Gastrointestinal Hemorrhage (GI Bleed)

Epidemiology

  • Anatomic Distribution of Sites of Gastrointestinal Hemorrhage: 90% of quantitatively important gastrointestinal hemorrhage episodes originate from a site above the ligament of Treitz
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Risk Factors

Coagulopathy

Acquired Vitamin K Deficiency (see Vitamin K, [[Vitamin K]])

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Anticoagulation

  • Coumadin (see Coumadin, [[Coumadin]])
  • Factor IIa (Thrombin) Inhibitors (see Factor IIa Inhibitors, [[Factor IIa Inhibitors]])
    • Argatroban (Acova) (see Argatroban, [[Argatroban]])
    • Bivalirudin (Angiomax, Angiox) (see Bivalirudin, [[Bivalirudin]])
    • Dabigatran (Pradaxa) (see Dabigatran, [[Dabigatran]])
    • Desirudin (Iprivask, Revasc) (see Desirudin, [[Desirudin]])
    • Lepirudin (Refludan (see Lepirudin, [[Lepirudin]])
  • Factor Xa Inhibitors (see Factor Xa Inhibitors, [[Factor Xa Inhibitors]])
    • Apixaban (Eliquis) (see Apixaban, [[Apixaban]])
    • Betrixaban
    • Danaparoid (Orgaran) (see Danaparoid, [[Danaparoid]])
    • Edoxaban (Lixiana) (see Edoxaban, [[Edoxaban]])
    • Fondaparinux (Arixtra (see Fondaparinux, [[Fondaparinux]])
    • Rivaroxaban (Xarelto) (see Rivaroxaban, [[Rivaroxaban]])
  • Heparins
    • Dalteparin (Fragmin) (see Dalteparin, [[Dalteparin]])
    • Enoxaparin (Lovenox) (see Enoxaparin, [[Enoxaparin]])
    • Heparin (Unfractionated) (see Heparin, [[Heparin]])

Antiplatelet Agents

Coagulopathic Conditions

IIb/IIIa Inhibitors (see IIb IIIa Inhibitors, [[IIb IIIa Inhibitors]])

  • Abciximab (ReoPro) (see Abciximab, [[Abciximab]])
  • Eptifibatide (Integrilin) (see Eptifibatide, [[Eptifibatide]])
  • Tirofiban (Aggrastat) (see Tirofiban, [[Tirofiban]])

Thrombocytopenia (see Thrombocytopenia, [[Thrombocytopenia]])

Thrombolytics (see Thrombolytics, [[Thrombolytics]])

Drugs

  • Bisphosphonates (see Bisphosphonates, [[Bisphosphonates]])
    • Physiology: xxx
  • Selective Serotonin Reuptake Inhibitors (SSRI’s) (see Selective Serotonin Reuptake Inhibitors, [[Selective Serotonin Reuptake Inhibitors]])
    • Physiology: possibly related to their effects on platelet serotonin

Etiology-Upper Gastrointestinal Hemorrhage

Etiology-Lower Gastrointestinal Hemorrhage

  • Anal Fissure
  • Colorectal Cancer (see Colorectal Cancer, [[Colorectal Cancer]])
  • Colonic Arteriovenous Malformation (AVM): may manifest as small, recurrent bleeds or massive bleed
  • Colonic Ischemia (see Colonic Ischemia, [[Colonic Ischemia]])
  • Colonic Polyps
    • Espically may occur after polyp biopsy
  • Diverticulosis: typically arterial source -> may be brisk
  • Hemorrhoids
  • Infectious Colitis
    • Amebiasis (see Amebiasis, [[Amebiasis]])
    • Campylobacter (see xxxx, [[]])
    • Shigellosis (see xxxx, [[]])
  • Inflammatory Bowel Disease (IBD)
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Etiology

Toxin

  • Glyphosate Ingestion (see Glyphosate, [[Glyphosate]])
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Drugs

  • Tolvaptan (Samsca) (see Tolvaptan, [[Tolvaptan]])

Diagnosis

NG Tube

  • Useful to exclude UGI source only if bile is returned (bile indicates adequate duodenal sampling)
    [Cuellar, Arch Int Med, 1990]

Rectal Exam

  • 10% of hematochezia is due to an UGI source
    [Jensen, Gastroenterol, 1988]

Tagged RBC Scan

  • Requires 0.1 ml/min bleeding to detect: higher sensitivity than angiogram
  • However, exact site of bleeding is not always clear, even when detected

IR Mesenteric Angiogram

  • Requires 0.5-1 ml/min bleeding rate to detect
  • Only 60% sensitive in detecting LGI bleeding site

Clinical Manifestations-Upper Gastrointestinal Hemorrhage

Cardiovascular Manifestations

  • Extent of Blood Loss
    • 15% loss of blood volume: usually readily tolerated and compensated by contraction of large veins and recruitment of fluid from extravascular site
    • 15-40% loss of blood volume: constriction of arterioles, shunting of cardiac output from nonvital areas such as skin and bone, tachycardia, decreased cardiac output, and orthostatic hypotension occur
      • The patient is likely to be thirsty and feel faint when standing
    • 40-50% depletion of blood volume: shock, impaired flow of blood to vital organs, tissue hypoxemia, lactic acidosis, and ultimately, death
  • Hypotension (see Hypotension, [[Hypotension]])
  • Syncope (see Syncope, [[Syncope]])

