Gastrointestinal Bleeding

Case…  Hassan is 45 y/o saudi gentleman, presents to ED at KKUH early morning, C/O vomiting blood.  How would you approach?  How would you manage?

Gastrointestinal Bleeding PERSPECTIVE Epidemiology o relatively common problem o requires early consultation and hospital admission.

Gastrointestinal Bleeding o Mortality rate for GI bleeding is approximately 10%. o Diagnostic modalities have improved much more than therapeutic techniques.

Gastrointestinal Bleeding GI bleeding o is often easy to identify …….when there is clear evidence of vomiting blood or passing blood in the stool. o may be subtle, ………with signs and symptoms of hypovolemia, such as dizziness, weakness, or syncope.

Gastrointestinal Bleeding o Management approach depends on whether the hemorrhage is located in the proximal or the distal segment of the GI tract (i.e., upper or lower GI bleeding). o These segments are anatomically defined by the ligament of Treitz in the duodenum.

Gastrointestinal Bleeding Lower GI bleeding (LGIB) o affects a smaller portion of patients o fewer hospital admissions than UGIB.

Gastrointestinal Bleeding o Occur in persons of any age. o Most commonly affects people in their 40s through 70s. o Most deaths in patients older than 60 years. o UGIB is more common in men than in women (in a 2 : 1 ratio) o LGIB is more common in women.

Gastrointestinal Bleeding o Significant UGIB requiring admission is more common in adults. o LGIB requiring admission is more common in children.

Gastrointestinal Bleeding DIAGNOSTIC APPROACH Differential Considerations o Peptic ulcer disease o gastric erosions o varices three fourths of adult patients with UGIB. 80% of adults with LGIB. o Diverticulosis o angiodysplasia

Gastrointestinal Bleeding o Esophagitis o Gastritis o peptic ulcer disease o infectious colitis o inflammatory bowel disease most common causes of UGIB most common causes of LGIB. In children,

Gastrointestinal Bleeding Meckel’s diverticulum & intussusception o At all ages, anorectal abnormalities are the most common cause of minor LGIB. most common cause of massive LGIB in children younger than 2 years of age

Gastrointestinal Bleeding o No source of bleeding is identified in approximately 10% of patients with GI bleeding.

Gastrointestinal Bleeding o In abdominal aortic grafts pt with with GI bleeding, the possibility of aortoenteric fistula should be considered o Prompt surgical consultation in the ED should be obtained if this is suspected, because bleeding can be massive and fatal.

Gastrointestinal Bleeding Rapid Assessment and Stabilization o Most patients with GI bleeding are easy to diagnose by history +/- physical exam

Gastrointestinal Bleeding o If hemodynamically unstable should undergo rapid evaluation and resuscitation. o should be undressed quickly with placement of cardiac and oxygen saturation monitors. o supplemental oxygen should be given as needed.

Gastrointestinal Bleeding o At least two large-bore (minimum 18- gauge); o Send samples for o CBC, for hg, plat, hematoc. o Coagulation profile o type and screen or type and crossmatch o crystalloid resuscitation should be initiated.

Gastrointestinal Bleeding o NS 2-L bolus in adults or 20 mL/kg in children until the patient’s vital signs have stabilized or the patient has received 40 mL/kg of crystalloid in an adult or 60 mL/kg as a child.

Gastrointestinal Bleeding o If remain unstable give type O, type-specific, or cross matched blood, depending on availability. o Persistently unstable patients should receive immediate consultation with a gastroenterologist for UGIB and with a surgeon for LGIB.

Gastrointestinal Bleeding History In 50% o Patients typically complain of vomiting red blood or coffee grounds–like material, or passing black or bloody stool. o Hematemesis (vomiting blood) occurs with bleeding of the esophagus, stomach, or proximal small bowel.

Gastrointestinal Bleeding History o Hematemesis may be bright red or darker (i.e., coffee grounds–like) as a result of the conversion of hemoglobin to hematin or other pigments by hydrochloric acid in the stomach.

Gastrointestinal Bleeding o The color of vomited or aspirated blood from the stomach does not differentiate between arterial and venous bleeding. o Melena, or black tarry stool, will result from the presence of approximately 150 to 200 mL of blood in the GI tract for a prolonged period.

