Approach to Management of acute GI BleedDr. Bara AlMakadma

Definition and Classification: • Intraluminal Blood Loss anywhere from the

oropharynx to the anus

• Upper = above the ligament of Treitz

• Lower = below the ligament of Treitz

• “Severe” GIB ➔ requires hospitalization: defined as:

• having associated shock,

• orthostatic hypotension,

• decreased Hct by 6% (or Hb by 2g/dL),

• or requiring transfusion of >= 2u pRBCs.

Abbreviations

UGIB: upper GI bleeding

LGIB: lower GI bleeding

NSAID: non-steroidal anti inflammatory

ASA: aspirin (acetyl salicylic acid)

N/V: nausea/ vomiting

EtOH: ethanol

UOP: urine output

HCT: hematocrit

MCV: mean corpuscular volume

FFP: fresh frozen plasma

SBP: systolic blood pressure

H/O (h/o, or H/o): history of

LAN: lymphadenopathy

EGD: endogastroduodenoscopy

IR interventional radiology

Clinical Manifestations

• Hematemesis: blood in vomitus (UGIB)

• Coffee-ground emesis: blood exposed to gastric acid (UGIB)

• Melena: black, tarry stools from digested blood (usually UGIB, but can be from R. colon)

• Hematochezia: bloody or maroon-colored stools (LGIB) or rapid UGIB)

Initial ManagementApproach

Assess severity

Vital signs including orthostatic changes,

JVP

Tachycardia: can be masked by beta blocker use ➔ suggests 10% volume loss,

Orthostatic hypotension: 20% volume loss

Sock: > 30% volume loss

History

• Prior GIB

• Tempo of current bleed (how strong is it)

• Specific bleeding manifestations (such as ones outlined in clinical manifestations)

• Prior GI signs and symptoms• Abdominal pain• Changes in bowel habits• Weight loss• N/V

• NSAID/ASA use

• EtOH use

• Anticoagulation, antiplatelet drugs

• H/o or risk factors for cirrhosis

• Radiation

• Prior GI or aortic surgery

Physical Examination• Localizable abdominal tenderness

• Peritoneal signs

• Masses

• LAN

• Prior surgery signs

• Signs of liver disease

• Hepatosplenomegaly

• Ascites

• Jaundice

• Telangiectasias

• Rectal examination: masses, hemorrhoids, anal fissures and

• stool appearance, color, and stool for occult blood

Resuscitation

Placement of 2 large-bore (18-gauge or larger) intravenous

lines

Volume replacement: NS or LR to achieve

normal VS, UOP, and mental status

Lab studies

Hct (may be normal in first 24 hours of acute GIB before equilibration

2-3% decrease ➔ 500 mL blood loss

low MCV ➔ Fe deficient and chronic blood loss

Plt, PT, PTT

BUN/Cr (ratio > 36 in UGIB because GI resorption of blood +/- prerenal azotemia)

LFTs

Transfuse

Blood sample for type and cross match

Use O-negative if emergent; for UGIB (esp. with

portal HTN)

transfuse with more

restrictive Hb goal (e.g. 7

g/dL)

or > 8 g/DL if CAD

Reverse coagulopathy

FFP and Vitamin K to normalize PT

Platelets to keep count

above 50,000

From the moment of Triage

Alert endoscopist Consider ICU if unstable vital signs or poor end organ perfusion (signs of shock)

Intubation for emergent EGD if:

Ongoing hematemesis

Shock

Poor respiratory status

Changes in mental status

Out-patient management can be considered if all of the following conditions are met: SBP > 110, HR <100, Hb >=13, 12 (male and female respectively), BUN <18, no melena, no syncope, no heart failure, no liver disease

Diagnostic Studies

Approach

Nasogastric tube

• Can aid localization: by observing whether it is fresh blood or coffee grounds ➔ active vs recent bleed UGIB

• Nonblood gastric material ➔ does not exclude UGIB (about 15% are missed)

Diagnostic studies for UGIB

• EGD within 24 hours

• If severe bleed ➔ increase your diagnostic and treatability yield by gastric lavage and

• erythropoietin 250 mg IV 30 minutes prior to endoscopy ➔ significantly accelerates correction of anemia after acute bleed

Diagnostic studies of LGIB

• Colonoscopy: identifies cause in > 70%

• If severe, colonoscopy within 12 hours

• Colon has to be “prepared” – to have a clear field of vision: i.e. cleared of fecal matter: therefore:

• consider rapid purge with polyethylene glycol electrolyte solution (a laxative a.k.a. PEG) solution to be given 6-8L over 4 to 6 hours

• If hematochezia is associated with orthostasis: you have tobe concerned for brisk UGIB ➔ and exclude UGIB with an EGD first.

• If no yield: consider push enteroscopy • Capsule

• Anoscope

• Conclusion: endoscopy in combination with urgent colonoscopy results in diagnosis in more than 95% of patients

Imaging

• If too unstable for endoscopy or recurrent bleeding: consider interventional radiology procedure

• Note the advent of endoscopic ultrasound

• Otherwise: surgery

• Tagged RBC scan: can identify general luminal location if bleeding rate more than 0.04 mL/min

• Arteriography: can localize exact vessel if bleeding rates >= 0.5 mL/min and allows for IR treatment

Last Resort diagnostic study (that is naturally also a chance for immediate

treatment)

Emergent exploratory laparotomy is the last resort if no localization by all previous studies and life-threatening

bleed

Upper GI bleed by Etiology

UGIB causes; Treat the cause

• PUD: 20-67% of cases

• Erosive gastropathy : 4-31% of cases

• Erosive esophagitis : 5-18% of cases

• Esophageal or gastric varices: 4-20% of cases

• Portal HTN gastropathies:

• Vascular causes:

• Angioectasia AVMs, HHT, Dieulafoy’s lesion

• Gastric antral vascular ectasia (GAVE)

• Aortoenteric fistula: life threatening potential

• Malignancy: 2-8% of cases

• Mallory-Weiss tear 4-12% of cases

• Cameron’s lesions

• Post-sphincterotomy bleeding

LGIB causes; Treat the cause

• Diverticular bleed (30%)

• Polyp? Tumor (20%)

• Colitis (20%)

• Anorectal disorders (20%)

• Vascular (<10%)

• Meckel’s diverticulum

OBSCURE GIB

Definition: continued bleeding despite negative EGD and negative colonoscopy. manifested as:

Melena

Hematochezia

Seen in 5% of patients.

Etiologies:

Dieulafoy’s lesion

GAVE

Small bowel angiodysplasia

Ulcer or cancer

Crohn’s disease

Aortoenteric fistula

Meckel’s diverticulum

Hemobilia

How to diagnose obscure GIB

• MONITOR: as soon as bleeding becomes active ➔ while the patient is bleeding repeat EGD with push enteroscopy and/or colonoscopy

• If still negative: video capsule to evaluate the small intestines

• If still negative consider Tc pertechnetate scan (Meckel’s scan), enteroscopy (single balloon, double balloon

• Tagged RBC scan and arteriography

References

• (NEJM 2013:368:11)

• (Lancet 2009:373:42)

• Pocket Medicine

• (AmjGauro 2006:101:121)

• (AmJGostro 2015:110:1265 & 2016:111:755)

• (Gostro 2007:133:1694;CIE 2010:72:471)

• Kumar

• Google images