Gastrorrhagia as Early as 1500

¶ … Gastrorrhagia As early as 1500 BC, Egyptians recognized that gastric hemorrhage that could result from ulcers (Thompson 1996). Today, gastrorrhagia, or a gastric hemorrhage or bleeding, represents a challenge for the healthcare provider because of the serious implications of failing to provide appropriate and timely interventions.

To this end, this paper provides an overview of the identification of an imaginary patient presenting at the emergency department with gastrorrhagia, an analysis of the patient's pathophysiological response to the condition, and a discussion and analysis of the features of the holistic assessment this patient requires to elicit this problems using history taking or triage processes.

The justification of the planning and implementation of appropriate treatment plans and interventions used is followed by a discussion of health education advice required and an analysis of the nurse's role within the multidisciplinary team. Finally, a summary of the research and salient recommendations are provided in the conclusion. Review and Discussion Identification of Patient Presenting at the ER with Gastrorrhagia.

Gastrorrhagia, or a gastric hemorrhage or bleeding, can be caused by a wide range of conditions, but immediate (same day) specialist referral is indicated for patients presenting with dyspepsia together with significant acute gastrointestinal bleeding (Clinical Guideline 17: Dyspepsia 2004).

According to the current NICE guidelines, urgent specialist referral for endoscopic investigation is indicated for patients of any age that are diagnosed with dyspepsia when they present with any of the following: (a) chronic gastrointestinal bleeding, (b) progressive unintentional weight loss, - progressive difficulty swallowing, (d) persistent vomiting, (e) iron deficiency anaemia, or (f) epigastric mass or suspicious barium meal (Clinical Guideline 17: Dyspepsia 2004).

Current practices using endoscopic treatment typically include the following: Thermal - heater probe or multi-polar electrocoagulation; Injection - adrenaline (1:10,000-100,000); Alcohol 98%; Sclerosants - ethanolamine or 1% polidoconal; Procoagulants - thrombin or fibrin glue; and, Mechanical - clips, sutures or staples (Upper Gastrointestinal Bleeding, 2006). If bleeding is controlled, it is recommended that the endoscopy be performed again at 24 hours; however, if rebleeding occurs, the patient should be referred for surgery (in high-risk cases) or have one more attempt at endoscopic treatment and then refer for surgery if unsuccessful (in low-risk cases).

According to the guidance provided by PatientPlus, surgery is currently the most effective way of preventing and treating bleeding, but the invasive intervention has a high incidence of morbidity and mortality (Upper Gastrointestinal Bleeding, 2006). If the patient presents at the emergency room with no obvious causes of bleeding, the following incremental steps are recommended: Minor bleed - manage conservatively and discharge early Major bleed - consider angiography, colonoscopy or operative entroscopy.

Prognosis 10% hospital mortality but many of these are older patients with advanced cardiovascular, respiratory or cerebrovascular disease (Upper Gastrointestinal Bleeding, 2006). Analysis of the Patient's Pathophysiological Response. The most common cause of bleeding in the upper gastrointestinal tract is a peptic ulcer that has a history of proven ulcer or ulcer-like dyspepsia in approximately 80% of the cases; the condition is commonly associated with use of aspirin or NSAID (Upper Gastrointestinal Bleeding, 2006).

Less common is infection with Helicobacter pylori in bleeding ulcers, a condition associated with uncomplicated cases; in more severe cases, bleeding is caused by erosion of the artery by the ulcer with the severity depending on the size of ulcer and the defect (Upper Gastrointestinal Bleeding, 2006).

In instances where the ulcer is greater than 1mm in size, the ulcer will likely be unresponsive to endoscopic treatment nor will the ulcer stop bleeding spontaneously; furthermore, large ulcers in the posterior part of the duodenal cap can erode the gastroduodenal artery, resulting in rapid bleeding but bleeding from gastric erosions, vascular malformations or oesophagitis normally resolves spontaneously (Upper Gastrointestinal Bleeding, 2006).

Patients suffering from gastrorrhagia may experience so-called Malory-Weiss tears which are caused by the retching typically associated with alcohol abuse and other signs of gastro-intestinal disease; in most cases, bleeding stops spontaneously and bleeding from upper gastro-intestinal neoplasm is not normally severe and is rarely fatal absent other comorbidities (Upper Gastrointestinal Bleeding 2006). Likewise, oesophageal varices are fairly uncommon; however, such varices can frequently cause severe bleeding and have been associated with other features of liver disease such as ascites, jaundice, splenomegaly and fluid retention (Upper Gastrointestinal Bleeding 2006).

In those patients that have undergone aortic aneurysm surgery, consideration should be given to an aortoduodenal fistula as the source if the patient develops profuse bleeding (Upper Gastrointestinal Bleeding, 2006).

If there is a variceal haemorrhage, current guidelines indicate the first use of vasoactive drugs such as terlipressin; if this intervention is not effective, a modified Sengstaken-Blakemore (Minnesota) tube is recommended but this intervention is merely a holding technique intended to control active bleeding until more definitive treatment (typically with endoscopy) can take place; after the varices have been removed, the patient should have portal pressure reduced with the use of propanolol in order to reduce risk of subsequent re-bleeding, but again, if this is not effective, current best practices call for the use of TIPPS (Kullavanuaya, Manotaya, & Thong-Ngam et al.

2001). Discussion and Analysis of the Features of the Holistic Assessment.

