GI Bleed: Examination & Diagnosis

00:01 Now, when we’re doing our exam we wanna make sure we're paying attention to the vital signs.

00:06 And that you're looking at the blood pressure and the heart rate in making sure that the patient is hemodynamically stable.

00:13 Now, if they are not hemodynamically stable, you wanna try and intervene on that.

00:18 Next, you wanna try and inspect the vomit or the stool.

00:20 This goes back to potentially having a patient if they've brought in a picture or they can show you a picture or if they’ve thrown up in the Emergency Department to kind of have that saved in some way so you’re able to take a peek at it.

00:33 So you're able to see what exactly is going on.

00:36 Sometimes, and a patient tells me a story and I'm kind of underwhelmed by what they’re describing and then they show me a picture, it can really, really change the way that I'm viewing that patient.

00:45 You also wanna perform a good abdominal exam.

00:47 The abdominal exam can be used to assess for tenderness, to look for rebound tenderness.

00:52 Again, the most worrisome thing that you could be looking for would be a perforated viscus or a perforation in the stomach.

00:59 You wanna look for a mass and also possibly for ascites in the abdomen.

01:03 Ascites can clue you in as to the fact that the patient may have liver disease.

01:07 And then further on from that liver disease can clue you in and make you think about the fact that the patient may have esophageal varices.

01:15 You also wanna look at the patient’s skin.

01:17 You wanna look for conjunctival pallor, so you basically pull down the patient’s lower lid and you look and see if that area is pink or more of a pale whitish, very light pink kind of a color.

01:29 You wanna look at the patient’s skin.

01:30 Is their skin pale? Do they look like they have normal coloration? Is there delayed capillary refill and you can get that information by kind of pinching their finger and seeing how quickly it takes for the blood to kinda fill back in there.

01:44 And ideally, in a patient who is well perfused, that time will be less than two seconds.

01:50 Lastly, you wanna do a rectal exam.

01:52 The rectal exam can help you get a sample of stool that you can do stool guaiac on.

01:57 We’ll talk about that in a moment.

01:58 But it can also might help you see if there’s any masses , if there is a fissure, which is a small cut in that lining of the rectum, and also if there’s a hemorrhoid there.

02:08 So all of that information can really help you.

02:12 Now what are the tests we wanna do? So one of the first things we wanna do is a stool guaiac test.

02:18 Again, we wanna make sure that there’s really, truly blood in that GI tract.

02:23 Now, a stool guaiac test is performed by taking a little bit of stool that’s obtained on a rectal exam and you put it in a small guaiac card and you either send it to the lab or you can sometimes go ahead and do that testing at the bedside in the Emergency Department if you're trained to do so.

02:38 Now, if that patient’s stool is positive, the sample will turn blue on the slide, and if it’s negative, it won’t turn blue.

02:47 Now again, this is important because who knows, maybe someone is coming in and they're telling you that their stool was very red.

02:53 Potentially, it’s due to the fact that they ate beets or drank a lot of Gatorade.

02:57 So having that stool guaiac test further supports or goes against the fact that the patient is having a true GI bleeding.

03:05 Other blood test to gather.

03:06 CBC, that’s gonna tell you what your hemoglobin is, what your hematocrit is and give you an idea as to whether or not that patient needs blood or doesn’t need blood.

03:15 Then you're gonna think about coagulation test.

03:18 You’re gonna wanna send in an INR and a PTT to take a look and see if the patient is anticoagulated.

03:24 It’s important to remember that in patients with liver disease they may be innately anticoagulated.

03:29 So even if they're not on any medication, their coagulation test, especially that INR may be abnormal so you're gonna wanna think about that.

03:38 The other thing to think about is what the newer oral anticoagulant medications, or your coagulation test actually appear normal.

03:44 So if someone is on those, you still wanna be thinking about the fact that you may need to reverse their anticoagulation.

03:51 You also wanna send a type and crossmatch, especially for that hemodynamically unstable patient.

03:57 You wanna go ahead and you wanna make sure that if they need a blood transfusion that they have that blood available to them.

04:03 For some patients, the type and crossmatch process is very easy.

04:06 So it’s very easy to go ahead and get blood.

04:09 If you have a patient whose been transfused a bunch of times in the past, you may have a harder time finding blood for that patient.

04:16 So get that process started early for a majority of people.

04:20 And then your chemistry and liver function test can also help you figure out if the patient has underlying liver disease.

04:28 Now, there is a certain value in the chemistry panel that you send that can give you vital information on patients with the GI bleeds.

04:35 That lab value is the BUN.

04:37 So the BUN or the blood urea nitrogen becomes elevated in patients who have an upper GI bleed.

04:43 And this is due to the fact that there is digestion and absorption of the hemoglobin causes the BUN to be elevated.

04:50 So again, if someone comes in and they tell you that they’re having melena and concern for GI bleed, if you get that and the BUN alone is elevated without an elevation in the creatinine level, that is something that points you in the direction that the patient is actually having this digestion and absorption of the hemoglobin.

05:09 We also should talk about whether or not to put an NG tube in a patient.

05:13 So an NG tube is a nasogastric tube.

05:15 It’s a tube that goes in the patient’s nose and then into their stomach.

05:20 NG tube insertion used to be very common place in patients who are presenting with a GI bleed.

05:24 And it used to be common place because people used to use it for diagnostic purposes.

05:29 So they would put in a nasogastric tube, and then they would suck stuff out, and they would see if there was any blood in what was removed from the stomach.

05:38 Now, it’s no longer recommended for the diagnosis of upper GI bleeds.

05:42 And there are a few reasons for that.

05:44 One is that it’s a very painful procedure for patients.

05:47 It’s actually been found or in certain studies has been quoted being the most painful thing that we do for patients in the Emergency Department.

05:54 And we do definitely a lot of painful things to patients.

05:57 So if this is the most uncomfortable, we wanna make sure that it has real value, that we’re actually gonna get something out of it.

06:05 There is also a risk of aspiration.

06:07 So when you're putting something down someone’s nose into their stomach, there’s a risk that they could aspirate some of those gastric contents in the process.

06:15 You also run the risk sometimes of taking this tube and accidentally putting it in a patient’s lung.

06:21 As you can imagine that’s not a great thing to do and if you do it, you could potentially cause the patient to get a pneumothorax.

06:27 So that’s a certain risk and a very real risk that can be associated with NG tube placement.

06:33 Lastly, there’s also concern for risk of perforation that the NG tube could potentially make a hole in something that would be a friable area of the stomach or the esophagus.

06:45 So does imaging help us diagnose GI bleed? Now, if you're worried about perforation, you’re worried that someone had a peptic ulcer that then in turn make a hole, a CT scan is the best test to evaluate for this.

06:57 You know, if your patient is unstable you might wanna consider getting an upright chest X-ray to take a look and see if there's any free air under the diaphragm .

07:06 For lower GI bleed, you can consider angiography versus scintigraphy.

07:11 Angiography is when you go ahead and you take a look at the patient’s blood vessels using contrast.

07:17 Scintigraphy is radio-labeled dye that’s given to a patient that can help take a look and identify the area of bleeding.

07:27 Angiography has a benefit in a sense that you can treat the patient and embolize a vessel if you see something that’s bleeding.

07:34 Again, these are patients who we generally will send to this treatment when you're worried about lower GI bleed and oftentimes, when they get there, the bleeding has stopped and no bleeding is found.

07:45 That’s really what happens most commonly for these patients.

07:48 But for sure, angiography is a little bit more beneficial for patients but a little bit more resource intensive and potentially harder to get for a patient.