Upper GI Bleeding - Elsevier Assignment notes PDF

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Upper GI Bleeding Etiology and Pathophysiology Most serious loss of blood from upper GI is characterized by sudden onset, insidious occult bleeding can be a major problem. Severity depends on if the origin is venous, capillary, or arterial.  Bleeding from an arterial source is profuse and the blood is bright red, indicating that it has not been in contact with gastric hydrochloric acid secretion o Coffee-ground vomitus indicates that the blood has been in the stomach for some time Massive upper GI hemorrhage is a loss of more than 1500 mL of blood or 25% of the intravascular blood volume.  Melena (black, tarry stools) indicates slow bleeding from an upper GI source  The longer the passage of blood through the intestines, the darker the stool color because of the breakdown of hemoglobin and release of iron Causes of GI bleeding: Drugs

  

Corticosteroids NSAIDs/OTC Salicylates

Physical insult to esophagus

Esophageal varices Chronic esophagitis Mallory-Weiss tear

Physical insult to stomach & duodenum

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Systemic diseases

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Stomach cancer Hemorrhagic gastritis Peptic ulcer disease Polyps Stress-related mucosal disease Blood dyscrasias (leukemia, aplastic anemia) Renal failure

Risk Factors by Origin The sources of upper GI bleeds range from the esophagus to parts of the stomach and duodenum. Each origin has different risk factors. Esophageal Origin: caused by chronic esophagitis (caused by GERD, ingestion of drugs irritating to the mucosa, alcohol, and cigarette smoking). Other risk factors include having a Mallory-Weiss tear or esophageal varices (secondary to cirrhosis of the liver). Stomach & duodenal Origin: bleeding peptic ulcers account for 40% of cases. In addition, drugs, such as NSAIDs and corticosteroids, can cause irritation and disruption of the gastroduodenal mucosa.

Upper GI Bleeding Stress-related mucosal disease (SRMD): SRMD, also called physiologic stress ulcers, are caused by severe burns, trauma, or major surgery; diffuse superficial mucosal injury; or discrete deeper ulcers in the fundus and body of the stomach. Patients with coagulopathy and respiratory failure resulting in mechanical ventilation for more than 48 hours are also at risk. Signs & Symptoms Symptoms will vary according to severity of blood loss:  Occult bleeding: small amounts of hidden blood in gastric secretions, vomitus, or stool. Occult bleeding is detectable by examining the stool using a guaiac test, getting a reaction of the feces and hydrogen peroxide on guaiac paper.  Massive hemorrhaging or extreme loss of blood: may lead to shock, as identified by tachycardia, weak pulse, hypotension, cool extremities, prolonged capillary refill, and apprehension Signs & symptoms of upper GI bleeding span multiple body systems: Integumentary  Clammy, cool, pale skin  Pale mucous membranes, nail beds, and conjunctivae  Spider angiomas  Jaundice  Peripheral edema Respiratory & Cardiovascular  Rapid, shallow respirations  Tachycardia  Weak pulse  Orthostatic hypotension  Slow capillary refill Gastrointestinal  Red or coffee-ground vomitus  Tense, rigid abdomen, ascites  Hypoactive or hyperactive bowel sounds  Hematemesis  Decreased gastric motility  Melena o Black, tarry stools (often foul smelling) due to presence of iron in the stool Urinary  

