Gastrointestinal Bleeding

Aka: Gastrointestinal Bleeding, Acute Gastrointestinal Hemorrhage, Acute Gastrointestinal Bleeding Management, Gastrointestinal Bleeding Management, GI Bleed, Hematochezia, Bright Red Blood Per Rectum, Melena, Maroon Stool

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II. Definitions

  1. Overt Gastrointestinal Bleeding
    1. Visible Gastrointestinal Bleeding (e.g. Hematemesis, Hematochezia)
  2. Obscure Gastrointestinal Bleeding
    1. Recurrent Gastrointestinal Bleeding without a source identified despite diagnostic evaluation
    2. Most commonly associated with Small Intestinal Bleeding
  3. Occult Gastrointestinal Bleeding
    1. Gastrointestinal Bleeding not visible on stool examination
    2. Presents with occult occult blood test positive (e.g. guiaic stool testing or FIT Testing) or Iron Deficiency Anemia
  4. Hematochezia (Bright Red Blood Per Rectum)
    1. Grossly bloody or dark red stool that usually correlates with Lower GI Bleeding
    2. Differentiate from Maroon Stool which is associated with brisk Upper Gastrointestinal Bleeding
  5. Melana (Black Stool)
    1. Black stool is typically associated with Upper GI Bleeding, with heavier bleeding suggested by tarry black stool
    2. Lower GI Bleeding is responsible for one third of black stool cases
  6. Maroon Stool
    1. Suggests rapid Upper GI Bleeding

III. History

  1. Characteristics
  2. Gastrointestinal Bleeding sites and characteristics
    1. Hematemesis
      1. Consider non-gastrointestinal sources (e.g. Hemoptysis, Epistaxis and other oropharyngeal bleeding)
      2. Coffee-ground Emesis suggests Upper Gastrointestinal Bleeding
    2. Bloody stool
      1. Black tarry stools or Melena suggests Upper Gastrointestinal Bleeding
      2. Bright Red Blood Per Rectum or Hematochezia
        1. More suggestive lower GI source (but may be upper source if bleeding is brisk, esp. maroon)
  3. Associated Symptoms
    1. Abdominal Pain
      1. Location (e.g. epigastric) may help differentiate upper from lower GI source
    2. Weight loss
      1. Consider Inflammatory Bowel Disease, malignancy
    3. Fever
      1. Consider Acute Inflammatory Diarrhea (Dysentery)
    4. Light Headedness, Dizziness or Syncope
      1. Consider severe volume depletion (heavy GI Bleeding)
  4. Past History: Gastrointestinal
    1. Peptic Ulcer Disease
    2. Prior Gastrointestinal Bleeding
    3. Prior abdominal surgery
    4. Chronic Liver Disease
      1. Cirrhosis
      2. Chronic Hepatitis
      3. Esophageal Varices
  5. Past History: Comorbidity
    1. Coronary Artery Disease or other cardiovascular disease
    2. Diabetes Mellitus
    3. Chronic Kidney Disease
    4. Chronic Obstructive Pulmonary Disease
    5. Coagulopathy
  6. Habits
    1. Tobacco Abuse
    2. Alcohol Abuse
  7. Medications
    1. See Drug Induced Platelet Dysfunction
    2. Aspirin
    3. Clopidogrel (Plavix)
    4. Warfarin (Coumadin) and other Anticoagulants (e.g. Factor Xa Inhibitor)
    5. NSAIDs
    6. Corticosteroids
    7. Selective Serotonin Reuptake Inhibitors (SSRI)
      1. Inhibit Platelet aggregation

IV. Causes: Sources of acute Gastrointestinal Bleeding

  1. Upper Gastrointestinal Bleeding (70%)
    1. Annual Incidence (U.S.): 100-200 per 100,000
  2. Small Intestinal Bleeding or Middle Gastrointestinal Bleeding (5%)
    1. Bleeding source between Ligament of Treitz (distal duodenum) and ileocecal valve (distal ileum)
  3. Lower Gastrointestinal Bleeding (24%)
    1. Annual Incidence (U.S.): 20-27 per 100,000

V. Exam: Vital Signs

  1. Orthostatic Blood Pressure and Pulse (variable efficacy)
  2. Blood Pressure
    1. Hypotension may be an ominous sign of impending cardiovascular collapse
  3. Heart Rate
    1. Tachycardia in most cases
    2. Paradoxical Bradycardia causes
      1. Beta Blockers or nitrates
      2. Vagal response due to GI Bleed
  4. Oxygen Saturation
  5. Follow Urine Output

