Orifice Bleeding

[thegenius]

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Just thinkin about this.....and I think this ought to be a rhetorical question.

Why are we docs so quick to discharge vaginal bleeding and hematuria, but we are so fearful of rectal bleeding and admit them so readily?

I discharged two hematurias last night and didn't even flinch with my decision making. But rectal bleeding in anyone > 40....oh boy first thing I check is whether GI is even on, and who the hospitalist is, and whether I'm going to get pushback from the hospitalist. LOL

 

[deleted109597]

One reason it is exceedingly rare to have life threatening vaginal or urethral bleeding. It's rare for rectal bleeding too, but higher than the others. But I send rectal bleeding home pretty often as well.

 

[Rendar5]

If patient has a large bleed urologically they’re usually being admitted for CBI since they’ll clot and obstruct. Most hematuria cases are blood tinged urine. Just that blood tinged can be quite red when it comes to urine.

 

[betamale]

One reason it is exceedingly rare to have life threatening vaginal or urethral bleeding. It's rare for rectal bleeding too, but higher than the others. But I send rectal bleeding home pretty often as well.

My last vag bleeder went into shock and needed emergent surgery and last hematuria needed to have CBI for 2 days transfused 3 PRBCs and last nosebleeder needed embolization by IR. Different gradients of severity I guess; as long as not on blood thinners, Hgb stable, PCP is accessible, and no obvious surgical issues, may potentially go home.

Are you guys admitting posterior nosebleed with posterior nasal packing?

I have been ordering CTs on these a lot recently though since the most recent hematuria had possible early colovesical fistula, rectal bleeders have diffuse colitis.

I sent home 3 rectal bleeders last night.

 

[BoardingDoc]

But rectal bleeding in anyone > 40....oh boy first thing I check is whether GI is even on, and who the hospitalist is, and whether I'm going to get pushback from the hospitalist. LOL

I assume this is case by case for you? For me, suspected UGIB gets admitted most of the time. LGIB goes home most of the time unless on thinners, unstable, actively bleeding between BMs, can't get reliable followup etc etc etc. That said, I would say that 80-90% of my over 40 LGIB pts go home.

 

[deleted109597]

Are you guys admitting posterior nosebleed with posterior nasal packing?

100% of them.
It's unlikely to stop on its own, everybody that has that bleed is usually on bloodthinners, and then there's the vagally mediated arrhythmias that kill them.
So yeah, they all get admitted.

 

[WilcoWorld]

Are you guys admitting posterior nosebleed with posterior nasal packing?

Heck yes.

Anterior is a different story.

 

[deleted836128]

I admit all posterior nosebleeds with the posterior packing.

 

[betamale]

I admit all posterior nosebleeds with the posterior packing.

Lol, yup redundant, k, I'm not crazy then thx

 

[VisionaryTics]

Lol, yup redundant, k, I'm not crazy then thx

Posterior packs also have risk of nasocardiac reflex with bradycardia and hypotension. Patients should be on telemetry if true posterior pack is in - ENT.

 

[TooMuchResearch]

Show of hands:
Who's seen someone die from a vagal response during NG placement?
*raises hand*

 

[thegenius]

I assume this is case by case for you? For me, suspected UGIB gets admitted most of the time. LGIB goes home most of the time unless on thinners, unstable, actively bleeding between BMs, can't get reliable followup etc etc etc. That said, I would say that 80-90% of my over 40 LGIB pts go home.

Yea it’s case by case.....but like a lot of things it’s hard to get people follow up, people don’t want to take care of themselves, and maybe it’s our group there is just a reflex to admit rectal bleeding vs. the other ones. I dunno

 

[namethatsmell]

I assume this is case by case for you? For me, suspected UGIB gets admitted most of the time. LGIB goes home most of the time unless on thinners, unstable, actively bleeding between BMs, can't get reliable followup etc etc etc. That said, I would say that 80-90% of my over 40 LGIB pts go home.

Really?

90%+ of my older LGIBs get admitted which seems to be par for the course in all the places I've worked.

What kind of follow up do you have for your folks?

 

[thegenius]

100% of them.
It's unlikely to stop on its own, everybody that has that bleed is usually on bloodthinners, and then there's the vagally mediated arrhythmias that kill them.
So yeah, they all get admitted.

Sometimes it’s hard to know if it’s truly posterior or just somewhere else than kesselbach’s plexus. Unless you have fancy cameras....one can see only so far in the nose. If I'm putting in a posterior packing (which is very rare...I always start with anterior packing) then I'm definitely watching them in the ED and they probably get admitted. I can't remember the last time I've admitted an undifferentiated epistaxis requiring posterior packing as it's very rare.

