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GI Bleeding

  • Paul Ellis Marik
Chapter

Abstract

• The urgency with which GI bleeding is managed is dictated by the rate of bleeding:

– The patient with trace heme-positive stools and without severe anemia can be managed as an outpatient.

– Visible blood requires hospitalization and inpatient evaluation.

– Persistent bleeding or rebleed with hemodynamic instability necessitates ICU admission.

Keywords

Transjugular Intrahepatic Portosystemic Shunt Variceal Bleeding Endoscopic Therapy Gastric Varix Proton Pump Inhibitor Therapy 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Initial Assessment

  • The urgency with which GI bleeding is managed is dictated by the rate of bleeding:
    • The patient with trace heme-positive stools and without severe anemia can be managed as an outpatient.

    • Visible blood requires hospitalization and inpatient evaluation.

    • Persistent bleeding or rebleed with hemodynamic instability necessitates ICU admission.

    • Massive bleeding is defined as loss of 30% or more of estimated blood volume or bleeding requiring blood transfusion of 6 or more units/24 h.

  • Hemodynamic assessment (see Table 36-1):
    • Blood pressure, pulse, postural changes, and assessment of peripheral perfusion.

  • The presence of comorbid disease must be determined, especially CAD and cardiac failure.

  • Estimating blood loss. This can be estimated by measuring the return from an NG tube.

  • An approximate estimate of blood loss can also be made by the hemodynamic response to a 2-L crystalloid fluid challenge:
    • If BP returns to normal and stabilizes, blood loss of 15–30% has occurred.

    • If BP rises but falls again, blood volume loses of 30–40% has occurred.

    • If BP continues to fall, blood volume loss of >40% has probably occurred.

  • History and examination: Attempt to localize most likely source of bleeding:
    • Use of NSAID, alcohol, anti-platelet drugs, and anti-coagulants.

    • History of GERD, chronic epigastric pain, renal failure, weight loss, vomiting before bleeding, etc.

    • Previous history of bleeding

    • The presence of melena indicates upper GI bleeding.

    • Hematemesis indicates upper GI bleeding.

    • When small amounts of bright red blood are passed per rectum, the lower GI tract can be assumed to be the source.

    • In patients with large-volume maroon stools, NG tube aspiration should be performed to exclude upper GI hemorrhage. It should be noted that in about 15% of patients with upper gastrointestinal bleeding, NG aspirate will fail to obtain blood or “coffee ground” material.

  • Nasogastric aspiration with saline lavage is beneficial to detect the presence of intragastric blood, to determine the type of gross bleeding, to clear the gastric field for endoscopic visualization, and to prevent aspiration of gastric contents. NG tube placement is essential to monitor ongoing bleeding and to decompress the stomach.

  • Concerns that placement of a nasogastric tube may induce bleeding in patients with coagulopathies are outweighed by the benefits of the information obtained.

  • Laboratory tests:
    • Serum chemistries (incl. BUN and creatinine), CBC, coagulation profile (PT, PTT, INR), liver function tests.

    • Cardiac enzymes (troponins) and ECG.

Table 36-1.

Correlation between physical signs and severity of UGIB.

Physical Sign

Mild

Moderate

Severe

Blood loss

<1 l

1–2 l

≥2 l

Blood pressure

Normal

N-borderline low

Hypotensive

Orthostasis

No

Possible

Likely

Tachycardia

None–mild

Moderate

Severe

Skin

Warm, perfused

Diaphoretic

Cool, clammy

Urine output

Normal

Diminished

Poor

Sensorium

Alert/anxious

Anxious

Confused/drowsy

Initial Resuscitation

  • Establish two large bore IV lines or a large bore central line.

  • Insert NG tube and aspiration (by hand).

  • Volume expansion with crystalloids (LR preferred, see  Chapter 8).

  • Monitor BP, pulse, and urine output.

