Week 14 - GIBleed (Moodle Version) (1).pdf

gastrointestinal bleeds Week 14 - CMS 150 objectives 1. Differentiate between gastrointestinal causes of blood in or on stool 2. Understand the epidemiology, timing, signs and symptoms of conditions presenting with blood in or on stool 3. Define gastrointestinal bleeding and its subtypes 4....

gastrointestinal bleeds Week 14 - CMS 150 objectives 1. Differentiate between gastrointestinal causes of blood in or on stool 2. Understand the epidemiology, timing, signs and symptoms of conditions presenting with blood in or on stool 3. Define gastrointestinal bleeding and its subtypes 4. Compare and contrast medical tests used in the evaluation of a patient with blood in or on stool based on evidence of accuracy 5. Develop and refine a differential diagnosis based on new information related to blood in or on stool 6. Apply diagnostic evidence to clinical reasoning in the presence of bloody stool 7. Prioritize issues to be addressed in a patient encounter where there is blood in or on stool 8. Understand when referral is warranted in the context of a patient with blood in or on stool 9. Understand colorectal cancer screening guidelines alarm symptom: gastro-intestinal (GI) BLEEDING overt GI bleed (acute) - visible blood from the gastro-intestinal tract in the form of hematemesis, melena or hematochezia. - hematemesis - blood in vomit may be bright red or black / dark brown like coffee grounds - melena - the passage of black, tarry stools - hematochezia - the passage of fresh blood per anus, usually in or with stools occult GI bleed (chronic) - microscopic blood loss obscure GI bleed (recurrent) - source is not identified review: alarm symptoms - diarrhea - blood in stools - more than 10% unintentional weight loss - disease that wakes the patient up during the night - fever (> 38.0°C or > 100.4°F) - new onset of signs and symptoms after 50 yrs of age - fHx of colorectal cancer, inflammatory bowel disease (IBD) or celiac disease - unexplained anemia - elevated white blood cell count (WBCs) - abdominal mass review: diarrhea - loose, watery stools 3 or more times a day. acute - 1 or 2 days (typically self-resolving) persistent - lasts longer than 2 weeks and less than 4 weeks. chronic - lasts at least 4 weeks (may be continuous or intermittent) Bristol Stool Chart pd GI bleeding - acute massive rectal bleeding Upper GI tract Prevalence (%) Lower GI tract Prevalence (%) Peptic ulcer disease 40 - 79 SI angiodysplasia 70 - 80 Gastritis/duodenitis 5 - 30 Diverticular disease 17 - 40 Esophageal varices 6 - 21 AV malformations 2 - 30 Mallory-Weiss tear 3 - 15 Colitis 9 - 21 Esophagitis 2-8 Colonic neoplasms 11 - 14 Gastric cancer 2-3 Anorectal causes 4 - 10 Full algorithm: Kim, 2014 suspected acute overt GI bleed referral based initial evaluation and on GBS Score resuscitation consider repeat upper endoscopy upper endoscopy and/or and/or colonoscopy as guided by colonoscopy clinical presentation source found no source found specific treatment unstable or stable or low massive bleed volume bleed Glasgow-Blatchford Bleeding Score (GBS) - a well-validated, pre-endoscopic risk assessment tool for upper GI bleeding to determine the need for intervention - a score of ≤1 indicates survival without intervention (i.e. identifies low risk patients that are appropriate for out-patient care) Finding Sensitivity LR + LR - GBS score ≤1 98.6% 1.5 0.04 online calculator: mdcalc.com Glasgow-Blatchford Bleeding Score (GBS) Blood Urea mmol/L 6.5 - 7.9 (2 pts) 8 - 9.9 (3 pts) 10-24.9 (4 pts) ≥ 25 (6 pts) Hemoglobin g/dL (men)