GI bleed

Talal Dahhan

 

Definition:  Any bleeding from the oropharynx to the anus, any intraluminal bleeding is counted as a Gastrointestinal (GI) Bleeding.

 

Classification Link

  • Upper = The upper GI tract includes the esophagus, stomach, and first part of the small intestine; above the ligament of Treitz.
  • Lower = The lower GI tract includes much of the small intestine; below the ligament of Treitz, large intestines, rectum, and anus.

 

Symptoms and Signs:

  • Hematemesis = Voomiting of blood; Sign of Upper GI bleeding
  • Hematochezia = Usually lower GI Bleeding or rapid upper GI Bleeding. (Hematochechezia from an UGI source usually yields maroon stools and implies a bloodloss of ≥ 1000ml,oftenaccompanied by hypovolemia, hypotension and tachycardia. When it is from a LGIB, blood is brighter)
  • Melena = black, tarry stools from digested blood (usually upper GI bleeding, and typically indicated PUD or small intestinal bleeding)

 

Etiologies of upper GI bleeding

  • Peptic ulcer disease (50%): H. pylori, NSAIDs, gastric hypersecretory states.
  • Varices (10–30%): esophageal ± gastric, 2° to portal HTN. If isolated gastric → r/o splenic vein thrombosis.
  • Gastropathy/gastritis/duodenitis (15%): NSAIDs, ASA, alcohol, stress, portal hypertensive source.
  • Erosive esophagitis/ulcer (10%): GERD, XRT, infectious (CMV, HSV or Candida if immunosuppressed), pill esophagitis (bisphosphonate, NSAIDs; ± odynophagia)
  • Mallory-Weiss tear (10%): GE junction tear due to retching against closed glottis
  • Vascular lesions (5%):
    • Dieulafoy’s lesion: superficial ectatic artery usually in cardia of stomach, that usually causes sudden, massive Upper GI bleeding.
    • AVMs, angioectasias, HHT: submucosal, anywhere in GI tract.
    • Gastric antral vascular ectasia (GAVE):  “watermelon stomach,” tortuous, dilated vessels; a/w cirrhosis, atrophic gastritis, CREST syndrome.
    • Aortoenteric fistula: AAA or aortic graft erodes into 3rd portion of duodenum; p/w “herald bleed”; if suspected, diagnose by endoscopy or CTA.
  • Neoplasms: esophageal or gastric carcinoma, gastrointestinal stromal tumor (GIST).
  • Oropharyngeal bleeding and epistaxis → swallowed blood. Can be misleading sometimes!

 

Etiologies of lower GI bleed

  • Diverticular hemorrhage (33%): 60% of diverticular bleeding localized to right colon
  • Neoplastic disease (19%): usually occult bleeding, rarely severe.
  • Colitis (18%): infectious, ischemic, radiation, inflammatory bowel disease (Ulcerative Colitis much more than Crohn’s disease)
  • Angiodysplasia (8%): most commonly located in ascending colon and cecum
  • Anorectal (4%): hemorrhoids, anal fissure, rectal ulcer.
  • Other: post-polypectomy, vasculitis.

 

History Clues:

In upper GI bleeding: Patients usually have vasovagal symptoms, coffee-ground emesis, epigastric pain, melena

In lower GI bleeding: diarrhea, tenesmus, BRBPR, hematochezia (unless rapid GI bleeding).

 

Evaluate the Patient!

You may look at this link for a table review!

Look at vital signs first:

  • Tachycardia (can be masked by β-Blocker use) suggests 10% volume loss.
  • Orthostatic hypotension; 20% loss.
  • Shock ; >30% volume loss.

Take History (clues may help as above, keep etiologies in mind)

Physical examination:

  • Monitor vital signs: If possible assess orthostasis, JVP
  • Examine the abdomen for localizable abdominal tenderness, peritoneal signs, masses, signs of prior surgery.
  • Signs of liver disease (hepatosplenomegaly, ascites, etc.)
  • Rectal exam: masses, hemorrhoids, anal fissures, stool appearance, color, occult blood is not important!
  • Pallor, jaundice, telangiectasias (alcoholic liver disease or HHT)

Lab studies:

  • Hemoglobin / hematocrit (may be normal in first 24 h of acute GI bleeding before equilibration).
  • Reduction by 2–3% → 500 mL blood loss;
  • Low MCV → Iron deficient and chronic blood loss.
  • Platelets level.
  • Prothrombin time (PT).
  • Partial Thromboplastin time (PTT).
  • BUN/Creatinine (ratio >36 in UGIB b/c GI resorption of blood ± prerenal azotemia).
  • Liver Function Tests (LFTs).
  • Blood bank sample for type & screen.

Resuscitation:

  • Placement of 2 large-bore (18-gauge or larger) intravenous lines
  • Volume replacement: Normal Saline (0.9% NS) or Lactate Ringer’s (LR)
  • Goals: achieve normal vital signs, urine output & better mental status.

Transfuse Blood Products:

  • Cross match a few units of blood (estimation depends on severity and target).
  • Use O- Packed RBCs in emergencies.
  • Transfuse as needed; for upper GI bleeding (especially in cases of portal hypertension) use a restrictive Hb goal (eg, 7 g/dL) Evidence
  • Reverse coagulopathy: fresh frozen plasma & vitamin K to normalize PT;
  • Treat Thrombocytopenia: platelets to keep count >50,000/mL.

 

When to consider ICU?

  • If unstable vital sign (hypotension, intractable bleeding).
  • Evidence of shock and/or poor end organ perfusion clinically or by lab tests.
  • If needed endotracheal intubation for emergent EGD.
  • If ongoing hematemesis, it becomes hard to monitor.
  • Poor respiratory status.
  • Altered mental status, as may need frequent monitoring or intubation.

 

May consider admission to the floor and possibly outpatient!  The Evidence

  • Systolic BP ≥110.
  • HR <100,
  • Hb ≥13 g/dL for males, or ≥12 g/dL for females.
  • BUN <18 mg/dL.
  • Absence of melena, syncope, heart failure and liver disease history

 

Further Management in the ICU

Nasogastric tube can aid localization of the bleeding:

If found;

Fresh blood → active UGIB.

Coffee grounds → recent upper GI bleeding.

Nonbloody bile → raise lower GI bleeding as a possibility, but does not exclude active UGIB (~15% missed)

 

For Upper GI bleeding, consider:

  • EGD in the first 24 hours for diagnosis and possible intervention.
  • Decreases Length of Stay (LOS) & need for surgery.
  • Consider erythromycin 250 mg IV 30 min prior to EGD to help with emptying stomach of blood. This increases diagnosis and management yield  The Evidence.
  • Proton-pump Inhibitors, consider omeprazole or pantoprazole bolus followed by infusion  for 72 hours after EGD.
  • Octreotide 50 ug IV bolus followed by 50 mcg IV/hour for 2-5 days.

 

For lower GI bleeding:

  • Make sure it is from a lower GI source.
  • Colonoscopy (identifies cause in >70% of cases).
  • Needs preparation.
  • No clear benefit of colonoscopy in 12 vs. 36–60 hours The Evidence.
  • CT angiogram might help to localize the lower GI bleeding source The Evidence.

 

Unstable or recurrent upper and/or lower GI bleeding:

  • Tagged RBC scan: can localize bleeding rates ≥0.1 mL/min.
  • Arteriography with possible embolization: can localize if bleeding rates ≥0.5 mL/min + could consider intervention (coiling, vasospasm, glue).
  • May need to consider emergent exploratory laparotomy (last resort).