  • Cross match blood. Blood products are the most efficient volume expanders and should be infused as soon as possible in patients with significant bleeds. Transfusion requirements are determined by multiple factors, including patient age, presence of comorbidities, cardiovascular status, baseline hematocrit, and tempo of the bleeding, along with the current hematocrit level. RBCs are transfused in patients who have significant blood loss, continuing active bleeding, and those who manifest cardiac, renal, or cerebral ischemia (regardless of HCT). The rate of blood transfusion is determined by the severity of the hypovolemia, by the tempo of the bleeding, and by the presence of cardiac, renal, or cerebrovascular comorbidities. Generally RBSs should be transfused to maintain a hemoglobin concentration between 8 and 10 g/dl (see  Chapter 51):
    • It is important to note that it takes up to 72 h for the hematocrit to reach its nadir after a single episode of bleeding (assuming no other intervention). Therefore, a normal hemoglobin (on admission) does not exclude significant bleeding. Blood transfusion should not be withheld from actively bleeding patients, based on their hemoglobin/hematocrit. Conversely a falling hematocrit does not imply continued bleeding but rather may represent equilibration of fluid between the intravascular and the extracellular extravascular compartment.

    • Patients who have variceal bleeding should be transfused to a hematocrit of 25–27 (Hb 8–9 g/dl) to avoid exacerbating the bleeding by increasing the portal pressure. In a small RCT, 25 cirrhotic patients who were transfused aggressively with transfusion of at least 2 units of PRBs had a significantly higher risk for rebleeding than did 25 similar cirrhotic patients who were transfused conservatively with transfusion only for shock or a hemoglobin <8.1

  • In patients with active bleeding, fresh frozen plasma should be given if the INR >1.4. Platelet transfusion is indicated if the platelet count is <50,000/mm3. In addition, FFP should be given after 6 units of RBCs and platelets after 10 units (see  Chapters 52 and  53).

  • Airway protection. The risk of aspiration is especially high in patients with massive bleeding or those who have an altered mental status. Endotracheal intubation is recommended in these patients. In addition, endotracheal intubation facilitates endoscopy. It may be advisable to place an NG tube prior to intubation in an attempt to empty the stomach and reduce the risk of aspiration during endotracheal intubation.

  • In patients with severe upper GI bleeding and clinical evidence or a history of advanced liver disease, or a history of previous variceal bleeding, an octreotide infusion should be commenced prior to endoscopy (see treatment of variceal hemorrhage below)

  • In patients with presumed UGIB, proton pump inhibitor (PPI) therapy is recommended before EGD. The rationale for PPI therapy is that the most common causes of UGIB, including ulcers, gastritis, duodenitis, and hemorrhagic reflux esophagitis, are medically treated with acid-suppressive therapy. PPI therapy is also useful, however, for hemostasis of lesions that are not caused by acid and are not in other circumstances treated by PPI therapy, probably because neutralization of intraluminal gastric acid promotes hemostasis by stabilizing blood clots. Experimental data have shown that gastric acid impairs clot formation, promotes platelet disaggregation, and favors fibrinolysis.

  • Intravenous erythromycin (70–100 mg), through its effect as a motilin receptor agonist, has been shown to promote gastric motility and substantially improve visualization of the gastric mucosa on initial endoscopy.

  • All patients who have acute GIB require gastroenterology consultation.

  • Surgical consultation is recommended for patients who have ongoing active bleeding, massive bleeding, recurrent bleeding, bleeding associated with significant abdominal pain, acute lower gastrointestinal bleeding, and abdominal findings suggestive of an acute abdomen.

Triage of Patients: Who to Admit to the ICU?

At the time of triage the following criteria can stratify patients into a high-risk group (high risk of rebleeding, requiring surgery, and dying):
  • A systolic blood pressure of <100 mmHg on admission;

  • Severe comorbid disease;

  • Evidence of active, ongoing GI hemorrhage at the time of triage;

  • INR >1.4.

The rate of rebleeding is approximately 3% in the low-risk group as compared to 25% in the high-risk group. Patients in the low-risk group do not require admission to an ICU and can be adequately managed on a general medical floor.

Upper GI Bleeding (UGIB)

Upper gastrointestinal bleeding (UGIB) is a common, potentially life-threatening condition responsible for more than 300,000 hospital admissions and about 30,000 deaths per annum in the United States. Accurate patient evaluation and appropriate early management before esophagogastroduodenoscopy (EGD) are critical to decrease the morbidity and mortality.2

UGIB is defined as bleeding proximal to the ligament of Treitz to differentiate it from lower gastrointestinal bleeding involving the colon and middle gastrointestinal bleeding involving the small intestine distal to the ligament of Treitz. It has a mortality of 7–10%.2 The mortality has decreased only minimally during the last 30 years despite the introduction of endoscopic therapy that reduces the rate of rebleeding. This observation has been attributed to the increasing percentage of UGIB occurring in the elderly who have a much worse prognosis than other patients because of their frequent use of anti-platelet medications or anti-coagulants and their frequent comorbid conditions.

