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© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
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© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
in the clinic
Acute
Gastrointestinal
Bleeding
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
Who is at risk for acute GI bleeding?
Risks factors vary by site and cause
 Upper GI bleeding
 Peptic ulcer disease (risk factors: NSAIDs, H. pylori)
 Increased gastric acid production
 Smoking
 Severe physiologic stress
 Host factors (genetic polymorphisms affecting cyclooxygenase and prostaglandin production)
 Varices, esophagitis, vascular abnormalities,
Mallory-Weiss tear, benign or malignant neoplasms
 ? Spicy foods (no convincing data they increase risk)
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
Who is at risk for acute GI bleeding?
Risks factors vary by site and cause
 Lower GI bleeding
 Diverticulosis (most common cause of hematochezia)
 Inflammatory bowel disease
 Infectious colitis
 Neoplasia
 Angioectasias
 Benign anorectal disease
 Upper GI sources
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
“Obscure” bleeding: 10-20% of GI bleeding
 Unknown cause despite evaluation, tests, imaging
 Recurrent or persistent bleeding (≈50%)
 Obscure-overt (visible blood w/ melena / hematochezia)
 Obscure-occult (recurrent iron-deficiency / positive FOBT)
 Many from small intestine: “Mid-GI bleeding” (mostly from
angioectasia)
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
Can acute GI bleeding be prevented?
 Peptic ulcer disease
 Reduce NSAID use
 Administer antacid Rx with H2-inhibitors or PPIs
 At-risk hospitalized pts
 Coagulopathy or thrombocytopenia
 Mechanical ventilation
 Traumatic brain or spinal cord injury, burns
 Prophylactic H2-inhibitors or PPIs
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
Can acute GI bleeding be prevented?
 Chronic liver disease and portal hypertension
 Nonselective β-blockers + endoscopic interventions
 Diverticulitis or angioectasias
 High-fiber diets may help
 Surgical intervention (diverticulosis) after ≥1major episode
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
CLINICAL BOTTOM LINE: Prevention…
 Upper GI bleeding
 Minimize use and appropriately prescribe NSAIDs,
antiplatelet agents, anticoagulants
 Primary and secondary prophylactic acid suppression
 Variceal bleeding
 Nonselective beta-blockers and endoscopic therapy
 Lower GI bleeding
 Reduce exposure to NSAIDS, antiplatelet agents,
anticoagulants
 Few measures help in prevention
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
What are symptoms of acute GI bleeding?
 Hematemesis
 Melena
 Bloody diarrhea
 Presyncope or syncope
 Fatigue; dizziness; pallor (anemia)
 Upper GI bleeding
 Nausea, dyspepsia
 Lower GI bleeding
 Altered bowel habits, lower abdominal pain,
rectal discomfort
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
What are the signs of acute GI bleeding?
 Hypotension (systolic BP < 90 mmHg)
 Tachycardia (>120 bpm)
 Orthostatic changes in BP (≥10mmHg), HR (≥30/min)
 Blood or coffee-grounds-like material in nasogastric
aspirate: upper GI source
 Pallor: poor indicator without corroborative evidence
 Perioral telangiectasias: hereditary hemorrhagic
telangiectasia syndrome
 Skin abnormalities: stigmata of cirrhosis, pigmented lip
lesions, acanthosis nigricans, vascular anomalies
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
What are the common causes of upper and
lower GI bleeding?
 Inflammatory
 PUD; esophagitis or esophageal ulceration
 Diaphragmatic hernia; diverticular disease; IBD
 Benign and malignant neoplasms
 Vascular anomalies
 Gastroesophageal varices, angioectasias
 Dieulafoy lesion
 gastric antral vascular ectasia
 Radiation proctopathy
 Drug-induced (aspirin; NSAIDs)
 Miscellaneous
 Post-polypectomy; Mallory–Weiss tear; Meckel diverticulum
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
Can risk for adverse outcomes be predicted
in patients with acute GI bleeding?
 Factors that portend a poorer prognosis
 Chronic alcoholism
 Active cancer
 Risk-stratification tools facilitate triage
 Rockall scoring system
 Glasgow–Blatchford Scale
 Incorporate clinical, lab, and/or endoscopic parameters
 Predict need for hospitalization or further intervention
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
Which patients may be evaluated as
outpatients, and which require the
emergency department or hospitalization?
