Gastrointestinal Bleeding

Dr. Mohammad AShaikhani.

MBChB –CABM - FRCP.

Key points:

• Patients with acute UGIB often present with melena, hematochezia, or hematemesis.

• Most episodes of UGIB will stop without intervention.

• Initial management of patients with acute UGIB include hemodynamic stabilization, finding /controlling the source of bleeding& preventing recurrence of bleeding.

• 98% of episodes of recurrent UGIB occur within 3- 4 days of the initial bleeding episode.

Introduction:• GIB is classified in several ways:

• 1) upper or lower

• 2) variceal or nonvariceal

• 3) acute or chronic.

• UGIB: bleeding into the lumen of the GIT proximal to the ligament of Treitz & further categorized into variceal or nonvariceal bleeding, depending on the presence of portal hypertension & bleeding varices.

• LGIB: bleeding into GIT lumen distal to the ligament of Treitz.

• Whether bleeding is acute or chronic is determined by the clinical presentation of the patient.

Evaluation:• Patients with acute UGIB often present with melena (black, tarry

stools), hematochezia (red or maroon-colored stools), or hematemesis (vomiting of blood or coffee-ground material).

• Melena can result from as little as 100 mL of blood in the GIT, whereas hematochezia due to UGIB is usually associated with an accumulation of at least 1000 mL of blood.

• Although hematochezia generally indicates LGIB, a more proximal source should be considered if:

• The patient has hematemesis• Hemodynamic instability • A NGT aspirate reveals fresh blood. • Such patients have significant bleeding associated with a

mortality rate of 30%. • if the bleeding is slow / chronic, the only manifestations may be

secondary to IDA.

Evaluation:• The initial assessment includes a brief history&physical exam. • Importantt points in the history include prior episodes of UGIB,

PUD, cirrhosis with portal hypertension, medication use (including aspirin, other NSAID, anticoagulants), a bleeding diathesis&significant comorbid conditions as HF.

• The presence of abdominal pain,but a bleeding PUD can occur without causing pain.

• Signs of volume loss (orthostatic hypotension)& ischemia (chest pain, dyspnea, or stroke-like features) need to be evaluated.

• A significant postural pulse change (≥30 beats/min) or severe postural dizziness is required to make a clinical diagnosis of hypovolemia from blood loss, often absent in patients with more moderate blood loss.

• The exam should then focus on vital signs, CV assessment& airway evaluation.

Management:• The management of a patient with UGIB includes 3 steps:• 1) Hemodynamic stabilization• 2) Finding / controlling the source of bleeding• 3) Preventing recurrence of bleeding. • Adequate IV access is imperative, either two large-bore IV access

sites or CV access should be secured. • Resuscitation with IVF/ blood products is the initial step in

stabilizing patients prior to upper endoscopy. • Endotracheal intubation should be performed prior to endoscopy

to prevent aspiration in patients who have ongoing bleeding & if altered level of consciousness, loss of the gag reflex, or continuing hematemesis.

• A CBC with blood type & cross-match & a coagulation profile should be done+ serum electrolytes,BUN, serum creatinine.

• The BUN:creatinine ratio does not reliably discriminate between U & LGIB&although this ratio tends to be higher in patients with UGIB, there is considerable overlap in values, suggesting that this ratio has low discriminatory ability.

Management:• The hematocrit may initially appear normal because of the loss of

whole blood; however, following redistribution of fluid into the vascular space, the hematocrit level will fall & will continue to fall for up to 72 hours.

• ECG is needed for patients 50 years of age & older & for younger patients with underlying cardiac disease or features of ischemia.

Management:• A NGT can be passed if the source of bleeding is not clinically

obvious. • A bloody NGT aspirate is significantly associated with high-risk

lesions (those with spurting, oozing, or a visible vessel) on upper endoscopy, whereas a clear aspirate reduces the likelihood of such lesions by nearly 50%.

• Upper endoscopy should then be performed (within 12 hours) to find the source of bleeding & estimate the risk of rebleeding.

• Athough patient should be stabilized prior to endoscopy but unstable patients require emergent endoscopy to control ongoing bleeding.

• Directed therapy can be initiated once the bleeding source is established.

• PPIs may be used to decrease gastric acidity & stabilize clots. • Use of IV PPIs in conjunction with endoscopic therapy has been

shown to reduce the risk of recurrent bleeding in patients with bleeding PUD & is a cost-effective approach for the management of hospitalized patients with ulcer-related bleeding.

