Gastrointestinal Bleeding

Lisa N. Flemmons, ACNP-BCVanderbilt University Medical Center

Medical Intensive Care Unit

Objectives• Learn how to effectively evaluate and manage

gastrointestinal bleeding in the critically ill patient• Distinguish upper gastrointestinal bleeding from lower and

discuss possible etiologies• Understand diagnostic testing and therapeutic interventions• Review and discuss transfusion strategies in the

gastrointestinal bleeding patient

Epidemiology• Common and potentially fatal diagnosis

accounting for ~30,000 admissions/year

• Upper GIB accounts for 20,000 deaths/year

• In our MICU, it is the 3rd most common diagnosis

Distinguishing upper vs lowerUpper GI bleed

– History• Previous PUD• Alcoholism/liver dz varices• Retching/vomiting Mallory

Weiss tear• Medications such as

anticoagulants, antiplatelets, NSAIDS → ulcers

– Symptoms• Nausea/vomiting• Hematemesis• Melena• Rarely hematochezia (massive

bleed)

Lower GI bleed– History

• Previous colon cancer• Previous colon surgery• Known diverticulosis• Known hemorrhoids

– Symptoms• Abdominal pain or can be

painless• Hematochezia • Melena (less common)

Evaluation and Assessment• ABCs of GIB

1. Airway and Access2. Blood products3. Correct Coagulopathy and

Consultation4. Drugs and Diagnostic testing

Airway and Access• Ensure adequate airway

–Hematemesis–Altered mental status–Shock–Needed for endoscopy

• Adequate access–2 large bore PIV vs CVC

Blood Products• Crystalloid infusion while waiting on

PRBC• Vasopressors are not a substitute for

volume resuscitation• Each PRBC should increase PCV by ~3%

per unit

Transfusion goal

• Randomized 921 patients to either liberal or restrictive strategy

• Liberal strategy transfusion trigger was Hgb <9 and restrictive strategy was 7

• The probability of survival at 6 weeks was higher in the restrictive-strategy group than in the liberal-strategy group (95% vs. 91%).

• Further bleeding occurred in 10% of the patients in the restrictive-strategy group as compared with 16% of the patients in the liberal-strategy group and adverse events occurred in 40% as compared with 48%.

6 week survival rate in the 2 groups

Correction of Coagulopathy• FFP transfusion

– Synthetic liver dysfunction– Warfarin

• Consider Vitamin K – Dilutional coagulopathy– Goal INR <1.5

• Platelet transfusion– in bleeding pt if less than 50K– Platelet dysfunction

• Anti-platelet agents or uremia– Goal platelets >50, 000/mm³

Correction of Coagulopathy

• Transexamic acid– Synthetic derivative of aminoacid lysine that

inhibits fibrinolysis or dissolution of the clot– Given as 1 gm loading dose followed by 1 gm IV

infusion over 8 hrs

Correction of Coagulopathy

• Prothrombin Complex Concentrate– Non-activated concentrate of Vitamin K dependent

factors (II, VII, IX, X)– Advantages compared to FFP:

1. small volume with rapid infusion time2. no time delays for ABO blood typing and thawing3. less risk of pathogen transmission, transfusion related

ALI, add circulatory volume overload4. less time to correct coagulopathy

Consultation• Urgent gastroenterology consult• Consider surgical consult

– Massive transfusion– Abdominal pain associated with GIB– Recurrent bleeding

Diagnostics• Upper GIB→EGD

(esophagogastroduodenoscopy)– Definitive test for diagnosis and treatment– Safe to perform once the airway is secure and pt is

reasonably hemodynamically stable– Interventional options: epinephrine injection,

cauterization, clipping, or banding of varices– May give 1 time dose of erythromycin 250 mg IV or Reglan

10 mg IVP to promote gastric emptying prior to procedure

Large ulcer Status post cauterization

Submucosal duodenal tumor

1.5 cm lesion s/p resection

Site of resection: friable and oozing with visible vessel S/p epinephrine and cauterization

Diagnostics continued• Lower GIB→colonoscopy

– If slow bleed consider bowel prep overnight to allow for maximum visualization

– If brisk bleed consider STAT colonscopy, tagged RBC scan, or angiography

• Tagged RBC scan vs angiography

• If upper and lower endoscopy fail to ID source then can consider video capsule or push enteroscopy

Drugs• Proton pump inhibitor BID

Am J Health-Syst Pharm—Vol 62 Jun 1, 2005 1165

Drugs• If hx of liver disease or ascites give SBP

prophylaxis (quinolone, CTX, or bactrim)• Octreotide gtt for hx of liver disease or known

varices• Hold beta blocker in the acute setting which

will prevent/block reflex tachycardia

Minnesota/Blakemore Tube

A flexible tube consisting of an esophageal and gastric balloon that is inflated and is used as a temporizing measure to tamponade gastric and/or esophageal varices.

Minnesota/Blakemore TubeUses• Should have experienced

personnel assist with insertion• Maximum amt of time 24-72

hrs• Must be to traction (usually a

football helmet)• KUB and CXR for confirmation

of placement (keep in mind after transfer from OSH)

Cautions• Necrosis if inflated too much

or too long• Nasal insertion can cause nose

bleeds and sinusitis• Can migrate upwards and

compress trachea especially in shorter stature patients

• Perforate or tear esophagus during insertion

Large esophageal varices with red wales sign Status post banding

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Increased pressure in PV forces blood to flow into smaller branches coming from abdominal organs that normally drain into the PV. These veins then enlarge and are referred to as varices

• 63 patients with cirrhosis and acute variceal bleeding randomly assigned within 24 hours after admission– 32 patients assigned to early TIPS group (within 72

hours)– 31 patients assigned to continuation of vasoactive

drugs, NS- beta blockade, and long term EBL with insertion of a TIPS as rescue therapy if needed.

• Results– rebleeding or failure to control bleeding occurred in 14

patients in the pharmacotherapy–EBL group as compared with 1 patient in the early-TIPS group (P=0.001).

– The number of days in the intensive care unit and the percentage of time in the hospital during follow-up were significantly higher in the pharmacotherapy–EBL group than in the early-TIPS group.

– The 1-year actuarial survival was 61% in the pharmacotherapy–EBL group versus 86% in the early-TIPS group (P<0.001).

References• CRASH-2 trial collaborators, Lancet 2010; 376; 23-32• Garcia-Pagan et al, NEJM 2010; 362: 2370-9• Lau JY, Sung JJ, Lee KKC, et al, NEJM 2000; 343: 310–316• Marini, J.J., Wheeler, A.W. (2010). Critical care medicine: The

essentials (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

• Rivkins, K., Lyakhovetskiy, A AJHP 2005; 62: 1164-1165• Sarode, R., et al, Circulation 2013; 128: 1234-1243• Villaneuva, C et al NEJM 2013; 368: 11-21