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Gastroenterology and Hepatology Postendoscopic care o test fbr H. pylori and treat if positive; retest if initial test was negative . provide long-term, daily PPI therapy fbr patients who must use aspirin and other antiplatelet drugs, NSAIDS, anticoagu lants, or glucocorticoids . provide nonselective p blockers (propranolol, nadolol, or carvedilol) and endoscopic band ligation for secclndary prophy- laxis of variceal hemorrhage . restart aspirin as soon as possible if discontinued in patients with recent ACS or stent o restart P2Y,, inhibitor within 5 days if discontinued for UGI bleeding . see General Internal Medicine section for information on reinitiation of anticoagulation DON'T BETRICKED . H2 receptor antagonists are not beneflcial in managing UGI bleeding. . Do not select nasogastric tube placement for diagnosis, prognosis, visualization, or therapeutic eft'ect. . Consider aortoenteric flstula in patients who previously had aortic graft surgery and present with UGI bleeding. Lower Gl Bleeding Diagnosis Acute, painless LGI bleeding in older adult patients is usually caused by colonic diverticula or angiodysplasia. STUDY TABLE: Differential Diagnosis of Lower Gl Bleeding lf you see this... Diagnose this... Painless, self-limited, massive hematochezia Diverticular bleeding (most common overall cause) Chronic blood loss or acute painless hematochezia in an older adult patient Colonic tumor, polyp, or angiodysplasia Recent colonic polypectomy Postpolypectomy bleeding Evidence of vascular disease in an older adult patient; typically with LLO Colonic ischemia abdominal pain Aortic stenosis Angiodysplasia (Heyde syndrome) History o{ bloody diarrhea, tenesmus, abdominal pain, fever IBD Aortic aneurysm repair Aortoenteric fistula (UGl bleeding most common) Painless hematochezia in a young patient and normal upper endoscopy Meckel diverticulum and colonoscopy Mucocutaneous telangiectasias Hereditary hemorrhagic telangiectasia

STUDY TABLE: Differential Diagnosis of Lower Gl Bleeding lf you see this... Diagnose this... Painless, self-limited, massive hematochezia Diverticular bleeding (most common overall cause) Chronic blood loss or acute painless hematochezia in an older adult patient Colonic tumor, polyp, or angiodysplasia Recent colonic polypectomy Postpolypectomy bleeding Evidence of vascular disease in an older adult patient; typically with LLO Colonic ischemia abdominal pain Aortic stenosis Angiodysplasia (Heyde syndrome) History o{ bloody diarrhea, tenesmus, abdominal pain, fever IBD Aortic aneurysm repair Aortoenteric fistula (UGl bleeding most common) Painless hematochezia in a young patient and normal upper endoscopy Meckel diverticulum and colonoscopy Mucocutaneous telangiectasias Hereditary hemorrhagic telangiectasia Treatment If the patient is hemodynamically unstable, provide resuscitation before diagnostic studies are performed. Transfusion management is the same as fbr UGI bleeding, as are decisions regarding discontinuation and/or reversal of antico- agulant and antiplatelet agents. Select colonoscopy within 24 hours of admission for hemodynamically stable patients without rapid bleeding. For hemodynamically unstable patients f<-rllowing resuscitation or ongoing bleeding: . C'lA o catheter based embolization if C'lA positive . upper endoscopy ifCTA negative 112