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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
- See Also
- Gastrointestinal Occult Bleeding
- Definitions
- Overt Gastrointestinal Bleeding
- Visible Gastrointestinal Bleeding (e.g. Hematemesis, Hematochezia)
- Obscure Gastrointestinal Bleeding
- Recurrent Gastrointestinal Bleeding without a source identified despite diagnostic evaluation
- Most commonly associated with Small Intestinal Bleeding
- Occult Gastrointestinal Bleeding
- Gastrointestinal Bleeding not visible on stool examination
- Presents with occult occult blood test positive (e.g. guiaic stool testing or FIT Testing) or Iron Deficiency Anemia
- Hematochezia (Bright Red Blood Per Rectum)
- Grossly bloody or dark red stool that usually correlates with Lower GI Bleeding
- Differentiate from Maroon Stool which is associated with brisk Upper Gastrointestinal Bleeding
- Melana (Black Stool)
- Black stool is typically associated with Upper GI Bleeding, with heavier bleeding suggested by tarry black stool
- Lower GI Bleeding is responsible for one third of black stool cases
- Maroon Stool
- Suggests rapid Upper GI Bleeding
- History
- Characteristics
- Gastrointestinal Bleeding sites and characteristics
- Hematemesis
- Consider non-gastrointestinal sources (e.g. Hemoptysis, Epistaxis and other oropharyngeal bleeding)
- Coffee-ground Emesis suggests Upper Gastrointestinal Bleeding
- Bloody stool
- Black tarry stools or Melena suggests Upper Gastrointestinal Bleeding
- Bright Red Blood Per Rectum or Hematochezia
- More suggestive lower GI source (but may be upper source if bleeding is brisk, esp. maroon)
- Associated Symptoms
- Abdominal Pain
- Location (e.g. epigastric) may help differentiate upper from lower GI source
- Weight loss
- Consider Inflammatory Bowel Disease, malignancy
- Fever
- Consider Acute Inflammatory Diarrhea (Dysentery)
- Light headedness, Dizziness or Syncope
- Consider severe volume depletion (heavy GI Bleeding)
- Past History: Gastrointestinal
- Peptic Ulcer Disease
- Prior Gastrointestinal Bleeding
- Prior abdominal surgery
- Chronic Liver Disease
- Cirrhosis
- Chronic Hepatitis
- Esophageal Varices
- Past History: Comorbidity
- Coronary Artery Disease or other cardiovascular disease
- Diabetes Mellitus
- Chronic Kidney Disease
- Chronic Obstructive Pulmonary Disease
- Coagulopathy
- Habits
- Tobacco Abuse
- Alcohol Abuse
- Medications
- See Drug Induced Platelet Dysfunction
- Aspirin
- Clopidogrel (Plavix)
- Warfarin (Coumadin) and other Anticoagulants (e.g. Factor Xa Inhibitor)
- NSAIDs
- Corticosteroids
- Selective Serotonin Reuptake Inhibitors (SSRI)
- Inhibit Platelet aggregation
- Causes: Sources of acute Gastrointestinal Bleeding
- Upper Gastrointestinal Bleeding (70%)
- Annual Incidence (U.S.): 100-200 per 100,000
- Small Intestinal Bleeding or Middle Gastrointestinal Bleeding (5%)
- Bleeding source between Ligament of Treitz (distal duodenum) and ileocecal valve (distal ileum)
- Lower Gastrointestinal Bleeding (24%)
- Annual Incidence (U.S.): 20-27 per 100,000
- Exam: Vital Signs
- Orthostatic Blood Pressure and Pulse (variable efficacy)
- Blood Pressure
- Hypotension may be an ominous sign of impending cardiovascular collapse
- Heart Rate
- Tachycardia in most cases
- Paradoxical Bradycardia causes
- Beta Blockers or nitrates
- Vagal response due to GI Bleed
- Oxygen Saturation
- Follow Urine Output
- Signs: Identify gastrointestinal source of blood
- Signs of upper GI sources of blood (>75% of GI Bleeds)
- Unstable patients are most likely to be from Upper GI Bleeding
- Hematemesis (present in 50% of Upper GI Bleed)
- Nasogastric aspirate positive for blood
- Melena (Black tarry stool)
- Black tarry stool requires 150 to 200 cc blood
- Black non-tarry stool requires 60 cc blood
- Blood must be in GI Tract 8 hours to turn black
- Stool remains black for several days in GI Tract
- Melana source
- Present in 70% of Upper GI Bleeding
- Present in 33% of Lower GI Bleeding
- Signs of lower GI sources of blood
- Blood per Rectum occurs with any GI source
- Hematochezia (seen in 80% of all GI Bleeding)
- Grossly bloody or dark red stool
- Usually correlates with Lower GI Bleeding
- Brisk Upper GI Bleeding may result in Maroon Stool (11%)
- Blood in toilet (e.g. Hemorrhoid source)
- Toilet water may appear bright red from 5 cc blood
- Evaluation
- Upper GI Bleeding evaluation
- See Upper GI Bleed
- See Upper GI Bleeding Score
- See Upper GI Endoscopic Evaluation of Bleeding
- Indication