Management:• Targeted medical therapy for bleeding varices in patients with

cirrhosis includes the use of vasoactive drugs such as octreotide plus endoscopic therapeutic hemostasis usually band ligation.

• After stabilization, triple therapy for Helicobacter pylori–related disease should be considered for patients found to be infected.

Management:• Endoscopic therapy to control bleeding incorporates injection

therapy (epinephrine, sclerosing agents), thermal techniques (probes, argon plasma coagulation), mechanical modalities (clips).

• The type of lesion & the presence or absence of ongoing bleeding determine which technique is used.

• Endoscopic therapy usually the combination of injection plus one of the other modalities, can decrease the rebleeding rate & the need for surgery.

• When endoscopic therapy is ineffective (usually because of active hemorrhage, ulcer size >2 cm, shock, or low hemoglobin level), a surgical or interventional radiology consultation should be obtained usually after a second endoscopic intervention trial.

• Surgical or radiology consultation is also indicated for patients with suspected aortoenteric fistulas, large vascular abnormalities, or ulcers located on the lesser curvature of the stomach (left gastric artery) or the posterior wall of the duodenum (gastroduodenal artery).

Management of patients at risk of recurrent bleeding:

• Many clinical features indicate a higher likelihood of rebleeding or death in a patient with UGIB.

• Older patients (>60 years of age)• Hematochezia• Bleeding during hospitalization• Bloody nasogastric aspirate• Large transfusion requirement (>5 units)• Ongoing or recurrent bleeding• Varices• Cancer& other comorbid illnesses. • Independent endoscopic predictors of rebleeding in patients with

high-risk lesions&require endoscopic interventions, include:• Arterial spurting (55-90% recurrence rate)• A visible vessel (40-50%)• Adherent clot that does not wash off (10-35%).

Management of patients at risk of recurrent bleeding:

• Lower rates of rebleeding occur in patients with:• Flat pigmented spots (7- 10%)• Ulcers with clean bases (3-5%)• These lesions do not require endoscopic therapy.

Management of patients at risk of recurrent bleeding:

• Most episodes of UGIB will stop spontaneously without intervention.

• Continued or recurrent bleeding is associated with significant mortality as a consequence of either the bleeding itself or the presence of a comorbid condition.

• 98% of all rebleeding episodes occur within 3-4 days after the initial episode.

• Patients with both low-risk clinical criteria for rebleeding & low-risk endoscopic lesions (clean-based ulcers, Mallory-Weiss tears) without stigmata of recent hemorrhage can be fed& discharged home after volume resuscitation&upper endoscopy.

• All low-risk patients require directed outpatient therapy& close follow-up.

• Patients who have the highest risk of rebleeding (active bleeding, visible vessel) or a significant comorbid condition should be observed initially in ICU.

Lower Gastrointestinal Bleeding • 20% of episodes of acute GIB result from LGT. • The most frequent causes of acute LGIB are diverticulosis,

angiectasia, ischemic colitis& perianal disease. • The most frequent causes of chronic LGIB are neoplasms,

angiectasia, IBD. • Most episodes of LGIB will stop without intervention.

Lower Gastrointestinal Bleeding • LGIB is defined as bleeding into the lumen of the GIT distal to

the ligament of Treitz.• The colon is the most common site of bleeding.• Similar to UGIB, LGIB can be either acute or chronic.• The incidence of LGIB increases with age, with a mean age range

at presentation of 63-77 years. • LGIB accounts for 20% of all episodes of GIB. • The most common causes of acute LGIB are diverticulosis,

angiectasia, ischemic colitis, perianal disease.

Lower Gastrointestinal Bleeding • Diverticular bleeding is often painless, can occur from the right or

left side of the colon,usually stops spontaneously. • Patients with a previous episode of diverticular bleeding have a

14-38% chance of having a repeat episode.

Lower Gastrointestinal Bleeding • Other causes include IBD, neoplasms, infectious colitis, radiation

colitis or proctitis, postpolypectomy ulcer, stercoral ulcer, Meckel's diverticulum, &much less frequently, colonic varices & Dieulafoy's lesions.

• The most frequent causes of chronic LGIB are neoplasms, angiectasia &IBD.

Lower Gastrointestinal Bleeding • Angiectasia refers to painless ectatic dilated submucosal vessels

that most commonly occur in the cecum& proximal colon in patients who are typically 60 years of age or older.

Lower Gastrointestinal Bleeding • Ischemic colitis is caused by a decline in mesenteric blood flow&

often involves the watershed areas of the colon, as the splenic flexure&sigmoid colon where perfusion is relatively decreased, although any segment of the colon may be affected.