We do have a few patients who come in with routine bleeding from a posterior source because they have hereditary telangectiasias in the nose that bleed from time to time, and that guy gets admitted everytime anyway so I'm not counting him

Show of hands:
Who's seen someone die from a vagal response during NG placement?
*raises hand*

not only not died, no hypoxia, no arrhythmias, no nothing besides screaming.
there isn't even hypoxia when the tube ends up in the lungs!



This is from uptodate:
COMPLICATIONS — A retrospective review of 250 patients hospitalized for epistaxis (including both anterior and posterior bleeds) found a 3 percent complication rate [14]. Complications included synechiae (intranasal adhesions), aspiration, angina, myocardial infarction, and hypovolemia.

The risks of posterior packing do NOT include the hypothetical "nasopulmonary reflex," which was once believed to account for hypoventilation and decreased arterial oxygen tension in patients with posterior nasal packs, leading to recommendations for early surgery [74]. Studies have failed to identify physiologic changes attributable to posterior packing. As examples, one report of 10 healthy volunteers who underwent posterior nasal packing found no changes in pulmonary or cardiac function [75], and a prospective study of 19 hospitalized patients with posterior packing who were observed with continuous pulse oximetry for a total of 1200 patient-hours found only two episodes of transient desaturation, both of which were attributable to other causes [43].

 

[betamale]

Show of hands:
Who's seen someone die from a vagal response during NG placement?
*raises hand*

I had someone code with rhinorocket placement once

 

[BoardingDoc]

Really?

90%+ of my older LGIBs get admitted which seems to be par for the course in all the places I've worked.

What kind of follow up do you have for your folks?

Most of my patients have pretty good outpt followup either through their PCP or directly with GI. That said, I think we probably have more similar numbers than you think. Maybe 60% of my older LGIB patients get admitted. That said, I don't consider 40+ "older" and the 40, 50, 60 yr old crowd is the majority of my lower bleeders and can go home for outpt followup. We used to admit these people all the time during residency too until we started talking to the GI folks and they asked us why. If they aren't hemorrhaging, their HCT is fine, they're stable and it's only with BMs... why do they need an admission?

 

[VisionaryTics]

Sometimes it’s hard to know if it’s truly posterior or just somewhere else than kesselbach’s plexus. Unless you have fancy cameras....one can see only so far in the nose. If I'm putting in a posterior packing (which is very rare...I always start with anterior packing) then I'm definitely watching them in the ED and they probably get admitted. I can't remember the last time I've admitted an undifferentiated epistaxis requiring posterior packing as it's very rare.

We do have a few patients who come in with routine bleeding from a posterior source because they have hereditary telangectiasias in the nose that bleed from time to time, and that guy gets admitted everytime anyway so I'm not counting him




not only not died, no hypoxia, no arrhythmias, no nothing besides screaming.
there isn't even hypoxia when the tube ends up in the lungs!



This is from uptodate:
COMPLICATIONS — A retrospective review of 250 patients hospitalized for epistaxis (including both anterior and posterior bleeds) found a 3 percent complication rate [14]. Complications included synechiae (intranasal adhesions), aspiration, angina, myocardial infarction, and hypovolemia.

The risks of posterior packing do NOT include the hypothetical "nasopulmonary reflex," which was once believed to account for hypoventilation and decreased arterial oxygen tension in patients with posterior nasal packs, leading to recommendations for early surgery [74]. Studies have failed to identify physiologic changes attributable to posterior packing. As examples, one report of 10 healthy volunteers who underwent posterior nasal packing found no changes in pulmonary or cardiac function [75], and a prospective study of 19 hospitalized patients with posterior packing who were observed with continuous pulse oximetry for a total of 1200 patient-hours found only two episodes of transient desaturation, both of which were attributable to other causes [43].

Those two studies encompass 29 total people, 10 of which were healthy volunteers. Many posterior epistaxis patients are old rickety people on blood thinners who have fallen.

I've had many patients have vagal episodes during packing placement, removal, suctioning out the nose, removing nasal casts, etc.

Not something to mess with.

Personally, in my practice, I'll just take them to the OR as soon as reasonable for sphenopalatine artery cautery rather than have them miserable with posterior pack for days.

 

[namethatsmell]

Most of my patients have pretty good outpt followup either through their PCP or directly with GI. That said, I think we probably have more similar numbers than you think. Maybe 60% of my older LGIB patients get admitted. That said, I don't consider 40+ "older" and the 40, 50, 60 yr old crowd is the majority of my lower bleeders and can go home for outpt followup. We used to admit these people all the time during residency too until we started talking to the GI folks and they asked us why. If they aren't hemorrhaging, their HCT is fine, they're stable and it's only with BMs... why do they need an admission?

Sounds like you have a nice setup with your GI on board. Not the case at my shops or the places I've worked where their practice patterns are all over the place. I still have one GI who insists on NGs for all possible UGIBs...

 

[Groove]

All my posterior nasal packers get admitted but damn....these are really rare cases for me. I can' remember the last time I had a true posterior nose bleed. I see anteriors all the time but most of those always go home.

