Acute Gastrointestinal Bleeding

Abstract

A greater understanding of the pathophysiology of gastrointestinal bleeding has been accompanied by a rapid advancement in therapeutic technology. Newer endoscopic and radiologic techniques are being tested to determine their appropriate uses, but pharmacologic therapy has yet to be proved beneficial. A discussion of the newer as well as some traditional therapies is presented.The approach to treating the patient with gastrointestinal (GI) bleeding is changing with newer diagnostic techniques, pharmacotherapeutics, and technologic advances. Despite recent progress, GI bleeding is still a major cause of morbidity and mortality. As many as 10% of patients admitted to hospitals with GI bleeding die from the bleeding or its complications. It is hoped that some of the more recent additions to the therapeutic armamentarium will reduce this high mortality rate. The benefits of traditional methods of treatment as well as newer modes of therapy are discussed. AssessmentMonitoring the patient's vital signs is the most important means of assessing the degree of bleeding. The rate of bleeding as well as the volume of blood loss determines changes in vital signs. Patients may . lose up to 10 to 15 % of their blood volume without a change in pulse or blood pressure. However, with extremely rapid bleeding, a loss of as little as 10% of blood volume can result in clinical signs of shock. Generally, orthostatic changes in pulse and blood pressure occur with a 15 to 20% loss of circulating volume. Shock is almost invariably present when the patient loses more than 30% of the blood volume.When hemodynamic parameters are available, the first sign of bleeding is an increase in the pulmonary artery pressure [1]. Central venous pres-_ sure, pulmonary capillary wedge pressure, and arterial pressure were less reliable measures of blood loss in patients studied before, during, and after hemorrhage. When large volumes of replacement fluids are needed to stabilize the patient, central monitoring is required. Patients who are hemodynamically unstable after initial fluid replacement should also be monitored with at least a central venous catheter. Although a single measurement of central venous pressure may not be helpful, continuous readings can help gauge fluid replacement.