Gastrointestinal Bleeding o Melena is seen in approximately o 70% of patients with UGIB o one third of patients with LGIB. o Blood from the duodenum or jejunum must remain in the GI tract for approximately 8 hours before turning black.

Gastrointestinal Bleeding o Occasionally, black stool may follow bleeding into the lower portion of the small bowel and ascending colon. o Stool may remain black and tarry for several days, even though bleeding has stopped.

Gastrointestinal Bleeding Hematochezia, or bloody stool (bright red or maroon) o most often signifies LGIB o Could be due to a brisk UGIB with rapid transit time through the bowel in 10 to 15% of patients. o a more proximal source of significant bleeding must be excluded before assuming the bleeding is from the lower GI tract.

Gastrointestinal Bleeding o Approximately two thirds of patients with LGIB present with red blood from bleeding per rectum. o Small amounts of red blood (5 mL) from rectal bleeding, such as bleeding due to hemorrhoids, may cause the water in the toilet bowl to appear bright red.

Gastrointestinal Bleeding DDX o Bright red stools also can be seen after ingestion of a large quantity of beets o Hemoccult testing would be negative and the patient also will report pink colored water in the toilet bowl.

Gastrointestinal Bleeding Important qs o duration and quantity of bleeding o associated symptoms o previous history of bleeding o current medications, o alcohol o NSAID ASA o allergies o associated medical illnesses o previous surgery

Gastrointestinal Bleeding symptoms of hypovolemia …..dizziness, weakness, or loss of consciousness, most often after standing up. o Other nonspecific complaints include dyspnea, confusion, and abdominal pain.

Gastrointestinal Bleeding o Rarely an elderly patient may present with ischemic chest pain precipitated by significant anemia due to a GI bleed. o One in five patients with GI bleeding may have only nonspecific complaints.

Gastrointestinal Bleeding o The history is of limited help in predicting the site or quantity of bleeding. o Patients with a previously documented GI lesion bleed from the same site in only 60% of cases.

Gastrointestinal Bleeding o Gross estimates of blood loss based on the volume and color of the vomitus or stool are inaccurate.

Gastrointestinal Bleeding Physical Examination o Vital signs and postural changes in heart rate and blood pressure are insensitive and nonspecific, with the exception of significant, sustained heart rate increase and hypotension.

Gastrointestinal Bleeding o All patients hypotensive and tachycardic should be assumed to have a significant hemorrhage.

Gastrointestinal Bleeding o Normal vital signs do not exclude a significant hemorrhage o postural changes in heart rate and blood pressure may occur in individuals who are not bleeding

Gastrointestinal Bleeding o general appearance o vital signs o mental status (including restlessness) o skin signs (e.g., color, warmth, and moisture to assess for shock, or presence of lesions such as telangiectasia, bruises, or petechiae to assess for vascular diseases or hypocoagulable states) o pulmonary and cardiac findings o abdominal examination

Gastrointestinal Bleeding o Frequent reassessment is important because a patient’s status may change quickly.

Gastrointestinal Bleeding o Rectal Examination Rectal and stool examinations are often key to making or confirming the diagnosis of GI bleeding. o The finding of red, black, or melenic stool early in the assessment is helpful in prompting early recognition and management of patients with GI bleeding.

Gastrointestinal Bleeding o The absence of black or bloody stool, however, does not exclude the diagnosis of GI bleeding. o Regardless of the apparent character and color of the stool, occult blood testing is indicated.

Gastrointestinal Bleeding Ancillary Testing Tests for Occult Blood o The presence of hemoglobin in occult amounts in stool is confirmed by tests such as ( Hemoccult, HemaPrompt). o Stool tests for occult blood may have positive results 14 days after a single, major episode of UGIB.

Gastrointestinal Bleeding False-positive o associated with the ingestion of o certain fruits (e.g., cantaloupe, grapefruit, figs), o uncooked vegetables (e.g., radish, cauliflower, broccoli) o red meat o methylene blue, chlorophyll, iodide, cupric sulfate, and bromide preparations.

