GASTROINTESTINAL BLEEDING

LEARNING OBJECTIVES:

KNOWLEDGE - students should be able to appreciate the following:

1. Define hematemesis, melena and hematochezia.
2. Define and describe, and prioritize the common causes for and symptoms of upper and lower GI blood loss, including:
   1. Esophagitis/esophageal erosions
   2. Mallory Weiss tear
   3. Peptic and duodenal ulcer disease
   4. Esophageal/gastric varices
   5. Erosive gastritis
   6. Arteriovenous malformations
   7. Gastrointestinal tumors, benign and malignant
   8. Diverticulosis
   9. Ischemia colitis
   10. Hemorrhoids
   11. Anal fissures
3. Define and describe the distinguishing features of upper versus lower GI bleeding including but not limited to the following:
   1. Recognize melena (usually indicating an upper GI source) is the most frequent cause of major GI bleeding, but all black stools are not melena
   2. Recognize hematochezie is usually a manifestation of lower GI bleeding but can be a manifestation of severe upper GI bleeding
   3. Recognize the most common cause of major upper GI bleeding is the peptic disorders. Diverticulosis is a common cause of major lower GI bleeding.
4. Recommend laboratory and diagnsotic tests to evaluate GI bleeding, which include (when appropriate): stool and gastric fluid tests for occult blood, CBC, PT/PTT, and colonoscopy.
   1. Recognize that upper endoscopy (EGD) is the initial diagnostic test and therapeutic modality of choice in upper GI bleeding and has predictive value of rebleeding
   2. Recognize that colonoscopy (after cessation of bleeding and colonic cleansing) is the test of choice in lower GI bleeding
   3. Identify the role of capsule endoscopy and arteriogram studies
5. Develop an appropriate evaluation and treatment plan for patients with a GI bleed that includes:
   1. Protecting the airway
   2. Establishing adequate venous access
   3. Administering crystalloid fluid resuscitation
   4. Ordering blood and blood product transfusion
   5. Determining when to obtain consultation from a gastroenterologist for upper endoscopy
6. Define and describe the role of contributing factors in GI bleeding such as H. pylori infection; NSAIDs, alcohol, cigarette use, coagulopathies; and chronic liver disease.

SKILLS – students should be able to demonstrate the following skills:

1. Obtain an accurate history and perform a rapid physical examination on the bleeding patient, while resuscitative measures are being instituted
2. Know the basic resuscitative measures in the GI bleeder (NG tube placement, volume replacement, oxygen administration, and laboratory evaluation).
3. Correctly recommend when to use endoscopic procedures and when to use angiography in the bleeding patient.
4. Know what pharmacologic agents are available for the GI bleeder and their efficacy.
5. Correctly recommend when to call for surgical consultation in the GI bleeder.

ATTITUDES AND PROFESSIONAL BEHAVIORS:

• Students should appreciate the scope of GI bleeding in the U.S. and its impact on the patient. Timing of appropriate tests is paramount for rapid, accurate diagnosis in the GI bleeder in order that appropriate therapy be instituted as soon as possible.

RECOMMENDED READINGS:

1. Yamada, Tadataka.   Handbook of Gastroenterology . 2000, Chap 4 (The Medicine Education Office, 7604, has a copy of this reference.)