Gastrointestinal Bleeding

Lutfiyah Haji, DO

2010

GI Bleeding• Initial Evaluation• Approach to the Patient• Sources• Upper GI Bleeds• Lower GI Bleeds• Etiology• Management• Admission Orders

History– HPI

• Hematemesis (coffee grounds vs. bright red)• Hematochezia• Melena - dark, tarry stool• Pain symptoms

– PMHx• ulcer disease, joints, skin

– Social Hx• EtOH

– Medications• NSAIDs, steroids, ASA, Plavix, Coumadin, Lovenox, Heparin,

Iron

Physical Exam Including:• HR, BP, tilt test, RR, O2 saturation• General appearance, Mental status• Neck veins, oral mucosa• Skin temperature and color• Abdominal exam• Rectal• Stigma of Cirrhosis• NG Tube findings (upper vs. lower g.i. source)• Urine output

Work Up

• Labs

• CBC• Serial HgB• Platelets

• BMP• BUN, Cr

• Type and Crossmatch• Coagulation studies• Stool WBCs to eval for infectious etiol• Imaging studies?

Sources of GI Bleeding

• Upper GI Tract• Proximal to the Ligament of Treitz• 70% of GI Bleeds

• Lower GI Tract• Distal to the Ligament of Treitz• 30% of GI Bleeds

Localization of Bleeding

• History

• NG Tube

• EGD

• Colonoscopy

• Tagged RBC Scan

• Angiography

Upper GI Bleed• 50% present with hematemesis

• NGT with positive blood on aspirate

• 11% of brisk bleeds have hematochezia

• Melena (black tarry stools)—this develops with approximately 150-200cc of blood in the upper GI tract. – Stool turns black after 8 hours of sitting within the

gut.

• 50% present with hematemesis

• NGT with positive blood on aspirate

• 11% of brisk bleeds have hematochezia

• Melena (black tarry stools)—this develops with approximately 150-200cc of blood in the upper GI tract. – Stool turns black after 8 hours of sitting within the

gut.

Upper GI Bleed

• Risk Factors• NSAID use• H. pylori infection• Increased age

• Upper GI Bleeding accounts for approximately 350,000 hospitalizations per year.

Upper GI Bleed

• Etiology of Upper Bleeds• Duodenal Ulcer-30%• Gastric Ulcer-20%• Varices-10%• Gastritis and duodenitis-5-10%• Esophagitis-5%• Mallory Weiss Tear-3%• GI Malignancy-1%• Dieulafoy Lesion• AV Malformation-angiodysplasia

Duodenal Ulcer

Varices

Esophagitis

GI Malignancy

• Esophageal Tumor

GI Malignancy

• Gastric Carcinoma

Angiodysplasia

Lower GI Bleed• Acute LGIB: <3d• Chronic LGIB: > several days• Hematochezia• Blood in Toilet• Clear NGT aspirate• Normal Renal Function• Usually Hemodynamically stable

– <200ml : no effect on HR**– >800ml: SBP drops by 10mmHg, Hr increases by 10– >1500ml: possible shockOR– 10% Hct: tachycardia*– 20% Hct: orthostatic hypotension– 30% Hct: shock

Stops spontaneously (80 - 85% of the time)

Lower GI Bleed

• Etiology of hematochezia• Diverticular-17-40%

• Angiodysplasia-9-21%

• Colitis (ischemic, infectious, chronic IBD, radiation injury)-2-30%

• Neoplasia, post-polypectomy-2-26%

• Anorectal Disease (including rectal varices)-4-10%

• Upper GI Bleed-0-11%

• Small Bowel Bleed-2-9%

Barnet J and H Messmann H. Nat Rev Gastroenterol Hepatol 6, 637-646 (2009).

Diverticulosis

Diverticulitis-NOT A CAUSE OF GI BLEEDING

Colonic Polyps

Malignancy

• Colon Carcinoma

Hemmorrhoids

Management of GI Bleed

• Oxygen

• IV Access-central line or two large bore peripheral IV sites

• Isotonic saline for volume resuscitation• Start transfusing blood products if the patient remains unstable

despite fluid boluses.

• Airway Protection• Altered Mental Status and increased risk of aspiration with

massive upper GI bleed.

Management of GI Bleed• ICU admit indications• Significant bleeding (>2u pRBC) with hemodynamic instability

• Transfusion• Brisk Bleed, transfusing should be based on hemodynamic

status, not lab value of Hgb.• Cardiopulmonary symptoms-cardiac ischemia or shortness of

breath, decreased pulse ox

• 1 unit PRBC increases Hgb by 1mg/dL and increase Hct by 3%• FFP for INR greater than 1.5• Platelets for platelet count less than 50K

Basic Admission Orders• Admit to ICU/intermediate care/telemetry s/o

…• Dx: Upper/Lower G.I. Bleed• Condition:• VS:• Allergies:• Activity: Bedrest• Nursing: Is/Os, ? Foley• Diet: NPO

Basic Admission Orders (Cont.)

• IVF: NSS @ ?cc/h

• Medications: I.V. Protonix, convert medications to i.v., hold anti-hypertensives

• Labs: serial H/H, type and cross, coags, Chem 7, LFTs

• Consults: GI, +/- Surgery

Obscure GI Bleed• Present: Fe Defic anemia• Etiology:

– Younger than 40• Tumors• Meckel’s diverticulum• Dieulafoy’s lesion• Crohn’s Disease• Celiac Disease

– Greater than 40• Angioectasia• NSAID enteropathy• Celiac

Gerson LB. Clin Gastroenterol & Hepatol 2009;7:828-833.

Obscure GI Bleed

• Work Up– EGD, Colonoscopy both neg– Repeat – CE, PE or DE,– angiography

PillCam SB Latest Generation

PillCam SB

– 11 mm x 26 mm

– 1 camera

– 2 frames per second

– Std optics / 1 lens

– Standard lighting control

– Standard angle of view (AOV) 140°

– Depth of field 0-30 mm

PillCam SB 2

– 11 mm x 26 mm

– 1 camera

– 2 frames per second

– New optics / 3 lenses

– Advanced Automatic Light Control

– Extra wide angle of view (AOV) 156°

– Depth of field 0-30 mm

Image Spectrum: PillCam Capsule Endoscopy

Bleeding

Celiac DiseaseTumors

Suspected Crohn’s

References

• Harrison’s Principles of Internal Medicine 14th edition• Gastrointestinal Atlas.com endoscopy photos• Pocket Medicine, 3rd edition• Barnet J and H Messmann H. Diagnosis and management of lower gastrointestinal bleeding. Nat Rev

Gastroenterol Hepatol 6, 637-646 (2009).• Gerson LB. Recurrent Gastrointestinal Bleeding After Negative Upper Endoscopy and Colonoscopy. Clin

Gastroenterol & Hepatol 2009;7:828-833.• Melmed GY and Simon KL. Capsule Endoscopy: Practical Applications. Clin Gastrolenterol & Hepatology

2005;3:411-422.• AGA Institute. AGA Institute Medical Position Statement on Obscure Gastrointestinal Bleeding.

Gastroenterology 2007;133:1694-1696.

THE END