1. Acute Gastrointestinal Bleeding
Naveed Ahmad M.D
November 2012

2. QUESTION 1
Endotracheal intubation for airway protection in the management of acute Upper GI bleeding should be considered:
A. in all cirrhotic patients
B. in all patients with UGI bleeding
C. in patients with altered mental status and ongoing hematemesis
D. in patients with stable COPD
E. in all patients unless it delays urgent endoscopy

3. QUESTION 2
A 73 year old man presents with several episodes of hematemesis. Examination shows signs of orthostatic hypotension and melena. What is the first priority in caring for this patient?
A. Nasogastric tube placement and gastric lavage.
B. Resuscitation with adequate IV access and appropriate fluid and blood product infusion.
C. Intravenous infusion of H2-receptor antagonists to stop the bleeding.
D. Urgent upper endoscopy.
E. Urgent surgical consultation.

4. QUESTION 3.
A 58 year old female patient presents to the ED with a 24-hour history of several bloody bowel movements. She denies any abdominal pain but complains of light headedness. She is found to be hypotensive with systolic blood pressure of 90mmHg supine. Hb 7gm/dl. Resuscitative measures are instituted. What is the most appropriate next step?
A. Nasogastric tube placement
B. Flexible sigmoidoscopy
C. Colonoscopic examination
D. Tagged RBC scan
E. Angiography

5. Intraluminal blood loss anywhere from oropharynx to anus
Upper : above ligament of Treitz
Lower Below the ligament of Treitz

6. Incidence
Annual rate of hospitalization for any type of GIB in US 350/100,000
Annually, approximately 100,000 patients are admitted to US hospitals
UGIB 50%, Lower GIB 40%, 10% obscure bleeding.
Mortality rates from UGIB are 6-10% overall
The incidence of UGIB is 2-fold greater in males than in females, in all age groups; however, the death rate is similar in both sexes

7. Signs Hematemesis : blood in vomitus (UGIB)
Hematochezia : bloody stools (LGIB or rapid UGIB)
Melena : Black Tarry stools from digested blood (Usually UGIB but can be anywhere including right colon)

8. Etiologies (UGIB) Source Prevalence (%) Duodenal Ulcer 24.3
Gastric Erosions
23.4
Gastric Ulcer
21.3
Esophagogastric Varices
10.3
Mallory-Weiss tear
7.2
Esophagitis
6.3
Erosive Duodenitis
5.8

10. Etiologies (UGIB) Oropharyngeal bleeding and epistaxis
Immunocompetent host : GERD/Barrett’s/XRT
Immunocompromised host : CMV,HSV, Candida

11. Vascular Malformations (5%)
Dieulafoy’s Lesion (superficial ectatic artery in cardia -> sudden massive UGIB)
AVMs (isolated or with Osler-Weber-Rendu syndrome)
Aorto-enteric fistula (AAA or aortic graft erodes into 3rd portion of duodenum;presents with herald bleed)
Vasculitis
Neoplastic disease (esophageal or gastric)

13. Etiologies (LGIB) Source Prevalence (%) Diverticulosis 17 – 44
Colonic Angiodysplasia
2 – 30
Ischemic Colitis
9 – 21
Malignancy
4 – 14
Hemorrhoids/Anorectal
4 – 11
Postpolypectomy 6
Unknown
8 - 12

15. Clinical Manifestations
UGIB>LGIB: Nausea, vomiting, hematemesis, coffee ground emesis, epigastric pain, vasovagal reaction, syncope, melena
LGIB>UGIB: Diarrhea, tenesmus,BRBPR or maroon stools

16. Work Up
History : Acute or chronic GIB, number of episodes, most recent episode, hematemesis, vomiting prior to hematemesis, melena, hematochezia, abdominal pain, use of NSAIDs, anti coagulants, alcohol abuse, cirrhosis, prior GI or aortic surgery

17. Physical Exam Tachycardia at 10% volume loss
Orthostatic hypotension at 20% loss
Shock at 30% volume loss
Pallor, talengectesia (ETOH,cirrhosis, OWR Synd)
Chronic liver disease: jaundice,spider angiomata, gynecomastia, testicular atrophy, palmer erythema, caput medusae
Localized abdominal tenderness or peritoneal signs, masses, signs of prior surgery
Rectal Exam: appearance of stools, hemorrhoids, anal fissure