 Outpatient management if low-risk for rebleeding:
 Rockall score 0–2
 Glasgow–Blatchford score 0
 Inpatient management & consider admission to ICU:
 Brisk, active bleeding
 Other parameters for high risk for rebleeding, mortality
 Chronic alcoholism
 Higher Rockall or Glasgow–Blatchford score
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
What should the initial diagnostic evaluation
for possible acute GI bleeding include?
 History
 Associated signs and symptoms
 Use of NSAIDs, antiplatelet agents, anticoagulants,
SSRIs, β-blockers
 Prior GI bleeding episodes and comorbid conditions
 Physical exam
 Routine exam + assess vital signs on postural changes
 Examine stool
 Check for resting hypotension or tachycardia
 Check for increase in pulse (≥30/min) or severe
lightheadedness when rising from supine position
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
 Lab tests
 CBC, prothrombin and partial thromboplastin times
 Platelet count, blood type and crossmatch, and routine
chemistry panel
 Ratio of blood urea nitrogen to creatinine
 Increased ratio suggests upper GI source
 Nasogastric or orogastric aspiration
 May confirm upper GI bleeding
 May provide prognostic information on severity
 False negative in ~15%
 No proof of altered outcomes
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
When should a gastroenterologist be consulted
in the evaluation of acute GI bleeding?
 Consult early
 To consider prompt endoscopy and facilitate triage
 Initial diagnostic tests of choice: EGD &/or colonoscopy
 EGD
 For melena and hematemesis
 For subset with hematochezia from upper GI source
 Early endoscopy (≤24h admission)
 For upper GI bleeding
 Ensure volume resuscitation + hemodynamic stabilization
 Urgent endoscopy (<12h admission)
 For suspected variceal bleeding
 Provides valuable information for appropriate triage
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
What is the role of prokinetic medications
before upper endoscopy in patients with
acute GI bleeding?
 Facilitate clearance of blood and clots from stomach
 Erythromycin, metoclopramide
 Administered IV 20-120 mins before upper endoscopy
 Improve endoscopic visualization
 Does not appear to alter important clinical outcomes
 Reserve for patients with red blood hematemesis or
blood in nasogastric aspirate
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
What adjunctive tests help evaluate or treat
patients with acute GI bleeding without an
identified source on EGD or colonoscopy?
 Small-bowel barium radiography (historically)
 Wireless video capsule endoscopy (VCE)
 Higher diagnostic yield (35%–76%)
 Can’t provide hemostatic interventions
 Many institutions can’t perform urgent VCE inpatient
 Angiography
 Allows intervention if lesion localized
 Requires active bleeding at time of study
 CTA or CT/MR enterography
 Enables visualization + therapeutics deep in small intestine
 Low-risk; no need for high-risk intraoperative enteroscopy
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
CLINICAL BOTTOM LINE: Presentation
and Diagnosis…
 Presents with myriad signs and symptoms
 Asymptomatic to overt hematemesis or hematochezia
 Due to causes virtually anywhere along the GI tract
 Initial evaluation helps narrow differential diagnosis
 Including history and physical examination
 Routine laboratory tests
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
What interventions should be started
immediately for acute GI bleeding?
 Aggressive volume resuscitation
 Large-bore peripheral IV catheters to give fluids and blood
products rapidly
 Emesis  Intubate if unable to protect airway from aspiration
 Isotonic IV fluids to replenish intravascular volume
 Blood transfusions may be harmful in hypovolemic anemia
 Treat coagulopathy in patients receiving anticoagulants
 Don’t delay therapeutic endoscopy unless INR >2.5
 Except in cirrhosis (INR can’t predict bleeding risk)
 Target platelets > 50,000/μL if no platelet dysfunction
 > 100,000/μL if suspected dysfunction
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
How should acute upper GI bleeding due
to peptic ulcer disease be managed?
 Endoscopy – allows biopsy / assess cause
 ≈100% specific (rare false-+ result); >90% sensitive
 Forrest classification: describes ulcers, predicts risk
 Clean ulcer base or flat pigmented spot in ulcer base:
low rebleeding riskpharmacologic Rx only
 Adherent clots, nonbleeding visible vessels, or active
bleeding: high-risk continued or recurrent bleeding
endoscopic interventions + pharmacologic Rx
 High-risk lesions having endoscopic therapy: 3 days inhospital IV PPI required, then once-daily oral PPI; H2
blockers not as effective
 Low-risk lesions, hemodynamically stable, no serious
comorbidities: consider early D/C on daily PPI
 Consider pre-endoscopic PPIs (but don’t delay endoscopy
or replace resuscitation)
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
How should acute esophageal variceal
bleeding be treated?
