Internal Medicine

0521779407-08 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:47

616 Gastrointestinal Bleeding

➣Colonic diverticula

➣Colonic polyps

➣Colonic cancer

➣Vascular ectasias (also called “angiodysplasia” or “AVMs”)

■Major sources of “occult” GI bleeding

➣Nasopharyngeal bleeding

➣Gingival bleeding

➣Tracheobronchial tree

➣Occult gastric or duodenal varices

➣Vascular ectasias – “watermelon stomach”

➣Mesenteric varices

➣Dieulafoy lesions (large vascular AVMs)

➣Small bowel neoplasms or diverticula

➣Meckel’s diverticulum

➣Occult small bowel Crohn’s disease

➣Small bowel tuberculosis

➣Aorto-enteric fistulae (usually aortoduodenal)

Trauma-associated bleeding into bile duct (hemobilia) or pan-

creatic duct (hemosuccus pancreaticus)

management

What to Do First

■Resuscitate with adequate fluid and red cells

■Evaluate for cardiopulmonary compromise due to hypovolemia

■Correct any coagulopathy

General Management

■Seek surgical and GI consultation – early for acute bleeders

■Be persistent but appropriately aggressive

specific therapy

■Intravenous or oral proton pump inhibitors possibly helpful for acid-

peptic bleeding

■Antibiotic therapy for H. pylori-associated ulcers possibly decreases

early rebleeding

■Endoscopic therapy – heater probe, bipolar electrode, clip fixation,

injection of epinephrine decreases rebleeding, transfusions, costs,

hospital stay

follow-up

■For benign gastric and duodenal ulcers without NSAID use – treat

empirically for H. pylori or review gastric biopsies for H. pylori and

treat appropriately