GI bleeds....these are really case dependent. I'm not talking bleeding hemorrhoids, gastritis with bloody mucous when retching or the nontender pt with UC having mildly heme positive stool. I'm talking melena or moderate hematochezia and/or hematemesis with or without significant comorbities. With most of the cases they get admitted. This has also been true in the majority of places where I've worked. If there is a borderline case where I think they can go home, I virtually always discuss it with GI and document the consult. Most get admitted though.

Vaginas....meh. What can I say, those things bleed a lot.

 

[southerndoc]

I use a lot of the combo 7 cm ant/post Rhinorockets. I send nearly all home unless they need both nares packed (rare, but happens). Not sure why, but my shop sees a lot of epistaxis patients. Then again, at our volume we see a lot of everything (think we saw 165,000 last year).

 

[turkeyjerky]

All my posterior nasal packers get admitted but damn....these are really rare cases for me. I can' remember the last time I had a true posterior nose bleed. I see anteriors all the time but most of those always go home.

GI bleeds....these are really case dependent. I'm not talking bleeding hemorrhoids, gastritis with bloody mucous when retching or the nontender pt with UC having mildly heme positive stool. I'm talking melena or moderate hematochezia and/or hematemesis with or without significant comorbities. With most of the cases they get admitted. This has also been true in the majority of places where I've worked. If there is a borderline case where I think they can go home, I virtually always discuss it with GI and document the consult. Most get admitted though.

Vaginas....meh. What can I say, those things bleed a lot.

Yeah, I think it depends on exactly what you're calling a GI bleed. I send home the vast majority of my "upper GI bleeds" because a lot of patient claim to be "vomiting blood".

I'll occasionally send home a true UGIB with a low GBS score and good f/u. I rarely send home true LGIBs though (but again, I'm talking about hematachezia or melena, not heme+ stool or streaks of blood on TP) since I find it so much harder to quantify blood loss.

 

[RoyBasch]

My take:

GI:
Legit UGIB has the potential to be very serious and accelerate rapidly. I almost always admit tele vs. ICU pending hemodyanics. Exception is if I essentially don't really believe the patient (seems they are exaggerating more garden variety nausea, vomiting, diarrhea, abdominal pain symptoms. ["It's so bad I vomited blood once!"])and I can document a Glasgow Blatchford Bleeding Score of 0 (99% + Negative predictive value for death, bad outcome, or requiring urgent endoscopy).

LGIB, depends on many factors, history (does it seem like it's just an ano-rectal issue with blood streaked turds with painful hard defecation) or is it really legit hematochezia. Of note, I would say if the patient is describing melena, I put them in the UGIB category not LGIB. How long has it been going on for (5 days and hgb is still 15?). Some combination of age, comorbidity, history, onset, hemodynamics plus Hgb/Hct, and the presence of coagulopathy or anticoagulation factors in. It's kind of a red flag-type dispo in my opinion. If red flags appear, the pt gets admitted for telemonitoring and serial H/H. Absence of any red flags and can go home with GI follow up. I do inform every one of these patients even if I suspect only an ano-rectal problem that they need follow up with GI and possibly a colonoscopy to rule out malignancy. I would say I admit 25-40% (most of the pt's I see are on the elderly side and many are anticoagulated or dual anti-plateleted).

Epistaxis:
anterior:
almost always dc'd except for rare situation where cannot get hemorrhage controlled or pt requiring bilateral pack. Agree with comments above patients with bilateral pack need telemonitroing because they are at high risk for apnea and vagal episodes.

posterior:
must admit, patient will need a procedure unless ruled out by ENT. If it's a true posterior bleed, they are probably bleeding rom an arterial source such as the sphenopalatine artery. These patients get a stat ENT consult and either go to the OR with ENT or for embo with IR.

Gyn:
Can be very variable, I think the good thing about these is with a pelvic exam you can directly visualize how brisk the bleeding is unlike GI bleeds where we--without endoscopy--are more indirectly estimating the amount of blood loss and rate based on hemodynamics, labs, patient appearance, and patient report. 90% go home. 10% or less admitted. Of those admitted the majority are bleeding so briskly they need emergent operative management such as a D&C.

urinary bleeding:
Rarely very brisk, I would say 95% go home with documented follow up plan with urology to rule out malignancy . The concern in these patients is not really exsanguination but rather urinary retention from clots. However, if they have gross hematuria with clots that does not clear with some reasonable bladder irrigation in the ER, then they need to be admitted for continuous bladder irrigation and urgent urology consultation and cystoscopy to evaluate and manage source of bleeding.
It is very rare (I've never personally seen it) but I suppose a uretero-vascular fistula could cause truly life threatening urinary hemorrhage. This patient would be an ICU admit by way of the OR with combined stat consults to vascular and urology.