Question about LGI bleed case

[al7139, ASN, RN]

Hi,

I am a nurse who works on a telly unit. We do accept medical pts if our census is low, but I do not have much experience with these cases.

I had a pt last pm that was admitted for a lower GI bleed and diarrhea. She was in her 60's, didn't have much of a med history (I think gout, smoker, and HTN). Anyway, in report I got that she was on q12 H&H, and IVF NS at 80/hr. Scheduled for a colonoscopy the next day. Bowel prep, clear liquids. Not alot of meds. Very poor appetite. Abdomen slightly distended, no pain. Weakness and dizziness. All else WNL. Vitals stable, B/P running slightly low. Any way the reporting RN told me that her H&H had dropped significantly from the night before (can't remember the exact numbers, but not critical). MD called. No orders except to continue to monitor. Did H&H at 900pm, lower than normal, but again not critical. Had had diarrhea, but no frank blood in it. At about midnight, called to room by NA, pt on toilet, some blood on bed, looked in toilet, lots of blood there and on pt. BP 105/60's pulse 131 (she's been tachy). Says shes weak and dizzy, but no more than usual. Call doc, STAT H&H, check B/P after pt gets in bed and call him w/ results. OK, B/P drops to 86/58 after pt lies down. pulse 103. H&H drpos about 2 points. Call doc, 500cc bolus and do H&H in am at 0500. Pt had 1 more apparently bloody stool, then one stool that did not appear bloody. H&H in am had risen slighltly.

My question is this: Can someone have an intermittent bleed that can cause the H&H to go up and down? What are the typical diagnoses in a pt with an on-off bleed? When I go back to work, I will see what the colo results were, but I am curious if anyone has any ideas or has seen something like this.

Thanks,

Amy

[flightnurse2b, LPN]

the only thing i can think of to cause lots of bleeding and drop in H&H that ive seen endoscopically with intermittent GI bleed is either very large and inflamed internal hemorrhoids or a mass in the colon (usually in the right colon/ileocecal area for some reason)...

[CritterLover, BSN, RN]

there may have been more over all fluid loss than blood loss.

so, even though she was bleeding some, she was dehydrating more quickly, and thus her hct went up.

a 500 cc bolus (+80 cc/hr) may not have been enough to make up for the amount of fluid she lost with the diarrhea.

i think a slow bleed can sometimes look like an intermittent bleed, because there isn't always enough blood in the stool (depending on how long it has been since they had a bm) to be very apparent.

anyway, thats my best idea.

[core0]

there may have been more over all fluid loss than blood loss.

so, even though she was bleeding some, she was dehydrating more quickly, and thus her hct went up.

a 500 cc bolus (+80 cc/hr) may not have been enough to make up for the amount of fluid she lost with the diarrhea.

i think a slow bleed can sometimes look like an intermittent bleed, because there isn't always enough blood in the stool (depending on how long it has been since they had a bm) to be very apparent.

anyway, thats my best idea.

the other thing to think about here is they are usually venous (low pressure) bleeds. you see this in ugi bleeds also. they bleed, the pressure drops, you transfuse, the pressure rises, they bleed ... you get the picture. what you were seeing is why a lot of gi bleeds in up in the unit. i would be a little leery of having someone that looks shocky on the floor.

david carpenter, pa-c

[monkeelouise]

I agree, with VS like that, we would have been called emergently, my docs think better safe than sorry.

[steelcityrn, RN]

I agree with the above. Due to fluid changes, the h+h can appear to change, all the while the patient can be bleeding. Some can bleed with each bm, others can bleed intermittently. Have had many a patient start coumadin or plavix, even asa too soon, only to go back in with another bleed.