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Gastrointestinal Bleeding

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Gastrointestinal Bleeding, Acute Gastrointestinal Hemorrhage, Acute Gastrointestinal Bleeding Management, Gastrointestinal Bleeding Management, GI Bleed, Hematochezia, Melena

  • 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
  • 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 (5%)
  3. Lower Gastrointestinal Bleeding (24%)
    1. Annual Incidence (U.S.): 20-27 per 100,000
  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
  • 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, maroon or dark red stool
      2. Usually correlates with Lower GI Bleeding
      3. Brisk Upper GI Bleeding may cause (11%)
    3. Blood in toilet (e.g. Hemorrhoid source)
      1. Toilet water may appear bright red from 5 cc blood
  • 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), melanotic stool
      2. 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
  • 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
  • Diagnostics
  1. Electrocardiogram
    1. Monitor for cardiac ischemia
  • 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
        1. Endotracheal Intubation Preoxygenation is key
          1. Minimal reserve due to acute blood loss
  2. Intensive Care Unit admission indications
    1. Significant bleeding
    2. Hemodynamically unstable
  3. 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
  4. Transfusion platelet indications
    1. Platelet Count <50,000/mm3
    2. Aspirin or NSAID related GI Bleeding (no evidence)
    3. Clopidogrel (Plavix) use
    4. Cirrhosis (No evidence)
  5. Other measures in exsanguinating Hemorrhage
    1. Tranexamic Acid
  • 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
  • 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]