GI BLEEDING
Brad Martin, MD c/o Jason De Roulet, MD
July 18, 2012
OBJECTIVES
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Define some common terms associated with GI bleeds
Review the ways patients commonly present with GI
bleeds
Review how to assess patients presenting with GI bleed
Identify the most common causes of both upper and
lower GI bleeds
Identify key information to have available when calling a
GI consult
Review the medical and endoscopic treatments for
both upper and lower GI bleeds
DEFINITIONS
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Acute GI bleed
< 3 days duration
 hemodynamic instability
 requires blood transfusion
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Overt vs. occult
overt = visible blood (melena, bright red blood,
coffee grounds)
 occult = only detected by lab tests
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DEFINITIONS
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Upper vs. Lower GI bleed
UGIB = proximal to ligament of Treitz
 LGIB = distal to ligament of Treitz
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Ligament of
Treitz
GOALS OF CARE
Stabilize patient’s hemodynamics
 Assess patient, determine source of bleed
 Stop any active bleeding
 Treat underlying cause
 Prevent recurrence
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PRESENTATION
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“The patient has been vomiting blood”
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Usually indicates upper GI source
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Can include:
bright red blood
 coffee ground emesis
 clots
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PRESENTATION
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“The patient has had bloody stools”
need to determine stool characteristics, especially
color, consistency, and frequency
 melena = black, tarry stool (melena ≠ dark, formed
stool!)
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usually indicates upper GI bleed, although ~5% can be
from small bowel or proximal colon
 only need around 50cc of blood to get melena
 adjective is melenic, not melanotic
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hematochezia = BRBPR or clots
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usually indicates lower GI bleed, although can be brisk
upper bleed
brown stool, formed stool usually not aggressive
bleed
INITIAL ASSESSMENT
Is the patient hemodynamically stable?
 Replace intravascular volume
 History, physical exam
 Nasogastric intubation
 Lab evaluation
 Floor vs. ICU
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INITIAL ASSESSMENT – STABLE?
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Is the patient orthostatic?
requires loss of 20% of blood volume
 “dizzy when I get up”
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Is the patient in shock?
requires loss of 40% of blood volume
 hypotensive, tachycardic, pallor
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INITIAL ASSESSMENT –
RESUSCITATION
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Establish good access
2 large bore (ideally 18-gauge peripheral IVs)
 in MICU, may place triple-lumen or Cordis
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Replace intravascular volume
if hypotensive and/or orthostatic, give NS boluses
 if anemic, give PRBCs
 may need FFP and/or platelets if massive GI bleed
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INITIAL ASSESSMENT – HISTORY
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Age
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Previous bleeding
Comorbidities
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CAD
heart failure
AAA repair
liver disease
Previous endoscopies (look at reports!)
Associated symptoms
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risk, mortality increase with age
pain
retching
anorexia, weight loss
nausea/vomiting
early satiety
dysphagia
epistaxis, hemoptysis
Medication history – NSAIDs, warfarin, ASA, Plavix
INITIAL ASSESSMENT – PHYSICAL
Vital signs: tachycardia? hypotension?
hypoxia?
 Gen: distress? alert + oriented?
 HEENT: pallor, blood in nares or mouth
 Abd: distension, tenderness
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Rectal – visualize the stool!
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BRB, melena, maroon, brown, no stool in vault
“The ER said it was heme positive”
INITIAL ASSESSMENT – NG TUBE
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Nasogastric intubation, NG lavage
confirm NGT is in stomach (KUB)
 inject 250cc NS, then draw 250cc back or place to wall
suction
 can be repeated for up to total of 2L
 stop when fluid is clear (or when reach 2L)
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Contraindications
facial trauma, nasal bone fracture
 known esophageal abnormalities (strictures, diverticuli)
 ingestion of caustic substances, esophageal burns
 generally, esophageal varices are NOT a
contraindication to NG tube placement
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INITIAL ASSESSMENT – NG TUBE
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Interpretation of aspirate:
bright red, clots = active UGIB
 coffee grounds = slow bleeding, may have
stopped, localizes to upper GI source
 clear = indeterminate (NOT a guarantee that the
bleeding has stopped)
 bilious = bleeding has stopped
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INITIAL EVALUATION – LABS
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CBC
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H+H, including BASELINE
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Platelets
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BUN/Cr ratio
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see increased BUN in UGIB due to absorbed blood proteins
ratio usually > 20:1
Coags
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goal platelet count?
