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Gastrointestinal Bleeding

Gastrointestinal (GI) bleeding is a very common symptom that can be life threatening if not properly diagnosed and treated. Consequently, knowledge of etiology and risk factors as well as the approach to diagnosis and management is an important training problem for medical students. Patients frequently report rectal bleeding to their physician. They may complain of melena (black, “tarry” feces) or hematochezia (bright red, bloody stools). At other times, occult blood is identified in the stool of a patient as part of a rectal exam or during routine screening. Decisions regarding the severity and acuteness of the bleeding, as well as the pace and extent of the work up for the bleeding will be made by nearly every physician.

Required Skills/Procedures:

1. Perform situation-appropriate (problem-focused or complete) history and physical examinations
2. Interpret clinical information to formulate a prioritized differential diagnosis
3. Guide the creation of a patient-specific management plan

Appropriate Setting: Inpatient and Outpatient

Expected level of Responsibility: Direct supervision with real patients

Learning Topics during encounters with a patient with GI BLEEDING can include:

Medical Knowledge Learning Topics related to GI BLEEDING

1. Signs and symptoms of sources of GI bleeding, such as:

  • esophagitis/esophageal erosions
  • Mallory Weiss tear
  • peptic and duodenal ulcer disease
  • esophageal/gastric varices
  • erosive gastritis
  • arteriovenous malformations
  • gastrointestinal tumors, benign and malignant
  • diverticulosis
  • ischemic colitis
  • hemorrhoids
  • anal fissures

2. Distinguishing features of upper versus lower GI bleeding
3. Indications for inpatient versus outpatient evaluation and treatment
4. Principles of stabilization and treatment of acute massive GI blood loss
5. Contributing factors to GI bleeding such as H. pylori infection, NSAIDs, alcohol, cigarette use, coagulopathies, and chronic liver disease

Diagnostic Evaluation Learning Topics related to GI BLEEDING:

1. Age-appropriate medical history taking, documentation, and presentation that differentiates among etiologies of disease, including:

  • features that distinguish upper from lower GI bleeding
  • quantification of degree of blood loss
  • chronology and duration of bleeding
  • associated symptoms
  • relevant past medical history
  • medication history, including use of tobacco and alcohol

2. Physical examination to establish the diagnosis and severity of disease, including:

  • postural blood pressure and pulse
  • abdominal palpation for organomegaly, masses, and tenderness
  • search for stigmata of chronic liver disease
  • anal and rectal examination

3. Differential diagnosis generation recognizing specific history and physical exam findings that suggest a specific etiology for GI bleeding
4. Diagnostic and laboratory testing necessary to determine the cause of the disease, including indication, interpretation both prior to and after initiating treatment based on the differential diagnosis, and in the context of test performance, cost, and patient preferences. Examples may include:

  • stool and gastric fluid tests for occult blood
  • CBC
  • PT/PTT
  • hepatic function panel
  • tests for Helicobacter pylori infection

5. Diagnostic procedures, including indications and interpretation of results (with consultation) for GI bleeding, such as:

  • esophagogastroduodenoscopy (EGD)
  • colonoscopy
  • barium studies of the gastrointestinal tract

6. Basic procedural skills, such as:

  • intravenous line placement using a large bore (i.e., 18 gauge) needle
  • stool or emesis occult blood testing

8. Identification of the patient’s problem from all of the problems listed in the differential diagnosis by combining scientific knowledge, information obtained in the clinical encounter, and collective experience with similar patients
9. Evaluation and treatment planning, such as:

  • establishment of adequate venous access
  • administration crystalloid fluid resuscitation
  • blood and blood product transfusion
  • determination of when to obtain consultation from a gastroenterologist or a general surgeon.
  • use of a cost-effective approach based on the differential diagnosis
  • use of appropriate information systems and resources to help delineate issues related to gastrointestinal bleeding
  • incorporation of patient preferences
  • communication and planning for long-term management when appropriate (e.g., Helicobacter pylori eradication, antacid, H-2 blocker or proton pump inhibitor therapy, smoking /alcohol cessation, NSAID restriction, and dietary modification)

10. Communication to patients and families about the working diagnosis, differential diagnosis, and current plan, in a caring and compassionate manner

Management Plan Learning Topics related to GI BLEEDING:

1. Preventive measures
2. Treatment, such as the appropriate prescribing of pharmacologic therapy, appropriate use of consultants, and referral to specialists
3. Psychological support if indicated
4. The use of appropriate information systems to ascertain information about health system and community resources
5. Prognostic formulation and communication to the patient in a caring and compassionate manner
6. Communication to patients and families about the diagnosis, treatment plan, and prognosis of the disease in a caring and compassionate manner, reflecting an understanding of the emotional impact of the diagnosis
7. Cost and cost-effectiveness of the management plan
8. Follow-up planning

Potential Differential Diagnosis Topics Include:

Upper GI Bleed

  • peptic ulcer disease
  • gastritis
  • esophagitis
  • varices
  • epistaxis
  • Portal gastropathy
  • Mallory-Weiss tear
  • neoplasm
  • angiodysplasia and vascular ectasis
  • aortoenteric fistula
  • Dieulafoy’s erosion

Lower GI Bleed

  • diverticulosis
  • angiodysplasia
  • arterio-venous malformation (AVM)
  • neoplasm
  • anal fissures
  • hemorrhoids
  • inflammatory bowel disease
  • ischemic colitis
  • radiation induced colitis
  • Meckel’s diverticulum
  • intussusception
  • aortoenteric fistula