quently administered, although they have not been shown to

b e o f any benefit in the acute setting. Proton pump inhibitors

decrease the rate of re-bleeding. Pantoprazole 80 mg N bolus

followed by 5 mg!hr infusion is recommended. Octreotide is

beneficial in decreasing the rate of bleeding, the incidence of

rebleeding, and mortality by decreasing portal hypertension.

It is particularly useful in variceal bleeding, but may also

reduce bleeding from nonvariceal sources. Administer a

50-meg N bolus followed by 50 mcg!hr N drip. Emergent

endoscopy is indicated for patients with fresh blood in the

NG aspirate and hematochezia from an upper GI source.

Patients with liver disease also benefit from early endoscopic

intervention. Surgical intervention may be required in

patients with uncontrolled hemorrhage, perforation, or

patients with liver disease and portal hypertension.

In the setting of a suspected lower GI source of bleeding,

consult gastroenterology and surgical services early in unstable patients. Diagnostic and therapeutic options include

angiography, technetium-labeled RBC scan, colonoscopy, or

surgical intervention for partial colectomy. Angiography

allows for localization and arterial embolization, whereas a

technetium-labeled RBC scan localizes the bleeding site only.

In emergent cases, colonoscopy misses the diagnosis in 40%

of cases because of poor bowel preparation. When the site of

bleeding is identified during colonoscopy, it may allow for

therapeutic interventions to stop bleeding, but is unsuccessful in 20% of cases. Surgical intervention is required in cases

of massive lower GI bleeding when other therapies fail.

DISPOSITION

� Admission

Upper GI bleed. Most patients with an upper GI bleed

require admission. Admission to an intensive care unit

(ICU) setting should be strongly considered for patients

with unstable vital signs, age > 75 years, persistent bleeding

that does not clear with NG lavage, presence of coagulopathy or severe anemia (hematocrit <20%), evidence of portal

hypertension, or unstable comorbid conditions.

Lower GI bleed. Most patients with lower GI bleeding

will require admission. ICU admission is appropriate for

unstable patients. Mortality is higher in elderly patients

with comorbidities, and these features should prompt consideration for admission to an intensive care setting.

� Discharge

Upper GI bleed. Discharge with close follow-up can be

arranged for reliable patients who meet all of the following

criteria: age <65 years, no comorbidities including coagulopathy, no significant liver disease, normal vital signs, negative

NG lavage and no melena, and a hemoglobin > 10 grnldL.

Recent clinical scoring systems (Glasgow-Blatchford bleeding

score) may help predict which patients can be safely dis ­

charged from the ED without endoscopy.

Lower GI bleed. Young stable patients with normal

hemoglobin, no active bleeding, evidence of hemorrhoids

or fissures as a possible source, and no evidence of portal

hypertension, coagulopathy, or other significant comorbidities may be discharged with close follow-up.

SUGGESTED READING

Lo BM. Lower gastrointestinal bleeding. In: Tintinalli JE,

Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD.

Tintinalli's Emergency Medicine: A Comprehensive Study Guide.

7th ed. New York, NY: McGraw-Hill, 201 1, pp. 545-548.

Overton DT. Upper gastrointestinal bleeding. In: Tintinalli JE,

Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD.

Tintinalli's Emergency Medicine: A Comprehensive Study Guide.

7th ed. New York, NY: McGraw-Hill, 201 1, pp. 543-545.

Stanley AJ, Ashley D, Dalton HR, et al. Outpatient management

of patients with low-risk upper-gastrointestinal haemor ­

rhage: Multicentre validation and prospective evaluation.

Lancet. 2009;373:42.

Intestinal O bstruction

Conor D. Schaye, MD

Col leen N. Hickey, MD

Key Points

• Intesti nal obstruction presents with acute abdominal

pain, abdominal distension, and vomiting.