To accomplish a holistic assessment of the patient presenting with symptoms of gastrorrhagia, beyond the traditional triage data collected for such patients concerning diet and substance abuse (Govini, Mann & Smart 2003), the National Health Service (NHS) recommends the following factors be included: Review medications for possible causes of dyspepsia (for example, calcium antagonists, nitrates, theophyllines, bisphosphonates, corticosteroids and non-steroidal anti-inflammatory drugs (NSAIDs) for those patients requiring referral, suspend NSAID use; and, Consider the possibility of cardiac or biliary disease as part of the differential diagnosis (Clinical Guideline 17: Dyspepsia 2004).

Justification of the Planning and Implementation of Appropriate Treatment Plans/Interventions. The initial medical intervention commonly used to treat suspected variceal bleeding is to administer intravenous octreotide, a procedure that has been shown to safely and effectively control variceal bleeding by regulating vascular contraction and decreasing the pressure in the portal venous system (Barve et al. 2003; Garcia & Sanyal 2001).

The method that has proven most effective in controlling acute variceal hemorrhage is the endoscopic banding of the esophageal varices; however, when banding is not possible or advisable for whatever reason, Barve and his colleagues advise that injecting the varices with scarring substances can also be used (2003). According to these authors, "Because cirrhotic patients with gastrointestinal bleeding are at high risk of developing serious infections, a prophylactic 7-day course of the antibiotic norfloxacin is recommended" (p. 247).

Patients that have experienced their first episode of variceal bleeding are at an 80% risk of experiencing bleeding again within the next 3 years (Barve et al. 2003). Moreover, treatment with nonselective beta blockers, in a fashion comparable to primary prophylaxis, should be provided to patients that are not currently receiving these drugs; in addition, those patients that are unable to tolerate the medication, or for whom beta blockers are contraindicated, can be treated with repeated banding of the varices at 10- to 14-day intervals (Barve et al. 2003).

Those patients that continue to rebleed in spite of therapy with beta blockers and endoscopy should be considered for the TIPS procedure or surgery performing a distal spleno-renal shunt, a procedure that decreases the high pressure of the veins by connecting the high-pressure vessels to the inferior vena cava system, which is a low-pressure system (i.e., it carries oxygen-poor blood to the heart from the lower half of the body) (Barve et al. 2003).

According to current Guidance for General Practitioners and Primary Care Teams for Improving Outcomes in Upper Gastro-intestinal Cancers, these procedures should be provided by the Upper Gastro-intestinal Diagnostic Team at a local District General Hospital; however, they may also be provided within primary care by suitably trained endoscopists. According to "Improving Outcomes in Upper Gastro-intestinal Cancers, "Most patients with gastric cancer suffer from dyspepsia, but there is no clear symptom pattern that is peculiar to this disease and very few people with dyspepsia have cancer.

More advanced tumours close to the stomach exit (pylorus) tend to cause nausea and vomiting, whilst tumours near the entrance (cardia) cause problems with swallowing (dysphagia)" (p. 2). Furthermore, some patients may experience a loss of appetite, a sense of fullness, or nausea, which have been identified as other common symptoms, and anaemia and blood in stools are frequent laboratory findings; more extensive disease can cause anorexia, pain and weight loss and the diagnosis can be confirmed by endoscopy and biopsy (Improving Outcomes in Upper Gastro-intestinal Cancers, 2006).

In spite of the fact that TIPS is more effective than endoscopic therapy in decreasing rebleeding from esophageal varices (19% rebleeding with TIPS vs. 47% with endoscopic therapy), fully 33% of these patients will develop hepatic encephalopathy following TIPS, but this intervention has not been shown to affect survival rates (Barve et al. 2003). These authors add that, "Because of the problems with encephalopathy and the cost of TIPS, this approach usually is reserved as rescue therapy.

Liver transplantation is, of course, definitive therapy and should be considered for all of these patients" (Barve et al. 2003, p. 247). The use of NSAID has been associated with increased risks of gastrointestinal bleeding in unselected patients, approximately five-fold for musculoskeletal pain and two fold for secondary prevention of cardiovascular disease with low-dose aspirin (Clinical Guideline 17: Dyspepsia 2004).

Therefore, depending on the level of pain management required, a simple analgesic that can be used for pain management is paracetamol; this preparation does not cause bleeding of the stomach and it has been found to be highly effective in relieving mild to moderate pain; furthermore, it can be purchased without a prescription from chemists and supermarkets (Henderson & Wood 2000). Discussion of Health Education Advice Required. The U.K.

Department of Health recommends the following educational advice and support for people suffering from gastrointestinal bleeding: Patients and their relatives should be offered as much information as they want. GPs should ask what they would like to know, and give unambiguous answers to their questions. Information should be clear, full, and prompt, and should be available in both verbal and written forms.

It should include information about the disease, diagnostic procedures, the aims and anticipated benefits of treatment, and realistic estimates both of the probability of success and potential adverse effects. Specialist guidance should be available for patients from a dietitian, to advise on nutrition and minimising problems with eating, and to help those who have undergone resection to cope with post-surgical syndromes.

Many patients and carers will require both practical and social support; they should be given information about sources of help, such as local and national support groups and disability and benefits helplines. Psychological interventions such as counselling should be offered to patients who are anxious, depressed, or who have particular difficulty coping (Improving Outcomes in Upper Gastro-intestinal Cancers, 2006). Analysis of the Nurse's Role within the.