1. “I knew that he had a history of esophageal varices, buthe was so stable that I admitted him to the medical floor to await endoscopy.”
Esophageal varices that have recently bled have a high risk of rebleeding; therefore, patients should be admitted to a monitored or intensive care area until endoscopy has been performed. Once unleashed, the bleeding from esophageal bleeding can be brisk and can quickly result in hemodynamic instability.
2. “He had some abdominal pain in addition to vomiting blood. I just figured that the pain was due to the forceful vomiting.”
Patients with peptic ulcers can have those ulcers perforate, and the patient will then require emergent surgery. Failure to consider perforation in the differential diagnosis of abdominal pain in a patient with hematemes is will result in a delay in the diagnosis of a surgical abdomen. A bad patient outcome is likely.
3. “Although that 10-month-old had stool that was positive for occult blood, he looked great. What do you mean, he ended up in the hospital?”
Pediatric patients typically have different causes of GI bleeding than adults. Infants with GI bleeding may have conditions such as intussusception that are not seen in adults.
4. “I don’t change patients’ medications. I leave that up to the primary doctor. Besides, she was only taking ibuprofen.”
Young patients who appear to have minor GI bleeding should stop taking NSAIDs. Their seemingly minor problem may progress if modifiable risk factors for GI bleeding are not addressed.
5. “How could he have had a heart attack? He presented with some relatively mild GI bleeding!”
Anemia may sufficiently lower the oxygen-carrying capacity of the blood of a patient with pre-existing coronary artery disease to the point that myocardial ischemia or infarction develops. Since there are obvious problems with the administration of aspirin, heparin, thrombolytics, and other treatments for myocardial infarction in the setting of GI bleeding, it is better to treat mild anemias with the transfusion of packed red blood cells before myocardial effects occur.
6. “How could he have died? He just had a little bright redblood per rectum. I knew he had had an abdominal aortic aneurysm repair in the past, but he was going for colonoscopy first thing in the morning. ”
Some patients are at very high risk for complications associated with GI bleeding. The most lethal is an aortoenteric fistula. Although this can be a primary process, it is more commonly seen in patients who have undergone vascular grafting of their aorta in the past.
7. “What do you mean, she’s back in the intensive care unit? I sent her home. Sure, she had a little bit of a fast heart rate. I thought she was just anxious about having vomited blood. She was the nervous type.”
Supine tachycardia places a patient at high risk for rebleeding and complications. Missing a simple warning sign like this—especially one that’s almost always well-documented in the medical record—is just asking for trouble.
8. “He had a hemorrhoid. I just figured that that was where the blood was coming from.”
Assuming that a distal site is the cause of the bleeding without placing this information in the context of the overall clinical picture can be very dangerous. Many patients have external hemorrhoids. This finding, by itself, does not mean that the hemorrhoid is the cause of the bleeding. A much more ominous site may be lurking proximal to an external hemorrhoid.
9. “I know that he was unconscious, but since he had stool that was positive for occult blood, I just paged the gastroenterologist to have him scoped.”
Unless the patient has hepatic encephalopathy or is in profound hemorrhagic shock, minor GI bleeding is probably not the cause of altered mental status. Other etiologies must be entertained. Shock from any cause can cause a decrease in the blood flow to the intestines and lead to minor GI bleeding as a concomitant effect. Assuming that the major problem is GI bleeding may delay the identification of the true underlying emergency condition.
10. “I thought that I would let the endoscopist get a good night’s rest.”
In any patient with GI bleeding that is anything other than trivial—and certainly in high-risk patients—coordinated care with a gastroenterologist experienced in endoscopy is critical. Close consultation and prompt endoscopy can be life-saving.