18. Lab Studies
Hct: maybe normal before equiliberation which may take 24 hours, decreased 2-3%-> loss of 500cc blood.
Platelet count, PT,PTT BUN/Cr (ratio>36 in UGIB due to GI resorption of blood and prerenal azotemia)
LFTs

19. NG tube: Useful for localization (presence of non-boody bile in lavage excludes active bleeding proximal to ligament of Treitz), can also clear GI contents prior to EGD and detect continued bleeding

20. Glasgow-Blatchford Score
scores of 6 or more were associated with a greater than 50% risk of needing an intervention

21. Rockall Score
A score less than 3 carries good prognosis but total score more than 8 carries high risk of mortality

22. Diagnostic Studies UGIB  EGD (potentially therapeutic) LGIB 
(r/o UGIB)
Stable. Spontaneously stops- colonoscopy diagnostic in 70% cases also potentially therapeutic
Stable, ongoing bleeding- colonoscopy or Bleeding scan (Tc tagged RBC/albumin) detects rates >0.1 ml/min, localization difficult
Unstable, arteriography bleeding rates >0.5ml/min, potentially therapeutic
Ex Lap

23. RBC scan

24. Angiogram

25. Treatment IV access with 2 large bore (18 gauge or larger) IV lines
Vol resuscitiation (saline, Ringer’s)
Transfusion therapy
Correct Coagulopathies
NG/Prokinetics
Airway management
Consult GI and Surgery service as needed

26. Peptic Ulcer Disease Pharmacologic therapy
High Dose PPI therapy (Pantoprazole 80 mg IV bolus followed by 8gm/hr infusion)
Endoscopic therapy (Injection, Thermal, Laser)
Arteriography with embolization
Surgery if endoscopic and pharmacologic therapy fails

31. Varices Pharmacologic Non Pharmacologic
Octreotide 50 microgram IVB  50microgram/hr infusion (84% success; Lancet 1993)
Non Selective Beta Blocker therapy (once stable)
Non Pharmacologic
EVL has replaced sclerotherapy (>90% success)
Balloon Temponade (Sengstaken-Blakemore)
TIPS if Endoscopy fails

34. Esophagitis/Gastritis
Mallory-Weiss Tear
Usually stops spontaneously, endoscopic therapy if active
Esophagitis/Gastritis
PPI, H2- Antagonists

35. Diverticular Disease Usually stops spontaneoulsy Endoscopic therapy
Arterial vasopressin or embolization
Surgery

37. Angiodysplasia Endoscopic therapy Arterial vasopressin Surgery
Hormonal therapy

39. Risks of Rebleeding without Endoscopic Intervention

40. Summary
Acute GI bleeding remains a important cause for morbidity, hospital admissions and mortality
Early and prompt resuscitation is the key to management
Diagnostic and therapeutic modalities are ever improving

41. Thank you

42. QUESTION 1
Endotracheal intubation for airway protection in the management of acute Upper GI bleeding should be considered:
A. in all cirrhotic patients
B. in all patients with UGI bleeding
C. in patients with altered mental status and ongoing hematemesis
D. in patients with stable COPD
E. in all patients unless it delays urgent endoscopy

43. QUESTION 2
A 73 year old man presents with several episodes of hematemesis. Examination shows signs of orthostatic hypotension and melena. What is the first priority in caring for this patient?
A. Nasogastric tube placement and gastric lavage.
B. Resuscitation with adequate IV access and appropriate fluid and blood product infusion.
C. Intravenous infusion of H2-receptor antagonists to stop the bleeding.
D. Urgent upper endoscopy.
E. Urgent surgical consultation.

44. QUESTION 3.
A fifty-eight year old female patient presents to the emergency department with a 24-hour history of several bloody bowel movements. She denies any abdominal pain but complains of light headedness. She is found to be hypotensive with systolic blood pressure of 90mmHg supine. Hb 7gm/dl. Resuscitative measures are instituted. What is the most appropriate next step?
A. Nasogastric tube placement
B. Flexible sigmoidoscopy
C. Colonoscopic examination
D. Tagged RBC scan
E. Angiography