Which of these GI Bleeds would you send home?

[WilcoWorld]

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I've seen a lot of variability in how people handle GI bleeds. I'm curious to see what the spectrum on SDN is. Which of these would you send home?

1) Healthy 30 something with stable vitals who complains of blood streaked emesis after wretching that was preceeded by 3 days of binge drinking. Labs and exam are normal - except for mildly elevated AST/ALT. Rectal and NG lavage are negative for blood. Follow up reallistically wont occur for 3+ weeks, if ever.

2) 50's year old with a history of HTN who reports melana. Vitals are normal, rectal is negative, Hgb = 13.0, NG lavage is negative. Hgb gets re-checked and is 13.2 4 hours after the initial labs were checked. Pt has a PMD who she thinks she can see this week, but the PMD isn't calling you back.

3) 25 yo who, aside from being morbidly obese has no medical problems. Complains of "the toilet being full of blood". Vitals, labs and exam are normal, and, in spite of doing an exam you can't find a hemorrhoid. Pt has no PMD, is from out of town, and rolls his eyes when you start talking abobut follow up.

Yes, I know that #1 is probably Mallory-Weiss and that #3 is probably an internal hemorrhoid that I just can't see. I'm not asking for a diagnosis - I'm asking what you'd do with these patients in your ED.

Thanks.

 

[name?]

you could probably make a decent argument that all three could be sent home. No anticoagulation, stable vitals and normal hemoglobin with no e/o active bleeding? Seems very reasonable. Of course, a return if worsening/syncope/DOE conversation would follow, but it seems fair to give the top 2 a PPI/H2 blocker and let them go. If they don't seem like they'll return, then I'd consider admitting.

 

[xaelia]

Home, all of them. No NG lavages, either.

 

[txterp98]

Agreed. All 3 go home.

 

[deleted109597]

Yep, they all go home.

 

[Rendar5]

I'd consider keeping 3 if it were an older patient.

 

[Groove]

I've seen a lot of variability in how people handle GI bleeds. I'm curious to see what the spectrum on SDN is. Which of these would you send home?

1) Healthy 30 something with stable vitals who complains of blood streaked emesis after wretching that was preceeded by 3 days of binge drinking. Labs and exam are normal - except for mildly elevated AST/ALT. Rectal and NG lavage are negative for blood. Follow up reallistically wont occur for 3+ weeks, if ever.

2) 50's year old with a history of HTN who reports melana. Vitals are normal, rectal is negative, Hgb = 13.0, NG lavage is negative. Hgb gets re-checked and is 13.2 4 hours after the initial labs were checked. Pt has a PMD who she thinks she can see this week, but the PMD isn't calling you back.

3) 25 yo who, aside from being morbidly obese has no medical problems. Complains of "the toilet being full of blood". Vitals, labs and exam are normal, and, in spite of doing an exam you can't find a hemorrhoid. Pt has no PMD, is from out of town, and rolls his eyes when you start talking abobut follow up.

Yes, I know that #1 is probably Mallory-Weiss and that #3 is probably an internal hemorrhoid that I just can't see. I'm not asking for a diagnosis - I'm asking what you'd do with these patients in your ED.

Thanks.

1) PPI or H2 and to the house with instructions to f/u with PCP asap for re-check, I'd prob write on there recommendations for PCP to repeat LFTs and consider hepatitis panel, instructions to decrease EtOH use but not abruptly stop if chronic user. Not my problem if he origami's the D/C instructions into a Budweiser coaster and never follows up. Dx: alcoholic gastritis vs MWT, n with v

2) D/C home, f/u tomorrow with PCP or return to ED for re-check VS, rectal and HCT and try to contact PCP again at that point, just to be err on the side of caution. PPI/H2. Dx: normocytic(MCV?) anemia

3) Rectalize for FOBT, anoscopy to identify the internal hemorrhoid and make sure it's just oozing so I can document a good reason for a CC of "toilet being full of blood" (anoscopy bills nice too and is quick), then d/c home on stool softeners and dietary instructions, f/u with PCP at earliest convenience, return for any worsening of sx. See ya. Dx: Internal hemorrhoid

In short... all go home though.

 

[Interpolfanclub]

Home, all of them. No NG lavages, either.

This.

 

[Cerberus]

I've seen a lot of variability in how people handle GI bleeds. I'm curious to see what the spectrum on SDN is. Which of these would you send home?

1) Healthy 30 something with stable vitals who complains of blood streaked emesis after wretching that was preceeded by 3 days of binge drinking. Labs and exam are normal - except for mildly elevated AST/ALT. Rectal and NG lavage are negative for blood. Follow up reallistically wont occur for 3+ weeks, if ever.