Gastrointestinal Bleeding False-negative o uncommon but can be caused by bile or ingestion of magnesium containing antacids or ascorbic acid. o Tests to evaluate gastric contents for occult blood (e.g., Gastroccult) can be unreliable and should not be used for this purpose.

Gastrointestinal Bleeding Clinical Laboratory o The initial hematocrit may be misleading in patients with preexisting anemia or polycythemia.

Gastrointestinal Bleeding o Changes in the hematocrit may lag significantly behind actual blood loss. o rapid infusion of crystalloid in nonbleeding patients also may cause a decrease in hematocrit by hemodilution.

Gastrointestinal Bleeding o hemoglobin concentration of 8 g/dL or less (hematocrit <25%) from acute blood loss usually require blood therapy. o After transfusion and in the absence of ongoing blood loss, the hematocrit can be expected to increase approximately 3% for each unit of blood administered (hemoglobin level increases by 1 mg/dL).

Gastrointestinal Bleeding o The PT should be used to determine whether a patient has a preexisting coagulopathy. An elevated PT may indicate o vitamin K deficiency o liver dysfunction o warfarin therapy o consumptive coagulopathy.

Gastrointestinal Bleeding o Patients with anticoagulants or with an elevated PT and evidence of active bleeding should receive sufficient FFP to correct the PT. o Serial platelet counts are used to determine the need for platelet transfusions (i.e., less than 50,000/mm3).

Gastrointestinal Bleeding Blood Bank Blood o should be sent for “type and hold” or type and crossmatch studies early in the patient’s care. o Immediate transfusion needs in unstable patients can be met with O-positive packed red blood cells (O-negative packed red blood cells in women of childbearing age whose Rh status is unknown).

Gastrointestinal Bleeding o Type-specific blood is usually available within 10 to 15 minutes. o Group O blood and type-specific blood are safe for patients and cause few transfusion reactions. o Fully crossmatched blood may take 60 minutes to prepare.

Gastrointestinal Bleeding Other Laboratory Tests o Electrolytes usually normal o Urea and creatinin

Gastrointestinal Bleeding Patients with repeated vomiting, may develop, o Hypokalemia o Hyponatremia o metabolic alkalosis correct with adequate hydration and the resolution of vomiting.

Gastrointestinal Bleeding o Patients with shock often have metabolic acidosis from lactate accumulation. o High Urea as a result of o absorption of blood from the GI tract o hypovolemia causing prerenal azotemia

Gastrointestinal Bleeding ECG in all patients with a GI bleed who are o older than 50 years o preexisting ischemic cardiac disease, o significant anemia o chest pain o shortness of breath o persistent hypotension. Asymptomatic myocardial ischemia may develop in the setting of GI bleeding.

Gastrointestinal Bleeding o Patients with GI bleeding and myocardial ischemia should receive packed red blood cells as soon as possible

Gastrointestinal Bleeding Imaging o No need for plain abdominal radiography unless aspiration or with signs and symptoms of bowel perforation. o air consistent with bowel perforation is a rare finding with UGIB o Need immediate surgical consultation and operative repair.

Gastrointestinal Bleeding DIFFERENTIAL DIAGNOSIS o Swallowing blood during epistaxis or from the oral cavity may cause hematemesis or melena. o Red vomitus may be due to food products (e.g., Jell-O, tomato sauce, wine), and black stool may be due to iron therapy or bismuth (e.g., Pepto-Bismol).

Gastrointestinal Bleeding MANAGEMENT o Quick identification o Aggressive resuscitation o Prompt consultation

Gastrointestinal Bleeding After initial resuscitation of the patient, o it is important to identify whether the hemorrhage is proximal or distal to the ligament of Treitz (i.e., UGIB or LGIB). o If the patient’s vomitus demonstrates blood, then the diagnosis of UGIB is confirmed.

Gastrointestinal Bleeding o If a patient reports bloody or “coffee grounds” emesis or if melenic stool is present, an upper GI bleed is more likely.

Emergency management of patients with gastrointestinal bleeding. ED, emergency department; IV, intravenous; LGIB, lower gastrointestinal bleeding; UGIB, upper gastrointestinal bleeding.

