Approach & management Acute lower Gastrointestinal Bleeding

DR ABDUL RUB PGY3 MEM

Definitions

Upper GI bleed – arising from the esophagus, stomach, or proximal duodenum

Mid-intestinal bleed – arising from distal duodenum to ileocecal valve

Lower intestinal bleed – arising from colon/rectum

Stool color and origin/pace of bleeding

• Guaiac positive stool– Occult blood in stool – Does not provide any localizing information– Indicates slow pace, usually low volume bleeding

• Melena– Very dark, tarry, pungent stool– Usually suggestive of UGI origin (but can be small

intestinal, proximal colon origin if slow pace)• Hematochezia

– Spectrum: bright red blood, dark red, maroon – Usually suggestive of colonic origin (but can be UGI

origin if brisk pace/large volume)

APPROACH TO A PATIENT WITH GI BLEED

68 yo male presents with a chief complaint of a large amount of “bleeding from the rectum”

Physical examination: BP 105/70, Pulse 100, (+) orthostatic changes Alert and mentating, but anxious appearing

Case – Physical Exam

HOPI: Describes bleeding as large volume, very dark maroon colored stool

Has occurred 4 times over past 3 hours He felt light headed and nearly passed out upon

trying to get up to go the bathroom

Case - HPI

Denies abdominal pain, nausea, vomiting, antecedent retching

No history of heartburn, dysphagia, weight loss No history of diarrhea or constipation/hard stools

Case – PMHx, Meds

Hepatitis C CAD – h/o MI AAA – s/p elective repair 3

years ago HTN HypercholesterolemiaScreening colonoscopy 10

years ago – no polyps, (+) diverticulosis

• Medications:– Aspirin– Clopidogrel– Atorvastatin– Atenolol– Lisinopril

examination

Anicteric Mid line scar, benign abdomen, no tender liver edge

palpable in epigastrium, no splenomegaly Rectal examination – no masses, dark maroon blood

APPROACH STARTS FROM HISTORY & PHYSICAL EXAM

History Localizing symptoms History of prior GIB NSAID/aspirin use Liver disease/cirrhosis Vascular disease Aortic valvular disease,

chronic renal failure AAA repair Radiation exposure Family history of GIB

Physical Examination

• Vital signs, orthostatics• Abdominal tenderness• Skin, oral examination • Stigmata of liver disease• Rectal examination

– Objective description of stool/blood

– Assess for mass, hemorrhoids– No need for guaiac test

Case - Labs

Labs Hct 21% (Baseline 33%) Plt 110K BUN 22, Cr 1.0 Alb 3.5 INR 1.6 ALT 51, AST 76

Initial Considerations

Differential diagnosis? What is most likely source? What diagnosis can you least afford to miss?

How sick is this patient? (risk stratification) Determines disposition Guides resuscitation Guides decision re: need for/timing of endoscopy

Differential Diagnosis – Upper GIB

Peptic ulcer disease Gastroesophageal varices Erosive esophagitis/gastritis/duodenitis Mallory Weiss tear Vascular ectasia Neoplasm Dieulafoy’s lesion Aortoenteric fistula Hemobilia, hemosuccus pancreaticus

Rare, but cannot afford to

miss

Most commo

n

Differential Diagnosis – Lower GIB

Diverticular-20% AVM-10% Malignancy-2-26% Inflammatory Bowel Disease-10% Ischemic Colitis Acute Infectious Colitis Radiation Colitis/Proctitis Aortoenteric Fistula

Most common diagnosis

Narrowing the DDx: Upper or Lower Source?

Predictors of UGI source: Age <50 Melenic stool BUN/Creatinine ratio

If ratio ≥ 30, think upper GIB

J Clin Gastroenterol 1990;12:500Am J Gastroenterol 1997;92:1796Am J Emerg Med 2006;24:280

Utility of NG Tube

Most useful situation: patients with severe hematochezia, and unsure if UGIB vs. LGIB Positive aspirate (blood/coffee grounds) indicates UGIB

Can provide prognostic info: Red blood per NGT – predictive of high risk endoscopic lesion Coffee grounds – less severe/inactive bleeding

Negative aspirate – not as helpful; 15-20% of patients with UGIB have negative NG aspirate

Ann Emerg Med 2004;43:525Arch Intern Med 1990;150:1381Gastrointest Endosc 2004;59:172

Initial Assessment Always remember to assess A,B,C’s Assess degree of hypovolemic shock

Resuscitation

IV access: large bore peripheral IVs best (alt: cordis catheter) Use crystalloids first Anticipate need for blood transfusion

Threshold should be based on underlying condition, hemodynamic status, markers of tissue hypoxia Should be administered if Hgb ≤ 7 g/dL 1 U PRBC should raise Hgb by 1 (HCT by 3%) Remember that initial Hct can be misleading (Hct remains the same with loss of whole blood, until re-equilibration occurs)

Correct coagulopathy

Resuscitation

IV access: large bore peripheral IVs best (alt: cordis catheter) Use crystalloids first Anticipate need for blood transfusion

Threshold should be based on underlying condition, hemodynamic status, markers of tissue hypoxia Should be administered if Hgb ≤ 7 g/dL 1 U PRBC should raise Hgb by 1 (HCT by 3%) Remember that initial Hct can be misleading (Hct remains the same with loss of whole blood, until re-equilibration occurs)

Correct coagulopathy

Transfusion Strategy

Randomized trial: 921 subjects with severe acute GIB Restrictive (tx when Hgb<7; target 7-9) vs. Liberal