• Patients with ischemic colitis typically report relative hypotension followed by mild abdominal pain &passage of bright red blood from the rectum approximately 24 hours later.

Lower Gastrointestinal Bleeding • Patients with perianal disease, as hemorrhoids/ fissures, may have

pain with defecation & bleeding after using toilet paper & careful perianal exam with anoscopy may assist in the diagnosis.

Evaluation: • Patients with acute LGIB present with hematochezia, melena, or

passing of clots & may also have chest pain, shortness of breath, lightheadedness, syncope, or other ischemic features.

• Those with chronic LGIB may have symptoms of fatigue/dyspnea on exertion due to IDA, or the bleeding may be detected incidentally after a positive fecal occult blood test.

• The initial evaluation includes a brief history /physical exam. • The presence of associated diarrhea, fever, abdominal or rectal

pain should be noted. • The patient should also be asked about previous episodes of

LGIB, use of aspirin or other NSAIDs, a history of pelvic radiation therapy, episodes of relative hypotension, recent polypectomy& severe constipation.

• The physical exam should focus on the cardiopulmonary system, abdomen, rectum.

Evaluation: • Lab studies are the same as those for the diagnosis of UGUB• Independent risk factors for severe LGIB are an initial

hematocrit ≤35%, tachycardia, hypotension, gross blood on initial rectal exam.

Management:• Initial management involves hemodynamic stabilization.• Most episodes of LGIB stop without intervention. • The cause of the bleeding should be determined once the patient is

hemodynamically stable. • The initial step is to rule out brisk bleeding from UGIB because

10-15% of patients with presumptive LGIB may actually have a more proximal source.

• If features such as hematemesis, bloody NGT aspirate, or hemodynamic instability suggest a proximal lesion, upper endoscopy is performed first.

• If no features of UGIB are present, colonoscopy is the initial test of choice.

• Patients with chronic bleeding can be scheduled for elective colonoscopy with complete colonic purging prior to the procedure.

Management:• Patients with acute bleeding can safely undergo colonoscopy as

the first-line test. • Colonic purging should be attempted(sometime through NGT) in

order to provide better visualization, decrease the risk of perforation, permit therapeutic techniques that require adequate bowel preparation in order to be used safely.

• The injection, thermal, mechanical therapeutic modalities used to control UGIB can also be used during colonoscopy&the type of lesion found directs the therapeutic modality used.

• If colonoscopy identifies a source of bleeding, management can be focused,but if not, additional diagnostic studies, such as angiography or a radionuclide imaging study, are required.

Management:• Visualization of the bleeding site by angiography requires a

bleeding rate of at least 1 mL/min& should be done in place of colonoscopy in patients with:

• Massive bleeding.• Persistent bleeding despite endoscopic evaluation & treatment• The source of bleeding is still unknown after colonoscopy. • Angiography can also be used therapeutically to provide selective

microcoil embolization or vasopressin infusion. • Side effects of angiography include contrast-induced

complications, localized ischemia due to embolization &generalized ischemia due to vasopressin administration.

• Although it provides accurate localization if a bleeding site is found, angiography is not a sensitive study because of the high rate of ongoing bleeding required to identify a source.

Management:• Radionuclide imaging can detect bleeding occurring at a rate of

0.1–0.5 mL/min, is more sensitive than angiography, can be done prior to angiography to detect ongoing bleeding,but the images produced are not as specific as angiographic images for localizing the source of bleeding& therapeutic intervention is not possible

Management:• If angiography & radionuclide imaging studies fail to locate the

bleeding source, a small bowel evaluation using either push enteroscopy or capsule endoscopy should be performed.

• A Meckel scan should also be considered in younger patients with LGIB.

• Also patients with chronic bleeding & normal results on upper endoscopy & colonoscopy require small bowel evaluation because the slow bleeding rate precludes use of angiography & radionuclide imaging.

• Surgical consultation should be requested for patients who have an unidentified source of bleeding after initial endoscopic evaluation& who continue to have massive bleeding or become unstable.

Management:• Although most episodes of acute LGIB stop spontaneously,

patients usually require hospitalization because of the generally advanced age, the presence of comorbid conditions& the need for transfusions.

• Admission to an ICU should be considered for those with ongoing bleeding, large transfusion requirements, ischemic complications, or significant comorbid disorders.

• Mortality from LGIB is <5%& is highest in those who are hospitalized for other reasons when the bleeding episode occurs.