Gastrointestinal Bleed

Introduction:

Bleeding from the gastrointestinal tract may cause significant blood loss. The bleed-
ing may be from either the upper or lower gastrointestinal tract. Upper gastrointesti-
nal bleeds are commonly from ulcers, esophageal varices, neoplasms, arteriovenous
malformations, Mallory-Weiss tears secondary to vomiting, or anticoagulant use.
Lower gastrointestinal bleeds are commonly due to fissure formation, rectal trauma,
colitis, polyps, colon cancer, diverticulitis, vasculitis, or ulcerations.

PROGNOSIS

The amount and speed of blood loss coupled with the patient’s age and co-
morbidities account for the prognosis. The greater the loss of blood, the harder it
is for the system to overcome the stress. Multiple transfusions to replace the lost
blood increase the patient’s risk for a reaction. Patients with blood-clotting disor-
ders have a greater risk of a significant bleed. Patients may go into shock if the
amount of blood loss is great, as they become hemodynamically unstable.

SIGNS AND SYMPTOMS

• Hematemesis—vomiting of blood (red, maroon, coffee ground)
• Melena—black, tarry stool
• Hematochezia—red or maroon blood rectally
• Orthostatic changes—drop in BP of at least 10 mmHg with position changes
• Tachycardia as body attempts to circulate lesser blood volume
• Pallor due to decrease in circulating blood volume
• Lightheadedness

TREATMENT
• Maintain IV access.
• Administer isotonic fluids like normal saline.
• Monitor serial hemoglobin and hematocrit levels.
• Type and cross match for 3 to 6 units depending on amount of blood loss.
• Transfuse packed RBCs, type-specific when possible (type O negative when
type-specific unavailable—no time to get results back from lab yet).
• May need to administer albumin or fresh frozen plasma, depending on amount
of units transfused and comorbidities such as cirrhosis or clotting disorders.
• Endoscopic procedures to treat ulcer topically, with injectable or laser treatment.
• Esophageal varices may be treated by tamponade with Blakemore-Sengstaken
tube.
• Surgery indicated when bleeding uncontrolled.

NURSING DIAGNOSES

• Deficient fluid volume
• Decreased cardiac output

NURSING INTERVENTION

• Monitor vital signs for changes—drop in BP, increase in pulse or respiration.
• Monitor intake and output.
• Replace volume lost.
• Monitor abdomen for bowel sounds, tenderness, distention.
• Maintain large bore IV (14- to 18-gauge) access.
• Assess IV site for signs of redness or swelling.
• Monitor lab results—drop in lab values may lag behind blood loss.
• Monitor during blood transfusion as per institution protocol for checking
blood unit, patient identity, frequency of vital signs, and documentation
• Anxiety