This CE activity is approved by EMS World Magazine, an organization accredited by the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS) for 1 CEU. To take the CE test that accompanies this article, go to www.rapidce.com to take the test and immediately receive your CE credit. Questions? E-mail editor@EMSWorld.com.
- Review the anatomy of the gastrointestinal tract
- Describe the characteristics of GI bleeding
- Review causes of upper GI bleeding and lower GI bleeding
- Describe the assessment of a patient with GI bleeding
- Review the prehospital management of the patient with GI bleeding
Squad 15 had just finished cleaning up from their last transport when the alert tones went off for a 42-year-old female with gastrointestinal bleeding. While responding, the two EMTs developed a plan: If the patient was actively bleeding from the rectum, Michael would put absorbent pads on the stretcher while Sarah, his senior partner, obtained vital signs and got a complete history. When the crew walked inside a very clean, modern ranch home, they were directed to a side bedroom where a frail, pale and tired-looking woman was leaning over a garbage can vomiting clots of blood. As her family explained that she had been vomiting blood for two days, Sarah and Michael had to reset in their minds how they would manage this transport. As Michael went outside to get an emesis basin, he turned to Sarah and said, "I thought dispatch said this was for GI bleeding!"
Every year, more than 300,000 patients are hospitalized with gastrointestinal (GI) bleeding1 and countless more are managed in emergency departments. More than 150 out of every 100,000 people experience some sort of GI bleeding annually. Nearly 70% of GI bleeds occur in the upper GI tract and more than 50% of all GI bleeds are caused by peptic ulcer disease. Presently, the mortality from GI bleeding is around 10%, and this rises with age as patients begin to have multiple contributing underlying conditions like hypertension, diabetes and cardiac disease. For individuals younger than age 50, however, the most common cause of GI bleeding is hemorrhoids, which, while uncomfortable, is more of a nuisance than anything else.2
It is essential for EMS providers to understand the different causes of GI bleeding to help perform a thorough patient assessment and provide accurate care. Additionally, understanding how to evaluate GI bleeding helps determine the seriousness, rate and severity of bleeding.
Anatomy of the Gastrointestinal Tract
The gastrointestinal tract, or alimentary canal, is a hollow tube that begins at the mouth and ends at the anus. Materials inside this tract are technically not inside the body, but rather inside the tube. The purpose of the GI system is to break down materials inside this tube so that usable nutrients, minerals and liquids can be removed.
Food and liquids enter the GI tract at the mouth and are passed down through the elastic but muscular esophagus, which squeezes food boluses through with rhythmic muscle contractions. The cardiac sphincter is the valve at the distal end of the esophagus and the beginning of the stomach. One of the most important purposes of the cardiac sphincter is to prevent regurgitation of food and digestive acids from entering the esophagus. Inside the stomach, food is broken down by a variety of acids and muscle contractions. The stomach itself sits just inferior to the diaphragm and is protected by the rib cage; it is also situated just behind liver's left lobe. Once solid materials are broken down in the stomach, they exit through the pyloric sphincter and enter the duodenum, the first of three sections of the small intestine. Food boluses, now called chime, move through the intestinal tract via muscular contractions called peristalsis.