 1993). Question 12: What is the treatment of choice for H. Pylori infection? Answer 12: Treatment for H. Pylori typically consists of some type of acid inhibiting medication such as Omeprazole and an antibiotic. The FDA treatment option approved at this time includes a

GI BLEED CASE STUDY acid inhibiting medication such as Omeprazole and Metronidazole and Clarithromycin for 10-14 days. Antibiotic substitutions are available (de Boer & Tytgat, 2000).

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Chen, Z. J., & Freeman, M. L. (2011). Management of upper gastrointestinal bleeding emergencies: evidence-based medicine and practical considerations. World journal of emergency medicine, 2(1), 5–12. doi:10.5847/wjem.j.1920-8642.2011.01.001 de Boer, W. A., & Tytgat, G. N. (2000). Regular review: treatment of Helicobacter pylori infection. BMJ (Clinical research ed.), 320(7226), 31–34. doi:10.1136/bmj.320.7226.31 Gastrointestinal Bleeding. (n.d.). Retrieved December 1, 2019, from https://www.saem.org/cdem/education/online-education/m4-curriculum/group-m4approach-to/gi-bleed. GI Bleed | Gastrointestinal Bleeding. (2019, May 7). Retrieved November 30, 2019, from https://medlineplus.gov/gastrointestinalbleeding.html. Gutierrez, G., Reines, H. D., & Wulf-Gutierrez, M. E. (2004). Clinical review: hemorrhagic shock. Critical care (London, England), 8(5), 373–381. doi:10.1186/cc2851 Kerlin, M. P., & Tokar, J. L. (2013, August 6). Acute Gastrointestinal Bleeding. Retrieved December 1, 2019, from https://annals.org/aim/article-abstract/1723169/acutegastrointestinal-bleeding. Kim, B. S. M., Li, B. T., Engel, A., Samra, J. S., Clarke, S., Norton, I. D., & Li, A. E. (2014, November 15). Diagnosis of gastrointestinal bleeding: A practical guide for clinicians. Retrieved November 30, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4231512/. Lam, K. L. Y., Wong, J. C. T., & Lau, J. Y. W. (2015, August 28). Pharmacological Treatment in Upper Gastrointestinal Bleeding. Retrieved November 27, 2019, from https://link.springer.com/article/10.1007/s11938-015-0063-x.

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Lee, H. R., Han, K. S., Yoo, B. C., Park, S. M., & Cha, Y. J. (1993). Prevalence of Helicobacter pylori infection in patients with peptic ulcer diseases and non-ulcer dyspepsia. The Korean journal of internal medicine, 8(2), 73–77. doi:10.3904/kjim.1993.8.2.73 (Machicado & Jensen, 1970) Lee, J., Costantini, T. W., & Coimbra, R. (2009). Acute Lower Gi Bleeding for the Acute Care Surgeon: Current Diagnosis and Management. Scandinavian Journal of Surgery, 98(3), 135–142. doi: 10.1177/145749690909800302 Van, P. Y., Riha, G. M., Cho, S. D., Underwood, S. J., Hamilton, G. J., Anderson, R., … Schreiber, M. A. (2011, March). Blood volume analysis can distinguish true anemia from hemodilution in critically ill patients. Retrieved December 1, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/21610355. Whelan CT, Chen C, Kaboli P, Siddique J, Prochaska M, Meltzer DO, UGIB vs. LGIB. (2010). J. Hosp. Med;3;141-147. doi:10.1002/jhm.606...