Renal function panel
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how often to check?
goal H+H?
may take up to 72 hrs to equilibrate
goal INR < 1.5
reverse with FFP, vitamin K unless contraindicated
LFTs
Iron studies
THE STOOL GUAIAC
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Stool guaiac is a great tool for colon cancer
screening
It is NOT a test for acute GI bleed
Causes of false-positives include:
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Trauma
Extraintestinal blood loss
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Medications
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epistaxis
hemoptysis
ASA, NSAIDs (gastric irritation)
Exogenous peroxidase activity
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red meat consumption
fruits (grapefruit, cantaloupe, figs)
uncooked vegetables (broccoli, cauliflower, radish,
cucumber, carrot)
INITIAL EVALUATION - TRIAGE
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What necessitates a MICU admission?
Hemodynamic instability despite adequate volume
resuscitation
 NG lavage does not clear with 2L
 History of cirrhosis, concern for variceal bleed
 Continued bleeding
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Be concerned when:
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Age > 60
Multiple comorbidities
Coagulopathy (i.e. Plavix, warfarin, cirrhosis)
Known portal hypertension
Hematemesis is bright red blood
History of AAA repair in the past
DETERMINING THE SOURCE
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History is crucial
NSAIDs, postprandial epigastric pain (ulcer?)
 hypotension preceding BRBPR (mesenteric
ischemia?)
 retching or recurrent vomiting (Mallory-Weiss?)
 history of cirrhosis (variceal bleed?)
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Stool exam
 NG lavage
 11% of patients initially suspected of LGIB
actually have UGIB
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UPPER GI BLEED
Other
Erosions
Neoplasm
MalloryWeiss Tear
AVM
PUD
Esophageal
Varices
(Other includes Dieulafoy’s lesion, GAVE, foreign body, etc.)
LOWER GI BLEED
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Differential diagnosis:
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Diverticulosis (up to 42%)
Ischemia (up to 18%)
Hemorrhoids, fissures (up to 16%)
UGI or small bowel bleed (up to 13%)
Neoplasia (up to 11%)
Other (IBD, infectious colitis, post-polypectomy)
Unknown cause in up to 23% of cases
CALLING A GI CONSULT
Presentation
 PMHx, especially if h/o liver disease
 NG lavage results
 RECTAL EXAM!!-Stool characteristics
 Vital signs, hemodynamics, orthostatics
 Labs
 Previous endoscopy reports
 Have a differential
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MEDICAL THERAPY FOR UGIB
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PUD:
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PPI bolus of 80mg, then drip at 8mg/hr
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has been shown to accelerate resolution of bleeding
and decrease need for therapy during EGD
Varices
Octreotide 50-100mcg bolus, then 50mcg/hr drip
 If pt has ascites, will need antibiotics for 7 days for
SBP prophylaxis
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norfloxacin 400mg BID
 Bactrim DS BID
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ENDOSCOPIC THERAPY FOR UGIB
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PUD
epinephrine injection
 bipolar cautery
 hemoclip
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Varices
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endoscopic band ligation
>90% success
 30% rebleeding rate
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TIPS for hemorrhage refractory to banding
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also used for gastric varices
UGIB ADMISSION
NPO after midnight
 Call GI fellow first thing the next morning (8am)
 If patient cannot consent, make sure medical
decision maker is identified and have phone
numbers available
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TREATMENT OF LGIB
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No medical treatments
Diverticular bleeds stop on their own 75% of the
time
Bleeds due to angiodysplasia stop spontaneously
around 85% of the time
If pt continues to bleed
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CT angiography to localize bleed
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can often be accompanied by embolization to stop the
bleeding
requires > 0.5cc per minute of blood loss
Tagged RBC scan
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can detect bleeding at > 0.1cc per minute
unreliable localization, high false positive rate
TREATMENT OF LGIB
Usually no need for emergent colonoscopy
 If stable but continued bleeding can do “rapid
purge” (GoLYTELY 4L given quickly) and
colonoscopy can be done in 6-12 hours
 Colonoscopy reveals cause in > 70% of cases
 Tools used include
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epinephrine injection
 cautery
 hemoclip
 surgery
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LGIB ADMISSION (ON THE FLOOR)
Clear liquid diet the day prior to endoscopy
 1 gallon GoLYTELY started the
afternoon/evening before procedure
 Goal is for stool to be CLEAR
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SUMMARY
A detailed history is crucial in diagnosing GIB
 It is also very important to characterize the
emesis and/or stool to aid in diagnosis
 Stool guaiac testing is not indicated in acute
GIB
 Most important step is assessing hemodynamic
(in)stability and resuscitating with NS and/or
blood if needed
 In most cases, the patient will need
endoscopy, but you can help to improve
outcomes with specific medical treatments
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Thank you!
Enjoy your time in Cleveland!