(tx when Hgb<9; target 9-11) Primary outcome: all cause mortality rate within 45

days

NEJM 2013;368;11-21

Restrictive Strategy SuperiorRestrictive Liberal P value

Mortality rate 5% 9% 0.02Rate of further

bleeding10% 16% 0.01

Overall complication

rate

40% 48% 0.02

NEJM 2013;368;11-21

Benefit seen primarily in Child A/B cirrhotics

Resuscitation

IV access: large bore peripheral IVs best (alt: cordis catheter) Use crystalloids first Anticipate need for blood transfusion

Threshold should be based on underlying condition, hemodynamic status, markers of tissue hypoxia Should be administered if Hgb ≤ 7 g/dL 1 U PRBC should raise Hgb by 1 (HCT by 3%) Remember that initial Hct can be misleading (Hct remains the same with loss of whole blood, until re-equilibration occurs)

Correct coagulopathy

Weigh risks and benefits of reversing anticoagulation

Assess degree of coagulopathy

Vitamin K – slow acting, long-lived

FFP – fast acting, short lived- Give 1 U FFP for every 4 U PRBCs

Correction of Coagulopathy

FFP transfusion Synthetic liver dysfunction Warfarin

Consider Vitamin K Dilutional coagulopathy Goal INR <1.5

Platelet transfusion in bleeding pt if less than 50K Platelet dysfunction

Anti-platelet agents or uremia Goal platelets >50, 000/mm³

action

Early resuscitation and supportive measures are

critical to reduce mortality from GIB

Resuscitation

Early intensive resuscitation reduces mortality Consecutive series of patients with hemodynamically

significant GIB First 36 subjects = Observation Group (no

intervention) Second 36 subjects = Intensive Resuscitation Group

(intense guidance provided) – goal was to decrease time to correction of hemodynamics, Hct and coagulopathy

Am J Gastroenterol 2004;99:619

Risk Stratification

Identify patients at high risk for adverse outcomes Helps determine disposition (ICU vs. floor vs.

outpatient) May help guide appropriate timing of endoscopy

Lower GI Bleed

Bleeding arising from the colorectum In patients with severe hematochezia, first

consider possibility of UGIB 10-15% of patients with presumed LGIB are found to

have upper GIB

Lower GI Bleed

Differential Diagnosis- Diverticulosis (# 1 cause)- Angioectasias- Hemorrhoids- Colitis (IBD, Infectious, Ischemic)- Neoplasm- Post-polypectomy- Dieulafoy’s lesion

Large volume, painless

Smaller volume, pain, diarrhea

LGIB – Risk Stratification

Predictors of severe* LGIB: HR>100 SBP<115 Syncope nontender abdominal examination bleeding during first 4 hours of evaluation aspirin use >2 active comorbid conditions

0 factors: ~6% risk

1-3 factors: ~40%

>3 factors: ~80%

Arch Intern Med 2003;163:838Am J Gastroenterol 2005;100:1821

* Defined as continued bleeding within first 24 hours (transfusion of 2+ Units, decline in HCT of 20+%) and/or recurrent bleeding after 24 hours of stability

LGIB – Risk Factors for Mortality

• Age• Intestinal ischemia• Comorbid illnesses

• Secondary bleeding (developed during admission for a separate problem)

• Coagulopathy• Hypovolemia• Transfusion requirement• Male gender

Clinical Gastro Hepatol 2008;6:1004

Role of Colonoscopy

Like UGIB, ~80% of LGIBs will resolve spontaneously; of these, ~30% will rebleed Lack of standardized approach

Traditional approach: elective colonoscopy after resolution of bleeding, bowel prep – low therapeutic benefit Angiography for massive bleeding, hemodynamically unstable patient

Urgent colonoscopy approach Similar to UGIB – identify stigmata of hemorrhage, perform therapy

Radiographic Studies

Tagged RBC scan Noninvasive, highly

sensitive (0.05-0.1 ml/min) Ability to localize bleeding

source correctly only ~66% More accurate when

positive within 2 hours (95-100%)

Lacks therapeutic capability

Coordinate with IR so that positive scan is followed closely by

angiography

Role of Surgery

Reserved for patients with life-threatening bleed who have failed other options

General indications: hypotension/shock despite resuscitation, >6 U PRBCs transfused

Preoperative localization of bleeding source important

Algorithmic Evaluation of Patient with Hematochezia

Hematochezia

Assess activity of

bleed

NG lavage Prep for Colonoscopy

Positive

EGD

Negative

active inactive

Risk for UGIB

Hemodynamically stable?

No risk for UGIB

negativeTreat lesion positiv

e

Evaluation ACUTE LOWER GI BLEED

Study Yield % Comments

Colonoscopy 69-80 Therapeutic

Arteriography 40-78 1 ml/min, risks

Tagged RBC Scan 20-72 Localization

Zuccaro. ASGE Clinical Update. 1999.

Take Home Points

Always get objective description of stool color (best way – examine it yourself)

Don’t order guaiac tests on inpatients

Severe hematochezia can be from UGIB, even if NG lavage is negative

Take Home Points

• All bleeding eventually stops (and majority of nonvariceal bleeds will stop spontaneously, with the patient alive)

• Early resuscitation and supportive care are key to reducing morbidity and mortality from GIB

Always get objective description of stool

Take Home Point

Avoid noninformative terms such as “grossly guaiac positive”

If you need a card to tell you whether there’s blood in the stool, it’s NOT an

acute GIB

Take Home Point

Take Home Point

Upper GI bleed must still be considered in patients with severe hematochezia, even

if NG aspirate negative

THANKS