2) 50's year old with a history of HTN who reports melana. Vitals are normal, rectal is negative, Hgb = 13.0, NG lavage is negative. Hgb gets re-checked and is 13.2 4 hours after the initial labs were checked. Pt has a PMD who she thinks she can see this week, but the PMD isn't calling you back.

3) 25 yo who, aside from being morbidly obese has no medical problems. Complains of "the toilet being full of blood". Vitals, labs and exam are normal, and, in spite of doing an exam you can't find a hemorrhoid. Pt has no PMD, is from out of town, and rolls his eyes when you start talking abobut follow up.

Yes, I know that #1 is probably Mallory-Weiss and that #3 is probably an internal hemorrhoid that I just can't see. I'm not asking for a diagnosis - I'm asking what you'd do with these patients in your ED.

Thanks.

Well, I probably wouldn't have lavaged any of them to begin with since it is mostly useless and I only do it if GI absolutely insists but since you did, and it was negative, and in light of the rest of the history, I'd definitely send 1&2 home.The first has a pretty classic hx of mallory weiss and assuming everything else looked ok and they weren't vomitting blood in the ED, i'd probably be ok with sending them home. For the second, a hx of melana with heme negative stool (assuming you were able to get an actual stool sample) really drops my index of suspicion for significant gi bleed. Given at my shop, where we have GI fellows, I'd probably consult on all them prior to discharge.

 

[Groove]

It would also depend on the anemia... If it's microcytic and she's drinking lots of pepto-bismol, has a licorice fetish, etc.. then I'd be much less suspicious, but my opinion is that anybody with a low HCT with unknown etiology, needs a close f/u and if it can't be by her PCP then she should come back to the ED, but don't really see a reason why she can't sleep in her own bed tonight.

 

[WilcoWorld]

Thanks for the responses folks. I don't have "the right answer" to these cases, but I will say that I took pt #2 from a case I saw about a month ago as a bounce-back. Pt had presented as described & was dc'd 2 days prior by one of my colleagues (the anemia was normocytic at that time). I saw the pt when she came back after a syncopal event, was hypotensive (SBP in the 80's) and had a Hgb = 8. Of course, she hadn't yet made it to see her PCP, much less GI.

 

[BF2BC EMT]

Send #3 home with instructions to hit the gym

 

[deleted109597]

Thanks for the responses folks. I don't have "the right answer" to these cases, but I will say that I took pt #2 from a case I saw about a month ago as a bounce-back. Pt had presented as described & was dc'd 2 days prior by one of my colleagues (the anemia was normocytic at that time). I saw the pt when she came back after a syncopal event, was hypotensive (SBP in the 80's) and had a Hgb = 8. Of course, she hadn't yet made it to see her PCP, much less GI.

Yep. We can't fix the world.
Honestly, if you had admitted all 3, they all probably would have gone home anyway the next day if their labs stayed stable.
I would be unable to convince any of the medicine docs to admit those patients with all of the objective and subjective findings you laid out.

 

[TrumpetDoc]

Yep. We can't fix the world.
Honestly, if you had admitted all 3, they all probably would have gone home anyway the next day if their labs stayed stable.
I would be unable to convince any of the medicine docs to admit those patients with all of the objective and subjective findings you laid out.

This is so true!
I agree would be really hard to sell any if the above in many places.
I think of documentation is well done as to your MDM then there shouldn't even be a problem.

Admitting for the doesn't have follow up idea, while makes us feel good/safe and feel like we are perhaps really helping the patients...as above a lot of the times at least where I am, nothing gets done, they are summarily seen and discharged...sometimes with a bitter sarcastic statement to the tune of "sure, I'll admit your transfer of liability patient..."

 

[paramed2premed]

You can also use a Blatchford score to help make yourself feel better about sending someone home. It's a rating using history, vitals, and labs to judge a patient's risk of UGIB. A score of zero is thought to be low enough to send a patient home w/o endoscopy, at least in the U.K.!

Check it out at UTD, medcalc, whatever.

As for pt #1, the Blatchford score wouldn't help, as melena gets you a point.

 

[Mastodynia]

They can all go home, and should all go home.

#2 bouncing back is only a bad thing for the initial doc if there was more information like the patient on coumadin/plavix, had 4 melanotic stools, light headed/near syncope, recent procedure, or sometihng to suggest they may be more likely to have a significant bleed.

Patients are instructed to return if worse and this one did. Probably waited too long if the Hb went to 8. "Return if your stools continue to be bloody or you develop light headedness, shortness of breath, weakness, or feel like you might pass out". In the chart: "patient is demonstrating normal vital signs after five hours of observation in the ED, no further bleeding, not on blood thinners, is OK to go home and follow-up"