Question: You are paged during your lunch break about an ICU patient with maroon stools and blood pressure of 95/60.  The 36 year old female is intubated and has no known history of liver disease.  You are told that a NG lavage is negative.  The ICU team is pressing for immediate intervention.  What is your request?

A. prep her for a colonoscopy since this is not an upper GI bleed

B. plan for EGD

C. ask for capsule endoscopy, you have over half of your sandwich left

D. follow vital signs for the next few hours and see if she stabilizes

Answer: A GI bleed in the ICU is always fraught with management dilemmas.  You must always decide: 1) is a procedure necessary? 2) if so, EGD, colonoscopy, or both? and 3) what is the appropriate timing?  This is a young patient with hemodynamic instability (hypotension); a procedure is indicated.

Just because NG lavage is negative, you have not ruled out an upper GI bleed.  A proper NG lavage should include a full liter of H2O instilled into the stomach; oftentimes the volume of H20 used is half of that, and the entire stomach is not sampled.  Secondly, if the bleeding is post-pyloric (ie. the duodenum), blood is not necessarily refluxed into the stomach and detected on lavage.

Therefore, EGD is indicated along with volume resuscitation.  If it is negative, you can do a quick flexible sigmoidoscopy with the upper endoscope, or take your time and prep the patient for a full colonoscopy. Remember, it’s usually upper GI bleeds that are life threatening, and not typically so for lower GI bleeds.  Capsule endoscopy is usually reserved for occult GI bleeding, and will usually be non-diagnostic if there is no active bleeding.  (It’s ok to finish your sandwich in any case).

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