Vanderbilt University School of Medicine
VC3 – VANDERBILT CORE CLINICAL CURRICULUM

 

GI Bleed

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 third year medical students.

Patients frequently report rectal bleeding to their physician. They may complain of melena (black, "tarry" feces) or hematachezia (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.

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Prerequisites

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1.     Describe and discuss:

  • anatomy, physiology, and pathophysiology of the gastrointestinal tract
  • pharmacology of non-steroidal anti-inflammatory medication (a major contributing factor in etiology of gastrointestinal bleeding) as well as proton pump inhibitors and other agents used in the acute setting for treatment of gastrointestinal bleeding

2.     Demonstrate:

  • complete medical history
  • basic physical examination
  • basic communication skills, including patients from diverse backgrounds

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Apply Medical Knowledge in the Clinical Encounter

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1.  Describe the signs and symptoms of:

  • 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.     Describe the distinguishing features of upper versus lower GI bleeding.

3.     Describe the indications for inpatient versus outpatient evaluation and treatment.

4.     Describe the principles of stabilization and treatment of acute massive GI blood loss.

5.     Describe the role of contributing factors in GI bleeding such as H. pylori infection; NSAIDs, alcohol, cigarette use, coagulopathies; and chronic liver disease.

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Diagnose

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1.     Obtain, document and present an age-appropriate medical history 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.     Perform a physical exam 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.     Generate a differential diagnosis recognizing specific history and physical exam findings that suggest a specific etiology for GI bleeding.

4.     Order diagnostic and laboratory tests both prior to and after initiating treatment, based on the differential diagnosis. Justify ordering tests and consider test cost and performance characteristics as well as patient preferences.

5.     Recommend when to order diagnostic and laboratory tests and interpret results (with consultation):

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

6.     Define indications for and interpret with consultation results of:

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

7.     Perform basic procedural skills:

  • start an IV line using a large bore (i.e. 18 gauge) needle
  • perform a stool or emesis occult blood testing

8.     Identify 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.     Develop an appropriate evaluation and treatment plan for patients that includes:

  • establishing adequate venous access
  • administering crystalloid fluid resuscitation
  • ordering blood and blood product transfusion
  • determining when to obtain consultation from a gastroenterologist or a general surgeon.
  • using a cost-effective approach based on the differential diagnosis
  • accessing and utilizing appropriate information systems and resources to help delineate issues related to gastrointestinal bleeding
  • incorporating patient preferences
  • outlining 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.  Communicate the diagnosis, treatment plan, and subsequent follow-up to patients. Elicit questions from the patient and his or her family about the management plan.

11.  Record, present, research, critique, and manage clinical information.

12.  Access and use appropriate information systems and resources to help delineate issues related to GI bleeding. 

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Develop a Management Plan

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Make decisions about what to include from the following items and explain why each item selected should be included:

1.     Discuss preventive measures.

2.     Consider treatment measures such as the appropriate prescribing as well as appropriate use of consultants and referral to specialists.

3.     Provide psychological support if indicated.

4.     Access and utilize appropriate information systems to ascertain information about health system and community resources.

5.     Formulate a prognosis and communicate it to the patient in a caring and compassionate manner.

6.     Communicate the treatment plan and follow-up plan to patient.

7.     Consider the cost-effectiveness of the management plan.

8.     Plan for follow-up.

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Differential Diagnosis

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Upper GI Bleed

  • peptic ulcer disease
  • gastritis
  • esophagitis
  • varices
  • epistaxis
  • Porthal Gastropathy
  • Mallory_Weiss tear
  • neoplasm
  • angiodysplasia and vascular ectasis
  • aortoenteric fistular
  • Dieflafoy’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 fistulla