Bleeding

GI Bleeding

Upper GI Bleeding: Melena → EGD before Colonoscopy

• General management

  • Limit bleeding risk

    • Stop aspirin and NSAIDs

    • Reverse anticoagulants if possible, but do not delay EGD due to anticoagulation

  • Transition to NPO and start PPI IV (pantoprazole 80 mg loading dose followed by 40 mg q12 hours)

  • Transfuse for hemoglobin ≤ 7 mg/dL

  • Perform EGD within 24 hours of diagnosis

  • Glasgow-Blatchford score > 0: Hospitalize for 72 hours following EGD due to risk for rebleeding

• Differential diagnosis

  • Hematemesis: Esophageal varices, Mallory-Weiss tear

  • Esophagitis

  • Peptic ulcer disease

Lower GI Bleeding: Bright Red Blood per Rectum

• Red flags requiring colonoscopy

  • Age ≥ 50 years

  • Family history of colon cancer, familial polyposis

  • Symptoms

    • Fever, unintentional weight loss

    • Change in stool frequency, caliber, consistency

  • Anemia, positive FOBT

• Differential diagnosis

  • Anal canal

    • Anal fissure: Tearing pain with bowel movements, perianal skin irritation, small amount on toilet paper

    • Hemorrhoids: Internal hemorrhoid, external hemorrhoid

  • Colon: Colon cancer (adenomatous polyps), diverticulitis, ischemic colitis, colonic angiodysplasia

  • Irritable bowel disease: Ulcerative colitis, Crohn's disease

Abnormal Uterine Bleeding

Differential (PALM-COEIN)

• Structural

  • Polyp

  • Adenomyosis

  • Leiomyoma

  • Malignancy and hyperplasia

• Non-structural

  • Coagulopathy

  • Ovulatory dysfunction

    • Polycystic ovarian syndrome (PCOS)

  • Endometrial (e.g. infection, inflammation)

  • Iatrogenic (e.g. anticoagulants)

  • Not yet classified

Bleeding in Pregnancy

General Considerations

• Light bleeding at 3-5 WGA is most likely due to implantation

• Rule out cervical bleeding due to gonorrhea/Chlamydia

Early Pregnancy Bleeding (Algorithm)

• Gestational trophoblastic disease

• Ectopic pregnancy

• Subchorionic hemorrhage

Late Pregnancy Bleeding

• Placenta previa

• Placental abruption

• Vasa previa

Postpartum hemorrhage

Other

Von Willebrand Disease

• Mucosal bleeding, e.g. menorrhagia

• Most suggestive finding = prolonged PTT

• Refer to hematologist for diagnosis confirmation