Episode 101 GI Bleed Emergencies Part 1

This is EM Cases Episode 101 GI Bleed Emergencies Part 1 Join Anand Swaminathan, Salim Rezaie and Jeannie Callum to discuss the management of some of our most challenging GI bleed emergencies. In this Part 1 of our two part podcast on GI bleed emergencies we answer questions such as: How do you distinguish between an upper vs lower GI bleed when it's not so obvious clinically? What alterations to airway management are necessary for the GI bleed patient? What do we need to know about the value of fecal occult blood in determining whether or not a patient has a GI bleed? Which patients require red cell transfusions? Massive transfusion? Why is it important to get a fibrinogen level in the sick GI bleed patient? What are the goals of resuscitation in a massive GI bleed? What's the evidence for using an NG tube for diagnosis and management of upper GI bleeds?  In which patients should we give tranexamic acid and which patients should we avoid it in? How are the indications for massive transfusion in GI bleed different to the trauma patient? What are your options if the bleeding can't be stopped on endoscopy? and many more... Podcast production, sound design & editing by Anton Helman Written Summary and blog post by Shaun Mehta & Alexander Hart, edited by Anton Helman October, 2017 Cite this podcast as: Helman, A, Swaminathan, A, Rezaie, S, Callum, J. GI Bleed Emergencies Part 1. Emergency Medicine Cases. October, 2017. https://emergencymedicinecases.com/gi-bleed-emergencies-part-1/. Accessed [date]. Go to part 2 of this 2-part podcast on GI bleed emergencies How to distinguish LGIB from UGIB Distinguishing LGIB from UBIB is not always obvious clinically. STEP 1: Is the patient hemodynamically unstable? As a general rule, if a patient is hemodynamically unstable, assume UGIB because UGIB is more prevalent and is associated with a higher mortality. STEP 2: Is there bright red blood per rectum (BRBPR) with clots or hematemesis? BRBPR with clots can be considered almost pathognomonic for a LBIB while hematemesis can be for an UGIB source. Note that LGIB can manifest as melena and conversely, brisk upper GI bleed can manifest as hematochezia (without clots) in about 15% of cases. Melena on history was found to have an 80% sensitivity for UBIB with a +LR = 5.9 in a large systematic review in JAMA 2012 [1]. STEP 3: Calculate the BUN: Creatinine Ratio and consider the patient's age. The same JAMA systematic review found that a BUN:Cr ratio >30 is 93% specific for UGIB, with a +LR = 7.5. Note the units are mg/dL as used in the U.S. For other countries first divide the Creatinine by 88.42 (or roughly 100) before calculating the ratio. Age less than 50 years has a specificity of 92% and +LR = 2.5 for UGIB source. A study examining ED predictors of UGIB without hematemesis in 2006 found that 3 factors independently predict an UGIB source [2]: * Melena * BUN:creatinine ratio >30 * Age < 50 years Value of FOBT for detecting lower GI bleed emergencies In a large population based study of asymptomatic adults out of Taiwan in 2011 the sensitivity of fecal occult blood testing for predicting a LGIB source of bleeding was only 24.3%, the specificity 89.0%, the +LR = 2.22, the -LR = 0.85 and the accuracy 73.4%. While these were not ED patients with suspected GI bleed, the results give us a general idea of the limitations of FOBT [3]. FOBT false positives: Colchicine, iodine, boric acid, red meat FOBT false negatives: Vitamin C Imitators of melena