GI Bleeding

Upper GI Bleeding: 
Patients with acute upper gastrointestinal (GI) bleeding commonly present with hematemesis (vomiting of blood or coffee-ground like material) and/or melena (black, tarry stools). The initial evaluation of patients with acute upper GI bleeding involves an assessment of hemodynamic stability and resuscitation if necessary.  
 
Etiology
The most common causes of upper gastrointestinal bleeding include the following: 
  1. Gastric and/or duodenal ulcers ( H.Pylori, NSAID’s, Stress, Increased gastric acid production) 
  2. Esophagogastric varices with or without portal hypertensive gastropathy 
  3. Esophagitis ( Drugs, infectious, inflammatory) 
  4. Angiodysplasia 
  5. Mass lesions (polyps/cancers) 
  6. Dieulafoy's lesion 
  7. Erosive gastritis/duodenitis 
  8. Mallory-Weiss syndrome 
Diagnosis 
  1. CBC, BMP, liver tests, and coagulation studies.
  2. Serial electrocardiograms and cardiac enzymes may be indicated in patients who are at risk for a myocardial infarction, such as the elderly, patients with a history of coronary artery disease, or patients with symptoms such as chest pain or dyspnea. 
  3. TEG analysis may be helpful in patients who are on long term anticoagulation or on antiplatelt therapy.
 
Intial hemoglobin in actively bleeding patients may be normal before fluid resuscitation, as they are losing whole blood. Patients with acute bleeding also have normocytic anemia. Microcytic anemia or iron deficiency anemia suggest chronic bleeding. Patients with acute upper GI bleeding typically have a disproportionately elevated blood urea nitrogen (BUN)-to-creatinine or urea-to-creatinine ratio (>20:1 to >100:1). 
 
Upper endoscopy — Upper endoscopy is the diagnostic modality of choice for acute upper GI bleeding. Early endoscopy (within 24 hours) is recommended for most patients with acute UGI bleeding.  
 
Other diagnostic tests — Other diagnostic tests for acute upper GI bleeding include CT angiography and a tagged RBC scan, which can detect active bleeding. Tagged RBC scan is more preferred for minor occult bleeding and CT angiogram is preferred for active bleeding. Upper GI barium studies are contraindicated in the setting of acute upper GI bleeding because they will interfere with subsequent endoscopy, angiography, or surgery. 
 