The major causes of UGIB include the following:
  • Peptic ulcer disease

  • Esophageal and gastric varices

  • Hemorrhagic gastritis

  • Esophagitis

  • Mallory–Weiss tear

  • Upper GI malignancy

  • Dieulafoy lesion

Helicobacter pylori and the use of NSAIDs are the predominant cause of PUD in the United States accounting for approximately 50 and 25% of cases, respectively.3

Further Management of Upper GI Bleeding

Early upper gastrointestinal endoscopy is the cornerstone of management of upper gastrointestinal bleeding. Endoscopy within 12–24 h of presentation is generally recommended. EGD is the prime diagnostic and therapeutic tool for UGIB.4

Early endoscopy serves three vital roles:
  • Diagnosis:
    • It accurately delineates the bleeding site and determines the specific cause. EGD is 90–95% diagnostic for acute UGIB.

  • Treatment:
    • Non-variceal bleeding. Endoscopic therapy has been shown to improve outcomes in patients with non-variceal bleeding. The endoscopic methods of controlling bleeding include thermal coagulation of a bleeding vessel, injection of a bleeding site with epinephrine or a sclerosing agent, and laser therapy to produce tissue coagulation. Endoscopic therapy has been shown to be of benefit to patients with actively bleeding lesions or lesions that have a protuberance in the ulcer crater (i.e., a visible vessel) seen on endoscopy. The rate of rebleeding in patients with active bleeding or non-bleeding visible vessel is reduced by about 50% with endoscopic therapy.5 However, in about 20% of such patients, bleeding recurs.

    • Variceal bleeding. Endoscopic sclerotherapy and/or band ligation is the method of choice in controlling active variceal hemorrhage.

  • Risk stratification:
    • Establishing an endoscopic diagnosis of the lesion and associated stigmata greatly enhances the ability to predict outcomes (i.e., the risk of rebleeding).

    • The endoscopic appearance of a bleeding ulcer can be used to predict the likelihood of recurrent bleeding on the basis of the Forrest classification, which ranges from IA to III. High-risk lesions include those characterized by active spurting of blood (grade IA) or oozing blood (grade IB), a non-bleeding visible vessel described as a pigmented protuberance (grade IIA), and an adherent clot (grade IIB). Low-risk lesions include flat, pigmented spots (grade IIC), and clean-base ulcers (grade III).5

Further Management of Bleeding Peptic Ulcers

  • A meta-analyses showed that the use of PPIs significantly decreased the risk of ulcer rebleeding (odds ratio 0.40; 95% CI 0.24–0.67), the need for urgent surgery (odds ratio 0.50; 95% CI 0.33–0.76), and the risk of death (odds ratio 0.53; 95% CI 0.31–0.91).6

  • A pooled analysis of 16 RCTs that enrolled more than 3,800 patients suggested that an intravenous bolus loading followed by a continuous infusion of a PPI is more effective than bolus dosing alone in decreasing the rates of rebleeding and the need for surgery.7 Based on these data, an intravenous bolus followed by a continuous infusion of a PPI for 72 h after endoscopic hemostasis is recommended.

  • Planned, second-look endoscopy that is performed within 24 h after initial endoscopic therapy is not recommended.5

  • For most patients with evidence of persistent ulcer bleeding or rebleeding, a second attempt at endoscopic hemostasis is often effective, may result in fewer complications than surgery, and is the recommended management approach.4,8

  • Angiography with transcatheter embolization provides a non-operative option for patients in whom a site of acute bleeding has not been identified or controlled by endoscopy. Transcatheter embolization has been shown to significantly reduce mortality in patients with UGIB, although uncommon complications include bowel ischemia, secondary duodenal stenosis, and gastric, hepatic, and splenic infarction. In most institutions, radiological intervention is reserved for patients in whom endoscopic therapy has failed, especially if such patients are high-risk surgical candidates.