VI. Signs: Identify gastrointestinal source of blood

  1. Signs of upper GI sources of blood (>75% of GI Bleeds)
    1. Unstable Patients are most likely to be from Upper GI Bleeding
    2. Hematemesis (present in 50% of Upper GI Bleed)
    3. Nasogastric aspirate positive for blood
    4. Melena (Black tarry stool)
      1. Black tarry stool requires 150 to 200 cc blood
      2. Black non-tarry stool requires 60 cc blood
      3. Blood must be in GI Tract 8 hours to turn black
      4. Stool remains black for several days in GI Tract
      5. Melana source
        1. Present in 70% of Upper GI Bleeding
        2. Present in 33% of Lower GI Bleeding
  2. Signs of lower GI sources of blood
    1. Blood per Rectum occurs with any GI source
    2. Hematochezia (seen in 80% of all GI Bleeding)
      1. Grossly bloody or dark red stool
      2. Usually correlates with Lower GI Bleeding
      3. Brisk Upper GI Bleeding may result in Maroon Stool (11%)
    3. Blood in toilet (e.g. Hemorrhoid source)
      1. Toilet water may appear bright red from 5 cc blood

VII. Evaluation

  1. Upper GI Bleeding evaluation
    1. See Upper GI Bleed
    2. See Upper GI Bleeding Score
    3. See Upper GI Endoscopic Evaluation of Bleeding
    4. Indication
      1. Hematemesis (or blood on nasogastric aspirate)
      2. Melanotic stool or in cases of brisk Upper GI Bleeding, maroon
      3. Upper GI Bleed more likely in Unstable Patients
    5. Common Causes
      1. Duodenal Ulcer, Gastric Ulcer or Gastritis
      2. Esophageal Varices
      3. Esophagitis
  2. Lower GI Bleeding evaluation
    1. See Lower GI Bleed
    2. See Colonoscopy in GI Bleeding
    3. Indication
      1. No Hematemesis or nasogastric lavage/aspirate with bile but no blood
      2. Bright Red Blood Per Rectum
    4. Common Causes
      1. Diverticular Bleeding
      2. Arteriovenous Malformations
      3. Colon Polyps or Colorectal Cancer

VIII. Labs

  1. Complete Blood Count
    1. Baseline Hemoglobin (trails bleeding by 24 hours)
  2. Blood Type and Cross-match
  3. Coagulation Factors
    1. Prothrombin Time
    2. Platelet Count

IX. Diagnostics

  1. Electrocardiogram
    1. Monitor for cardiac ischemia
  2. Imaging
    1. See Upper GI Bleed and Lower GI Bleed for specific protocols
    2. See CT Angiography in Gastrointestinal Bleeding