- Hematemesis (or blood on nasogastric aspirate)
- Melanotic stool or in cases of brisk Upper GI Bleeding, maroon
- Upper GI Bleed more likely in unstable patients
- Common Causes
- Duodenal Ulcer, Gastric Ulcer or Gastritis
- Esophageal Varices
- Esophagitis
- Lower GI Bleeding evaluation
- See Lower GI Bleed
- See Colonoscopy in GI Bleeding
- Indication
- No Hematemesis or nasogastric lavage/aspirate with bile but no blood
- Bright Red Blood Per Rectum
- Common Causes
- Diverticular Bleeding
- Arteriovenous Malformations
- Colon Polyps or Colorectal Cancer
- Labs
- Complete Blood Count
- Baseline Hemoglobin (trails bleeding by 24 hours)
- Blood Type and Cross-match
- Coagulation Factors
- Prothrombin Time
- Platelet Count
- Diagnostics
- Electrocardiogram
- Monitor for cardiac ischemia
- Management: Acute
- ABC Management
- Oxygen
- Intravenous Access
- Two large bore IV (14-16 gauge)
- Start with Isotonic Saline (NS or LR)
- Intravenous FluidResuscitation
- Massive GI Bleed
- See Massive Hemorrhage
- Replace blood with blood
- Start with universal donor blood (O- in premenopausal women, O+ in men)
- Transfuse type specific blood when available
- Replace 1 unit plasma per unit pRBC and 1 unit apheresis Platelets for every 8 units pRBC
- Non-massive GI Bleed
- Crystalloid 10 cc/kg boluses until stable
- Reassess after 3 boluses (30 cc/kg)
- Consider transfusion for unstable after 3 boluses
- Endotracheal Intubation
- Indications
- Altered Mental Status
- Massive Upper GI Bleeding
- Controls airway to prevent aspiration
- Confirms source (via orogastric or Nasogastric Tube)
- Technique
- Endotracheal Intubation Preoxygenation is key
- Minimal reserve due to acute blood loss
- Intensive Care Unit admission indications
- Significant bleeding
- Hemodynamically unstable
- Transfusion Packed Red Blood Cells
- Indications
- Hemoglobin 8 g/dl or Hematocrit 25%
- Brisk active bleeding (replace blood with blood)
- Cardiopulmonary symptoms
- Cardiopulmonary comorbidity
- Do not base transfusion in acute bleeding on labs
- Hemoglobin And Hematocrit lag bleeding by 24 hours
- Active unstable bleeding requires Blood Products
- Base transfusion on Hemodynamic status
- Base on response to crystalloid (after 30 cc/kg)
- In Massive Hemorrhage, replace blood with blood as soon as universal donor blood available
- Replace 1 unit plasma per unit pRBC
- Replace 1 unit apheresis Platelets for every 8 units pRBC
- Once stabilized blood count may direct transfusion
- Transfuse for Hemoglobin 7 g/dl (Hematocrit 25%)
- Maintain Hemoglobin At 9 g/dl after transfusion
- Expect 1 g/dl Hemoglobin increase/unit transfused
- Expect 3% Hematocrit increase/unit transfused
- Goal is not a specific Blood Pressure, but rather improved mental status and Urine Output
- In non-exsanguinating Upper GI Hemorrhage
- Delaying transfusion until Hemoglobin <7.0 is associated with better outcomes
- Restrictive transfusion strategy had better outcomes regardless of cause (peptic ulcer or Cirrhosis)
- Villaneuva (2013) N Engl J Med 368(1): 11-21 [PubMed]
- Replace Coagulation Factors
- Consider Prothrombin Complex Concentrate (PCC 4) as an alternative to FFP
- Fresh Frozen Plasma (FFP) indications
- Exsanguinating Hemorrhage (transfuse RBC and FFP in 1:1 ratio)
- INR (Prothrombin Time) prolonged >1.5 times normal
- INR may be remarkably normal despite severe Coagulopathy (e.g. Cirrhosis)
- DDAVP
- Consider for Massive Hemorrhage in Renal Failure
- Transfusion Platelet indications
- Platelet Count <50,000/mm3
- Aspirin or NSAID related GI Bleeding (no evidence)
- Clopidogrel (Plavix) use
- Cirrhosis (No evidence)
- Other measures in exsanguinating Hemorrhage
- Tranexamic Acid
- Management: Based on Bleeding site
- Upper GI Bleed
- See Upper GI Bleeding
- If unclear source, assume Upper GI Bleeding, especially if patient is unstable
- Upper GI Bleeds cause >75% of GI Bleeds and have a much higher mortality, worse prognosis
- In massive GI Bleeding or unstable patient
- Focus on possible peptic ulcer and Esophageal Varices as most likely source
- Lower GI Bleed
- See Lower GI Bleeding
- Relatively low mortality of 4% compared with Upper GI Bleed
- Complications
- Cardiac ischemia
- Acute Renal Failure
- Acute Respiratory Distress Syndrome (ARDS)
- References
- Spangler, Swadron, Mason and Herbert (2016) EM:Rap C3, p. 1-11
- Henneman in Marx (2002) Rosen's Emergency, p 194-200
- Fallah (2000) Med Clin North Am 84(5):1183-208 [PubMed]
- Terdiman (1998) Postgrad Med 103(6):43-64 [PubMed]