  • Patients should be tested and treated for H. pylori infection.

  • Evaluation for any ongoing need for a non-steroidal anti-inflammatory or anti-platelet agent and, if such treatment is indicated, appropriate coadministration of a gastroprotective agent are important.

Further Management of Esophageal Varices

  • In patients with variceal hemorrhage, there remains a 40% chance of recurrent variceal bleeding within 72 h and a 60% chance within 10 days if no additional treatment is pursued.

  • Octreotide 50 μg bolus followed by an infusion of at a rate of 50 μg/h has been demonstrated to reduce the risk of early rebleeding.

  • Endoscopic banding in combination with an octreotide infusion is more effective than endoscopic therapy alone for controlling bleeding and reducing the incidence of rebleeding.

  • There is a close association between infection and variceal bleeding (see  Chapter 33). A complete microbiological workup, including blood cultures and diagnostic paracentesis, when appropriate should be performed. Furthermore, antibiotic prophylaxis has been demonstrated to reduce the risk of infections in patients with variceal bleeding and to improve short-term survival.9 Prophylaxis with a third-generation cephalosporin, quinolone, or amoxicillin–clavulanic acid is recommended.

  • Paracentesis significantly decreases variceal pressure and tension.10 This suggests that ascites removal can be useful in the treatment of variceal bleeding in cirrhotic patients.

  • There is a small chance that placement of a feeding tube/NG tube after variceal banding may dislodge the bands and or cause bleeding. This should therefore be delayed for 48–72 h.

  • Balloon tamponade with a Minnesota or Sengstaken–Blakemore tube can be lifesaving in the presence of severe ongoing bleeding when carried out by experienced staff. However, placement by inexperienced staff is associated with an increased risk of death largely due to esophageal perforation and pulmonary aspiration.

  • TIPPS (transjugular intrahepatic portosystemic shunt) is a radiological intervention that creates a portosystemic tract through the liver parenchyma, through which an 8–12-mm expandable metal stent is inserted. TIPPS has become the treatment of choice as rescue therapy in the 10–20% of patients with variceal hemorrhage unresponsive to endoscopic management. TIPPS has largely replaced emergency surgical shunting. The main limitations of TIPPS are the development of encephalopathy in about 20% of patients and progressive development of shunt insufficiency (thrombosis).

  • Gastric varices are the source of bleeding in 10–36% of patients with variceal hemorrhage. Unless the gastric varices are located on the proximal lesser curve, they are not amenable to endoscopic ligation and for this reason, early TIPPS is generally recommended.

  • Non-selective β-blockers (nadolol or propranolol) reduce the risk of rebleeding. A combination of endoscopic treatment together with β-blockers reduces overall and variceal rebleeding more than either therapy alone.11

  • The role of TIPPS in preventing recurrent bleeding is unclear with studies showing discordant results with no clear survival benefit.

Management of Patients with Lower GI Bleeding

Angiodysplasia and diverticular disease of the right colon account for the vast majority of episodes of acute lower GI bleeding. The spontaneous remission rate, even with massive bleeding, is approximately 80%. In patients with ongoing lower GI bleeding, a radionuclide bleeding scan is indicated. There are two types of bleeding scan. The first is a technetium-labeled sulfur colloid scan, which although very sensitive can only detect bleeding that occurs during the 1–2 h following injection of the isotope. Alternatively, a technetium-labeled (“tagged”) red blood cell bleeding scan can detect bleeding sites for up to 24 h after the cessation of bleeding. If the result of either type of bleeding scan is positive, angiography should then be performed.

Selective mesenteric angiography detects arterial bleeding that occurs at a rate of 0.5 ml/min or faster. It can be both diagnostic and therapeutic. When active bleeding is seen selective, arterial infusion of vasopressin arrests the hemorrhage in 90% of patients; adding sterile, absorbable gelatin powder further increases the efficacy of vasopressin. If bleeding continues and no source has been found, surgical intervention is warranted. Surgical intervention is also recommended in patients with recurrent diverticular bleeding.

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Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Division of Pulmonary and Critical Care MedicineEastern Virginia Medical SchoolNorfolkUSA

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