Decreased urine output Concentrated urine

Neurologic  

Agitation, restlessness Decreasing LOC

Upper GI Bleeding Clinical Findings  Decreased hematocrit and hemoglobin  Hematuria  Guaiac-positive stools (from occult blood), emesis, or gastric aspirate  Decreased levels of clotting factors  Increased liver enzymes  Abnormal endoscopy results Diagnostic Studies  Endoscopy: primary tool for diagnosing the source  Laboratory: complete blood count (CBC), blood urea nitrogen (BUN), serum electrolytes, prothrombin time, partial thromboplastin time, liver enzymes, and arterial blood gases (ABGs)  Angiography: used when an esophagogastroduodenoscopy (EGD) cannot be done or when bleeding persists after endoscopic therapy Emergency treatment Between 80-85% of patients experiencing a large hemorrhage will stop bleeding spontaneously. The reason for the bleed will still be identified and treatment for the bleed will begin. Once emergency care has been provided, a complete patient history can be conducted. Events leading up to the bleeding episode will be included in the patient history. A patient may experience a perforation in the abdominal area. If this occurs, the risk of peritonitis could occur. A sign that perforation and peritonitis have occurred is a rigid, tense, board like abdomen. A complete exam of the abdomen must be performed. The nurse will note bowel activity by the presence or absence of bowel sounds. Two IV lines will be started for blood and/or fluid replacement. The IV lines will be 16 or 18 gauge. The types of fluids are determined by lab findings and physical assessment of the patient. The most commonly used fluid is lactated Ringer's (an isotonic crystalloid solution). Blood products are commonly whole blood, packed red blood cells, and fresh frozen plasma if a large hemorrhage has occurred. Blood products are used for volume replacement and can prevent other complications like volume overload. PRBCs allow the rapid increase of hematocrit and hemoglobin. The patient may require oxygen to maintain a normal blood oxygen saturation. One of the best measurements of organ perfusion is urinary output. An indwelling urinary catheter is inserted to continually measure an accurate urinary output. The placement of a central venous catheter will allow the fluid volume of the patient to be assessed. A patient with the history of heart problems (valvular heart disease, coronary artery disease, heart failure) may require the insertion of a pulmonary artery catheter for closer monitoring. Endoscopic Therapy Treatment The first-line management of upper GI bleeding involves endoscopy and endotherapy. Endoscopy performed within the first 24 hours of bleeding is important for diagnosis and determination of the need for surgical or radiologic intervention. A patient in a hypovolemic shock state due to bleeding will be stabilized before undergoing endoscopy.

Upper GI Bleeding The goal of endoscopic hemostasis is to coagulate or thrombose the bleeding vessel. Several techniques are used, including  Thermal (heat) probe  Multipolar and bipolar electrocoagulation probe o Multipolar electrocoagulation and thermal probes are the two most commonly used procedures. The thermal probe coagulates tissue by directly applying a heating element to the bleeding site.  Argon plasma coagulation (APC), which does not come into contact with the mucosa, delivers current to the tissue  Ligation, injection sclerotherapy, and balloon tamponade are used for esophageal variceal bleeding. Drug Therapy During the acute phase, drugs are used to decrease bleeding, decrease HCl acid secretion, and neutralize the HCl acid that is present. Injection therapy with epinephrine (1:10,000 dilution) during endoscopy is effective for acute hemostasis. Efforts are made to reduce acid secretion because the acidic environment can alter platelet function and interfere with clot stabilization. Epinephrine produces tissue edema and, ultimately, pressure on the source of bleeding. During the acute phase of upper GI bleeding, empiric proton pump inhibitor (PPI) therapy with high-dose IV bolus and subsequent infusion is often started before endoscopy. This may decrease the amount of bleeding and the need for endoscopic therapy. Efforts are made to reduce acid secretion because the acidic environment can alter platelet function and interfere with clot stabilization. PPIs or histamine-receptor blockers are administered IV to decrease acid secretion. In patients with upper GI bleeding, somatostatin or its long-acting analog octreotide (Sandostatin) may be administered when endoscopy is not available. Both agents reduce blood flow to the GI organs and acid secretion. After an initial bolus, somatostatin is used for 3 to 7 days, whereas octreotide is given for 3 days after the start of bleeding. Treating upper GI bleed Drug

Source of Bleed MOA of drug

Vasopressin (pitressin)

Esophageal varices

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Octreotide (Sandostatin)

Upper GI bleed, esophageal varices

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Epinephrine

Bleeding from ulceration

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Causes vasoconstriction Dec. pressure in the portal circulation and stops bleed Somatostatin analog that dec. blood flow to GI tract Dec. HCl acid secretion by dec. release of gastrin Injection during endoscopy produces

Upper GI Bleeding  

hemostasis Causes tissue edema and pressure on the source of bleeding Injection therapy often combined with other therapies (laser)

Upper GI bleed

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Dec. acid in stomach by inhibiting the proton pump responsible for the secretions of hydrogen ions, dec. irritation of esophageal and gastric mucosa

H2-receptor blockers Upper GI bleed (tagamet, pepcid, axid, zantac)

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Dec. acid in stomach, blocks the action of histamine on the H2receptors, which in turn, dec. the HCl acid secretion, dec. conversion of pepsinogen to pepsin, and dec. irritation of the esophageal and gastric mucosa

PPIs (protonix, dexilant, nexium, prevacid, prilosec, aciphex)