Treatment of UGI Bleeding: 
  1. Closely monitor airway, clinical status, vital signs, cardiac rhythm, urine output, nasogastric output (if nasogastric tube in place) 
  2. Do not give patient anything by mouth . 
  3. Establish two large bore IV lines (16 gauge or larger) 
  4. Provide supplemental oxygen 
  5. Treat hypotension initially with rapid, bolus infusions of isotonic crystalloids. 
  6. Transfuse for: 
    • Hemodynamic instability despite crystalloid resuscitation 
    • Hemoglobin <7 g/dL. Restrictive strategy has been proved to be more beneficial than liberal transfusion strategy.  N Engl J Med. 2013 Jan 3;368(1):11-21. All the patients in this study underwent emergent upper endoscopy with a mean duration from admission to upper endoscopy of 5 hours.
  7. Avoid over-transfusion in patients with variceal bleeding, as it can worsen bleeding due to increased portal blood flow and increased prtal pressures.  
  8. Give fresh frozen plasma for coagulopathy; give platelets for thrombocytopenia (platelets <50,000) or functional platelet dysfunction (eg, chronic aspirin therapy). In patients receiving anticoagulants, correction of coagulopathy
    is recommended but should not delay endoscopy.  Following endoscopy, INR of even upto 2.7 is safely tolerated and doesn't increase the risk of rebleeding.
    Am J Gastroenterol. 2007 Feb;102(2):290-6
  9. Obtain immediate consultation with gastroenterologist; Consider early surgical and interventional radiology consultation for any massive bleeding 
  10. Nasogastric lavage in UGI bleeding is controversial. Gastrointest Endosc. 2011 Nov;74(5):971-80. Lavage may dislodge the clot and may worsen the bleeding. The only indication for NG lavage is if it is unclear between UGI and LGI bleed. Even then, gentle NG aspiration might be enough. 
  11. Give a proton pump inhibitor (eg, protonix 80 mg IV bolus, followed by 8 mg/hour. PPIs promote hemostasis because neutralization of gastric acid leads to the stabilization of blood clots.  
After successful endoscopic hemostasis, intravenous PPI continuous infusion for a total of 72 h should be given to patients who have an ulcer with active bleeding, a non-bleeding visible vessel, or an adherent clot. Patients with ulcers that have flat pigmented spots or clean bases can receive standard PPI therapy (e.g., oral PPI once daily). If there is no rebleeding, the patient may be switched to oral pantoprazole 40 mg/day.  It is unlikely that an IV PPI would be of significant benefit in patients who do not have active bleeding or other high-risk stigmata (such as a visible vessel or adherent clots) because their risk of recurrent bleeding is low. Such patients may be switched to a standard dose oral PPI immediately following endoscopy.  Aliment Pharmacol Ther. 2013 Oct;38(7):721-8 Am J Gastroenterol. 2014 Jul;109(7):1005-10
  1. Continuous vs Intermittent PPI: Intermittent PPI therapy is comparable to continuous infusion of PPIs in patients with endoscopically treated high-risk bleeding ulcers. JAMA Intern Med. 2014 Nov;174(11):1755-62
  2. Give somatostatin analogue (eg, Octreotide 50 mcg bolus, followed by 50 mcg/hour infusion) for variceal bleeding. Octreotide reduce splanchnic blood flow, inhibit gastric acid secretion, and may have gastric cytoprotective effects.  Lancet. 1974 Nov 9;2(7889):1106-9.
Even though Octreotide is not recommended for routine use in patients with acute nonvariceal upper GI bleeding, but it can be used as adjunctive therapy in some cases. There is evidence to support the use of octreotide in variceal and non-variceal upper GI bleeding (UGB). Ann Intern Med. 1997 Dec 15;127(12):1062-71As a somatostatin analogue, octreotide binds with endothelial cell somatostatin receptors, inducing strong, rapid and prolonged vaso-constriction. Octreotide reduces portal and variceal pressures as well as splanchnic and portal-systemic collateral blood flows. Octreotide inhibits both acid and pepsin secretion. As a result, it prevents the dissolution of freshly formed clots at the site of bleeding.  
  1. Give a prophylactic antibiotic for 7 days (eg, Ceftriaxone, Augmentin, or Quinolone) for variceal bleeding.  
  2. Balloon tamponade may be performed as a temporizing measure for patients with uncontrollable hemorrhage likely due to varices using any of several devices (eg, Blakemore tube, Minnesota tube); tracheal intubation is necessary if such a device is to be placed; ensure proper device placement prior to inflation to avoid esophageal rupture i.e. always confirm the placement of Blakemore tube in the stomach before inflating the balloon to minimize the risk of esophageal rupture.  
  3. Endoscopy within 24 hours remains the first choice therapy. Possible banding, sclerotherapy, epinephrine injection, or cryotherapy may be needed. During endoscopy, finding of a clot in an ulcer bed warrants targeted irrigation in an attempt at dislodgement, with appropriate treatment of the underlying lesion
  4. Surgery: Indications for surgery include hemodynamic instability inspite of volume resuscitation, recurrent bleeding and bowel perforation. 
  5. Patients with H. pylori -associated bleeding ulcers should receive H. pylori therapy. After documentation of eradication, maintenance antisecretory therapy is not needed unless the patient also requires NSAIDs or antithrombotics.  
  6. Erythromycin is a motilin receptor agonist that has been shown to enhance antroduodenal coordination and promote gastric emptying. Intravenous erythromycin improves the endoscopic visualization. The dose is 3mg/kg given 20-120 mins before the procedure.  Gastrointest Endosc. 2002 Aug;56(2):174-9 ,  Gastrointest Endosc. 2011 Feb;73(2):245-50
  7. Second-look endoscopy — Second-look endoscopy refers to a follow-up endoscopy, generally within 24 hours of the initial endoscopy, if there is active bleeding or a nonbleeding visible vessel. Data are conflicting regarding the benefits of second-look endoscopy, and in general, guidelines and reviews do not recommend it.  Ann Intern Med. 2010 Jan 19;152(2):101-13
  8. Persistent or Recurrent bleeding: 
    • Angiogram and transarterial embolization or intra-arterial vasopressin. 
    • RBC tagged scan 
    • Surgery 
  9. Patients with high-risk stigmata (active bleeding, visible vessels, and clots) should generally be hospitalized for 3 days assuming no rebleeding and no other reason for hospitalization. They may be fed clear liquids soon after endoscopy. 
  10. Patients with clean-based ulcers may receive a regular diet and be discharged after endoscopy assuming they are hemodynamically stable, their hemoglobin is stable, they have no other medical problems, and they have a residence where they can be observed by a responsible adult. 
  11. In patients with low-dose aspirin-associated bleeding ulcers, the need for aspirin should be assessed. If given for secondary prevention (established cardiovascular disease), then aspirin should be resumed as soon as possible after bleeding ceases in most patients: ideally within 1 – 3 days and certainly within 7 days. Long-term daily PPI therapy should also be provided. If given for primary prevention (i.e., no established cardiovascular disease), anti-platelet therapy likely should not be resumed in most patients.  
  12. In patients with idiopathic (non- H. pylori, non-NSAID) ulcers, long-term antiulcer therapy (e.g., daily PPI) is recommended. 
 