 Result of significant portal hypertension
 Bleeding occurs under high pressure and often brisk
 Monitor closely for adverse effects of volume replacement
 Target hemoglobin: 7–8 g/dL
 Antibiotic prophylaxis reduces infectious complications
 Medical Rx (infusion octreotide, somatostatin analogue)
 Endoscopic therapy (for known or suspected varices)
 Refractory to medical and endoscopic therapy?
 Balloon tamponade: temporizing measure
 TIPS placement: within 72 hours (recommended)
 Surgery: portosystemic shunting, esophageal transection,
liver transplant
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
How should acute lower GI bleeding from
colonic diverticulosis be treated?
 Initially: Fluid resuscitation, blood transfusion, testing
 Colonoscopy: to localize (difficult if brisk hemorrhage)
 Within 12-24 h of presentation with rapid colonic prep
 Allows exclusion of other causes (cancer)
 Can be therapeutic if visible vessel or adherent clot noted
 Nuclear imaging
 Angiography
 Surgical resection: if bleeding doesn’t resolve (≈20%)
 Segmental colectomy: if bleeding can be localized
 Subtotal colectomy: if bleeding can’t be localized source
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
What is the role of angiography?
 Local administration of vasopressin
 Controls bleeding in up to 80% of patients
 Rebleeding often occurs when infusion stopped
 Temporizing measure, allows for more controlled procedure
 Use with caution if CAD or PVD present
 Embolization of the source
 Injection of sealant materials or mechanical devices
 Alternative if vasopressin has failed or too risky
 More definitive means to control bleeding
 Contraindication: poor collateral blood supply
 More effective in absence of coagulopathy
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
How should therapy for acute GI bleeding
be monitored?
 Tachycardia
 Early warning recurrent bleeding, followed by hypotension
 Hemoglobin levels
 Check at least every several hours initially
 Possible ongoing blood loss if levels don’t increase by
≈1 g/unit of transfused packed RBCs
 Additional blood transfusions and diagnostic testing
 Consider if evidence of ongoing blood loss
 Platelet count and coagulation
 Measure serially to assess need for repeated transfusions
 If multiple transfusions of RBCs: monitor for hypocalcemia
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
When should a surgeon be consulted for
the management of acute GI bleeding?
 Early in evaluation and management
 For severe or hemodynamically significant bleeding
 Consult shouldn’t delay initial interventions
 Surgery indicated when…
 Life-threatening bleeding continues
 Hemodynamic compromise despite resuscitation
 Bleeding can’t be stopped by endoscopy / angiography
 Localization of site of bleeding critical for surgical planning
 Surgery type also depends on presence of comorbidities
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
What instructions do patients require
following acute GI bleeding?
 Signs and symptoms of recurrent bleeding
 Benefit and duration of targeted therapies
 Bleeding from…
 H. pylori: complete therapy; test for eradication  d/c PPI if
eradicated unless NSAID or antiplatelet Rx needed
 NSAID: discontinue NSAID if feasible
 Low-dose aspirin Rx: resume after bleeding stops for
secondary prevention of established CV disease
 Aspirin or clopidogrel for primary prevention of CV events:
weigh risks & benefits on individual basis
 Dual antiplatelet Rx: PPI prophylaxis as long as antiplatelet
Rx indicated
 Bleeding not associated with H. pylori, NSAID, or
antiplatelet agents: continue daily PPI indefinitely – no
good data
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
CLINICAL BOTTOM LINE: Treatment…
 Depends on cause and severity of bleeding
 Initial evaluation and management in all cases should include:
 History and physical examination
 Stabilization interventions
 Placement of IV access & IV fluid resuscitation
 Emergent endoscopy (within 6 h) rarely indicated
 Urgent endoscopy if variceal bleeding suspected
 PPI for suspected PUD (but don’t delay endoscopy)
 Transfusion: target hemoglobin of 7-8 g/dL
 Base outpatient follow-up on:
 Establish etiology of bleeding
 Estimated risk of re-bleeding
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.