Surgical Care Surgical intervention is indicated when bleeding continues, regardless of the conservative therapy provided and when the site of the bleeding has been identified. Surgical therapy may be necessary when the patient continues to bleed after rapid transfusion of up to 2000 mL of whole blood or remains in shock after 24 hours. The site (esophageal, stomach, or duodenum) of the hemorrhage determines the choice of operation. The mortality rates increase considerably in those over 60 years of age. Nursing Assessment First step in caring for a patient with an upper GI bleed is a complete nursing assessment. Once the immediate physical needs of the patient are met, the nurse can gather more detailed information about the bleeding. While getting the patient ready for treatment, the nurse will be conducting a nursing assessment, including monitoring and evaluating vital signs, LOC, skin color, and cap refill. An assessment performed on the abdomen will include checking the abdomen for distention, peristalsis, and guarding. Vital signs will inform the nurse if the patient is shock and establish a baseline to go by. Vital signs will be monitored frequently, every 15 to 30 minutes, to identify significant changes. After completing the initial nursing assessment, the nurse will inquire about the following:

Upper GI Bleeding      

Hx of previous bleeding Hx of past blood transfusions Blood transfusion reactions Other illnesses that could lead to the bleeding Illnesses or medications that could interfere with the treatment plan Cultural or religious practices that could impact care or treatment (such as blood products)

Acute Nursing Care A GI bleed can cause the patient to have severe anxiety. Approaching the patient with a calm manner can help decrease the patient's anxiety. Anxiety is one of the warning signs of shock so the nurse will be cautious when administering sedatives for restlessness. The sedatives can mask anxiety. The nurse should assess the patient for signs of shock (tachycardia, hypotension) before administering sedatives. Once IV access has been established, the nurse initiate and maintain the IV line for fluids or blood replacement. The patient's hydration status can be assessed by tracking the patient's intake and output. The nurse will measure urine output hourly. Close hemodynamic monitoring can provide the nurse with blood flow and pressure in the cardiovascular system. Closely monitor the patients who have a history of cardiac problems or who are of older age for signs of fluid overload. Be aware that patients receiving large amounts of fluid in a small amount of time are at risk for volume overload. Other nursing assessments the nurse will perform include:  Elevate the head of the bed  Observe and auscultate breath sounds, along with respiratory efforts  Monitor cardiac rhythm  Frequently assess vital signs  Monitor alcoholics closely for increased risk of bleeding and withdrawal  Observe for signs of alcohol withdrawal such as agitation, sweating, uncontrolled shaking, and vivid hallucinations Based on patient's health status, different interventions may be implemented. The nurse needs to be able to collect information regarding the patient's intake and output. NG tube assessment: frequently assess the NG tube position and aspirates contents for blood. If using the lavage technique, use 50-100 mL of fluid to instill within the stomach. The fluid can be aspirated or drained by gravity. When aspirating contents from the stomach, stop aspirating if resistance is felt. The tip of the NG tube may be next to the lining of the stomach. Stool assessment: assess the patient's stools for blood (hematochezia, black tarry, bright red). Prolonged bleeding results in black tarry stools. Be sure to assess the patient for menses and bleeding hemorrhoids to rule out sources of blood in the stool. When vomitus contains blood but the stool contains no gross or occult blood, the hemorrhage is considered to have been of short duration. Oral nourishment: once oral intake is started, observe the patient for symptoms of nausea and vomiting and a recurrence of bleeding. Clear fluids should be started first and given hourly until tolerance is determined. Gradual introduction of food follows if the patient exhibits no signs of discomfort.

Upper GI Bleeding Patient Education The nurse will ensure that patient goals are met before discharge. The patient will have no further bleeding, a normal BP, and will experience reduced anxiety. When the patient is ready for discharge, the nurse will instruct the patient and the caregiver how to avoid future bleeding episodes. Ulcer disease, drug or alcohol abuse, and liver and respiratory diseases can all result in upper GI bleeding. Assist the patient and the caregiver in understanding the importance of adhering to drug therapy. Emphasize that no drugs (especially NSAIDs, including aspirin) other than those prescribed by the healthcare provider should be taken. Smoking and alcohol should be stopped. These are sources of irritation and interfere with tissue repair. Long-term follow-up care may be necessary because of possible recurrence. Give the patient and family instructions on what to do if an acute hemorrhage occurs in the future....