Gastrointestinal Bleeding Anoscopy/Proctosigmoidoscopy o Patients with mild rectal bleeding who do not have obviously bleeding hemorrhoids should undergo anoscopy or proctosigmoidoscopy. o If bleeding internal hemorrhoids are discovered, and the patient does not have portal hypertension, the patient may be discharged with appropriate treatment and follow-up evaluation for hemorrhoids.

Gastrointestinal Bleeding o If hemorrhoids are not detected, it is important to determine if the stool above the rectum contains blood. o absence of blood above the rectum in a patient who is actively bleeding indicates that the source of bleeding is in the rectum.

Gastrointestinal Bleeding o Presence of blood above the anoscope or sigmoidoscope does not invariably indicate a proximal source of bleeding, because retrograde passage of blood into the more proximal colon commonly occurs. o Such patients need further evaluation.

Gastrointestinal Bleeding Endoscopy o Endoscopy is the most accurate diagnostic tool available for the evaluation of UGIB. o It identifies a lesion in 78% to 95% of patients with UGIB if it is performed within 12 to 24 hours of the hemorrhage.

Gastrointestinal Bleeding o Endoscopy-for upper GI bleeding. o Colonoscopy is an effective tool for diagnosis and selected treatment of LGIB.

Gastrointestinal Bleeding Angiography and Tagged Red Blood o Cell Scan Angiography can detect the location of UGIB in two thirds of patients studied. o Since the advent of endoscopy, however, the use of angiography has decreased significantly, and today angiography is used in only 1% of patients with UGIB.

Gastrointestinal Bleeding Nuclear isotope–tagged red blood cell scan o In some patients with more indolent or elusive bleeding, o Usually performed from the inpatient unit, may identify the bleeding site.

Gastrointestinal Bleeding Gastric Acid Secretion Inhibition o All patients with peptic ulcer disease documented by endoscopy should receive therapy with a proton-pump inhibitor (e.g., omeprazole). o There is no documented benefit to initiating this therapy or administering H2 antihistamines in the ED for patients with UGIB.

Gastrointestinal Bleeding Octreotide (Somatostatin Analogues) o IV infusion of octreotide at 25–50 μg/hour for a minimum of 24 hours o In patients with documented esophageal varices and acute upper GI bleeding o should receive in monitored bed.

Gastrointestinal Bleeding o Octreotide is a useful addition to endoscopic sclerotherapy and decreases rebleeding occurrences. o Octreotide may also reduce the incidence of lower GI rebleeding secondary to angiodysplasia.

Gastrointestinal Bleeding Sengstaken-Blakemore Tube o Rarely used in tertiary care centre. o Should not be used without endoscopic documentation of the source of bleeding because complications are common and significant (14% major, 3% fatal).

Gastrointestinal Bleeding o A trial of balloon tamponade should be considered in an exsanguinating patient with probable variceal bleeding in whom endoscopy is not immediately available. o Consultation with a surgeon or gastroenterologist is advisable.

Gastrointestinal Bleeding Surgery o For all hemodynamically unstable patients with active bleeding who do not respond to medical therapy. o Mortality rate for patients undergoing emergency procedures for GI bleeding is approximately 23%.

Gastrointestinal Bleeding Emergency surgical consultation for : o blood replacement exceeds 5 units within the first 4 to 6 hours or o 2 units of blood is needed every 4 hours

Gastrointestinal Bleeding DISPOSITION Risk Stratification o Risk stratification involves combining historical, clinical, and laboratory data to determine the risk of death and rebleeding in patients presenting to an ED with GI bleeding.

Gastrointestinal Bleeding o patients present to the ED with a vague complaint of vomiting blood or passing blood from the rectum in whom detailed history and examination allows a diagnosis of hemorrhoid, or anal fissure, or there may be little or no objective evidence of significant GI bleeding…..Discharge pt with education patients should be educated about the signs and symptoms of significant GI bleeding and when to return to the ED

Gastrointestinal Bleeding o Patents should undergo specific follow-up evaluation within 24 to 36 hours. o They should be instructed to avoid aspirin, nonsteroidal anti-inflammatory drugs, and alcohol.

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