Acute lower gastrointestinal bleeding 
 
Traditionally, acute lower gastrointestinal (GI) bleeding has referred to blood loss of recent onset originating from a site distal to the ligament of Treitz. However, many now differentiate between bleeding coming from the small bowel (mid GI bleeding) and the colon (lower GI bleeding). 
 
Melena implies a GI source proximal to the cecum and the black color is due to the effect of bacteria on blood as it passes through the colon.  
 
Etiology — The causes of lower gastrointestinal bleeding (LGIB) may be grouped into several categories: 
  • Diverticulosis
  • Angiodysplasia
  • Ischemic colitis
  • Hemorrhoids
  • Post polypectomy
  • Malignancy
  • Inflammatory bowel disease
  • Infectious colitis
  • Radiation-induced colitis
 
In addition, acute lower GI bleeding can occur after therapeutic interventions such as polypectomy.  
 
Clinical features — A patient with lower gastrointestinal (GI) bleeding typically reports hematochezia (passage of maroon or bright red blood or blood clots per rectum). Blood originating from the left colon tends to be bright red in color, whereas bleeding from the right side of the colon usually appears dark or maroon-colored and may be mixed with stool. Rarely, bleeding from the right side of the colon will present with melena. 
 
Diagnosis
The primary consideration in the differential diagnosis of hematochezia is upper GI bleeding. Findings that are suggestive of an upper GI source include hemodynamic instability, orthostatic hypotension, and an elevated blood urea nitrogen (BUN)-to-creatinine or urea-to-creatinine ratio (>20:1 or >100:1, respectively).  Lower GI bleed usually doesn’t cause significant rise in BUN as the heme protein from RBC is not absorbed into the system. If the suspicion for upper GI bleeding is moderate, a nasogastric lavage may help identify patients with upper GI bleeding. 
 
Hematochezia associated with hemodynamic instability may be indicative of an UGIB source, and an upper endoscopy should be performed. A nasogastric aspirate/lavage may be used to assess a possible upper GI source if suspicion of UGIB is moderate. 
 
Once an upper gastrointestinal (GI) bleeding source is excluded, colonoscopy is the initial examination of choice for the diagnosis and treatment of acute lower GI bleeding. Other diagnostic procedures include tagged RBC scan, CT angiography, and mesenteric angiography.  
 
Treatment
The basic principles in the management of acute lower GI bleed was mentioned in detail by american college of gastroenterology. Am J Gastroenterol. 2016 Apr;111(4):459-74.
 
Principles of treatment remains the same as UGI bleed except there is no role for protonix or octreotide. Octreotide, however, can used in lower GI bleed due to rectal varices. 
 
PEARLS
  • Blood is a great cathartic; UGI bleed is less likely if there are no bowel movements. 
  • Alka-seltzer contains ASA 
  • Do not use guiac cards for vomitus. Hcl will always turn the test positive. 
  • Do not fluid over load the variceal bleeders. When their portal pressure increases, they start bleeding 
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