X. Management: Acute

  1. ABC Management
    1. Oxygen
    2. Intravenous Access
      1. Two large bore IV (14-16 gauge)
      2. Start with Isotonic Saline (NS or LR)
    3. Intravenous Fluid Resuscitation
      1. Massive GI Bleed
        1. See Massive Hemorrhage
        2. Replace blood with blood
        3. Start with universal donor blood (O- in premenopausal women, O+ in men)
        4. Transfuse type specific blood when available
        5. Replace 1 unit plasma per unit pRBC and 1 unit apheresis Platelets for every 8 units pRBC
      2. Non-massive GI Bleed
        1. Crystalloid 10 cc/kg boluses until stable
        2. Reassess after 3 boluses (30 cc/kg)
        3. Consider transfusion for unstable after 3 boluses
    4. Endotracheal Intubation
      1. Indications
        1. Altered Mental Status
        2. Massive Upper GI Bleeding
          1. Controls airway to prevent aspiration
          2. Confirms source (via orogastric or Nasogastric Tube)
      2. Technique (minimize aspiration risk)
        1. Nasogastric Tube to empty Stomach contents
          1. Esophageal Varices are not a contraindication
        2. Consider Metoclopramide (Reglan) to increase LES pressure
        3. Elevate head of bed to 45 degrees
        4. Endotracheal Intubation Preoxygenation is key
          1. Minimal reserve due to acute blood loss
        5. Rapid Sequence Intubation (RSI)
          1. Succinylcholine raises LES pressure (may lower aspiration risk)
        6. Optimize chances for first pass success
          1. If BVM needed between attempts, use slow, gentle breaths (10 per minute)
        7. Vomiting
          1. Place patient in trendelenberg position to reduce aspiration risk
          2. Suction via Endotracheal Tube with meconium aspirator
      3. References
        1. Intubating the Critical GI Bleeder (Scott Weingart, MD)
          1. https://emcrit.org/emcrit/intubating-gi-bleeds/
  2. Anticoagulation and Antiplatelet Management
    1. Aspirin
      1. Stopping Aspirin has little impact on acute Gastrointestinal Bleeding
        1. Platelet inhibition effects last at least 3 days
      2. Stopping Aspirin in secondary prevention (e.g. known coronary disease) risks cardiovascular complications
        1. However, stopping Aspirin in primary prevention is low risk (since Aspirin has low efficacy in these cases)
    2. P2Y Receptor Antagonist (e.g. Clopidogrel)
      1. For patients on dual antiplatelet agents, stopping P2Y agent may have little effect on acute bleeding risk
      2. Stopping P2Y Inhibitor for <=4 days in patients on dual antiplatelet agents appears to have minimal effect in s/p stent
        1. However stopping >10 days risks stent thrombosis
    3. Direct Oral Anticoagulants (e.g. Apixaban)
      1. Prothrombin Complex Concentrates or PCC4 (unclear if benefit)
      2. Andexanet Alfa or Andexxa for Apixaban or Rivaroxaban use (unclear if benefit)
    4. Dabigatran (Pradaxa)
      1. Idarucizumab (Praxbind) does not appear to reduce GI Bleeding or mortality
    5. Warfarin (Coumadin)
      1. Prothrombin Complex Concentrates or PCC4 (may have benefit, but at least 25% continue to bleed)
      2. Fresh Frozen Plasma has less evidence of benefit than PCC4
    6. References
      1. (2022) Am J Gastroenterol 117(4): 542-58 [PubMed]
  3. Intensive Care Unit admission indications
    1. Significant bleeding
    2. Hemodynamically unstable
  4. Transfusion Packed Red Blood Cells
    1. Indications
      1. Hemoglobin 8 g/dl or Hematocrit 25%
      2. Brisk active bleeding (replace blood with blood)
      3. Cardiopulmonary symptoms
      4. Cardiopulmonary comorbidity
    2. Do not base transfusion in acute bleeding on labs
      1. Hemoglobin And Hematocrit lag bleeding by 24 hours
      2. Active unstable bleeding requires Blood Products
      3. Base transfusion on Hemodynamic status
      4. Base on response to crystalloid (after 30 cc/kg)
      5. In Massive Hemorrhage, replace blood with blood as soon as universal donor blood available
        1. Replace 1 unit plasma per unit pRBC
        2. Replace 1 unit apheresis Platelets for every 8 units pRBC
    3. Once stabilized blood count may direct transfusion
      1. Transfuse for Hemoglobin 7 g/dl (Hematocrit 25%)
      2. Maintain Hemoglobin At 9 g/dl after transfusion
      3. Expect 1 g/dl Hemoglobin increase/unit transfused
      4. Expect 3% Hematocrit increase/unit transfused
      5. Goal is not a specific Blood Pressure, but rather improved mental status and Urine Output
    4. In non-exsanguinating Upper GI Hemorrhage
      1. Delaying transfusion until Hemoglobin <7.0 is associated with better outcomes
      2. Restrictive transfusion strategy had better outcomes regardless of cause (Peptic Ulcer or Cirrhosis)
      3. Villaneuva (2013) N Engl J Med 368(1): 11-21 [PubMed]
    5. Replace Coagulation Factors
      1. Consider Prothrombin Complex Concentrate (PCC 4) as an alternative to FFP
      2. Fresh Frozen Plasma (FFP) indications
        1. Exsanguinating Hemorrhage (transfuse RBC and FFP in 1:1 ratio)
        2. INR (Prothrombin Time) prolonged >1.5 times normal
          1. INR may be remarkably normal despite severe Coagulopathy (e.g. Cirrhosis)
      3. DDAVP
        1. Consider for Massive Hemorrhage in Renal Failure
  5. Transfusion Platelet indications
    1. Platelet Count <50,000/mm3
    2. Clopidogrel (Plavix) use
    3. Cirrhosis (No evidence)
    4. Aspirin or NSAID related GI Bleeding is NOT recommended as an indication for Platelet Transfusion
      1. No evidence for Platelet Transfusion and may cause harm
  6. Other measures in exsanguinating Hemorrhage
    1. Tranexamic Acid

XI. Management: Based on Bleeding site

  1. Upper GI Bleed
    1. See Upper GI Bleeding
    2. If unclear source, assume Upper GI Bleeding, especially if patient is unstable
      1. Upper GI Bleeds cause >75% of GI Bleeds and have a much higher mortality, worse prognosis
    3. In massive GI Bleeding or Unstable Patient
      1. Focus on possible Peptic Ulcer and Esophageal Varices as most likely source
  2. Lower GI Bleed
    1. See Lower GI Bleeding
    2. Relatively low mortality of 4% compared with Upper GI Bleed

XII. Complications

  1. Cardiac ischemia
  2. Acute Renal Failure
  3. Acute Respiratory Distress Syndrome (ARDS)

XIII. References

  1. Spangler, Swadron, Mason and Herbert (2016) EM:Rap C3, p. 1-11
  2. Henneman in Marx (2002) Rosen's Emergency, p 194-200
  3. Fallah (2000) Med Clin North Am 84(5):1183-208 [PubMed]
  4. Terdiman (1998) Postgrad Med 103(6):43-64 [PubMed]

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