Gastrointestinal Manifestations

  • Coffee-Ground Emesis: emesis or gastric aspirate resembling dark brown coffee grounds
    • Generally indicates an upper GI source
  • Hematemesis: bright red bloody vomitus
    • Indicates an upper GI source
    • Indicates a large volume of hemorrhage
  • Melena: tarry/black stools
    • Generally indicates an upper gastrointestinal source (with source proximal to ligament of Treitz)
      • However, melena may be seen in some cases (with slow intestinal transit times) with a bleeding source in the small intestine or cecum
    • Melena is the most common presenting symptom of major GI bleeding
    • It takes at least 50 ml of blood in the stomach to turn stools black
    • Approximately 1-2L of blood administered orally will cause bloody or tarry stools for up to 5 days (the first such stool usually appearing within 4 to 20 hours after ingestion) -> therefore, melena indicates recent GI bleeding, but does not provide any informstion about the rapidity or quantity of bleeding
    • Black stools may also occur due to iron or bismuth use

Clinical Manifestations-Lower Gastrointestinal Hemorrhage

Cardiovascular Manifestations

  • Extent of Blood Loss
    • 15% loss of blood volume: usually readily tolerated and compensated by contraction of large veins and recruitment of fluid from extravascular site
    • 15-40% loss of blood volume: constriction of arterioles, shunting of cardiac output from nonvital areas such as skin and bone, tachycardia, decreased cardiac output, and orthostatic hypotension occur
      • The patient is likely to be thirsty and feel faint when standing
    • 40-50% depletion of blood volume: shock, impaired flow of blood to vital organs, tissue hypoxemia, lactic acidosis, and ultimately, death
  • Hypotension (see Hypotension, [[Hypotension]])
  • Syncope (see Syncope, [[Syncope]])

Gastrointestinal Manifestations

  • Hematochezia: bright red blood per rectum
    • Generally indicates a lower GI source (although some cases of brisk upper GI bleeding, especially esophageal variceal bleeding, may present with hematochezia)

Treatment

Treatment of Non-Variceal Upper Gastrointestinal Hemorrhage

Supportive Care

  • NPO Status
  • Intravenous Fluid Resuscitation : as required to mainatin circulatory status

Correction of Coagulopathy

  • xxx : in patients receiving anticoagulants, correction of coagulopathy is recommended but should not delay endoscopy. [Consensus Guidelines, Ann Int Med 2010; 152(2): 101-113]

Packed Red Blood Cell Transfusion

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Nasogastric Tube Insertion

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Proton Pump Inhibitors (PPI)

  • Intermittent Intravenous Proton Pump Inhibitor Dosing: less expensive than administration by continuous infusion
    • Pantoprazole (Protonix) (see Pantoprazole, [[Pantoprazole]]): 40 mg IV BID
  • Continuous Intravenus Proton Pump Inhibitor Infusion: recommended by current guidelines [MEDLINE], although it is more expensive and labor-intensive
    • Bolus Pantoprazole (Protonix) (see Pantoprazole, [[Pantoprazole]]): 80 mg IV x1
    • Maintenance Pantoprazole (Protonix) (see Pantoprazole, [[Pantoprazole]]): 8 mg/hr infusion x 72 hrs
  • Systematic Review and Meta-Analysis of Proton Pump Inhibitor Continuous Infusion vs Intermittent Intravenous Proton Pump Inhibitor Dosing (2014) [MEDLINE]
    • Study: systematic review and meta-analysis
    • Primary Outcome: rebleeding at 7 days (additional predefined outcomes: rebleeding within 3 and 30 days, need for urgent intervention, mortality, red blood cell transfusion, and length of hospital stay)
    • Main Findings: intermittent intravenous proton pump inhibitor dosing is comparable to continuous proton pump inhibitor intravenous infusion with endoscopically treated high-risk bleeding ulcers

Esophagogastroduodenoscopy (EGD)

  • Early endoscopy (within 24 hours of presentation) is recommended for most patients with acute upper gastrointestinal bleeding. [Consensus Guidelines, Ann Int Med 2010; 152(2): 101-113]

[MEDLINE]

  • Selected patients with acute ulcer bleeding who are at low-risk for rebleeding on the basis of clinical and endoscopic criteria may be discharged promptly after endoscopy. [Consensus Guidelines, Ann Int Med 2010; 152(2): 101-113]
    • Low-Risk Criteria
      • Clean ulcer base or flat pigmented spot
      • Hemodynamic stability
      • No serious concurrent medical illness
      • Easy accessibility to hospital
      • Adequate sociofamily support at home
  • Most patients who have undergone endoscopic hemostasis for high-risk endoscopic stigmata should be hospitalized for at least 72 hours thereafter. [Consensus Guidelines, Ann Int Med 2010; 152(2): 101-113]

Interventional Radiology Embolization

  • Where available, IR-embolization can be considered as an alternative to surgery for patients for whom endoscopic therapy has failed. [Consensus Guidelines, Ann Int Med 2010; 152(2): 101-113]

Reinstitution of Cardiovascular Anti-Platelet Agents

  • In patients with previous ulcer bleeding who require cardiovascular prophylaxis, it should be recognized that clopidogrel alone has a higher risk for rebleeding than ASA combined with a PPI. [Consensus Guidelines, Ann Int Med 2010; 152(2): 101-113]

Treatment of Variceal Upper Gastrointestinal Hemorrhage


Treatment of Lower Gastrointestinal Hemorrhage

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References

  • International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010 Jan 19;152(2):101-13. doi: 10.7326/0003-4819-152-2-201001190-00009 [MEDLINE]
  • Intermittent vs continuous proton pump inhibitor therapy for high-risk bleeding ulcers: a systematic review and meta-analysis. JAMA Intern Med. 2014;174(11):1755 [MEDLINE]