Gastrointestinal Bleeding

Rajeev Jain, M.D.

GI Bleeding

• Background

• Acute Upper GI Bleed

• Acute Lower GI Bleed

Clinical PresentationDefinitions

Hematemesis: bloody vomitus (bright red or coffee-grounds)

Melena: black, tarry, foul-smelling stool

Hematochezia: bright red or maroon blood per rectum

Occult: positive guaiac test

Symptoms of anemia: angina, dyspnea, or lightheadedness

Clinical Presentation

• Reflection of bleeding:–Site

–Etiology

–Rate

Initial Patient Assessment Hemodynamic Status

Resuscitation• 2 large bore peripheral IV’s• Colloid (normal saline or lactated Ringer’s)• Transfuse packed RBCs

– In elderly, goal Hct 30%– In young, goal Hct 20-25%– In cirrhotics, goal Hct 25-28%

• Correct coagulopathy• Reassess hemodynamics

History

• Prior history of bleeding• Previous gastrointestinal illnesses• Previous surgery• Other medical conditions (ie, cirrhosis)• Medications

– Aspirin, NSAIDs, & anti-platelet agents– Anticoagulants– ? SSRIs

• Abdominal pain, weight loss

Physical Exam & Labs

• Focused but thorough– Look for markers of liver disease

• Laboratory studies– CBC– INR– Electrolytes– Type and crossmatch RBCs

Acute BleedingChanges Before and After 2 Liter Bleed

0

1

2

3

4

5

6

Before During 24-72 Hrs

VO

LU

ME

( L

)

Plasma RBC

27%45%45%

Location of Bleeding

• Upper– Proximal to Ligament of Treitz– Melena (100-200 cc of blood)– Azotemia– Nasogastric aspirate

• Lower– Distal to Ligament of Treitz– Hematochezia

Acute UGIBDemographics

• Annual incidence of hospitalization: 100/100,000 persons

• 80% self-limited• Mortality stable at 10%• Continued or recurrent bleeding -

mortality 30-40%

• Cause of bleeding

• Severity of initial bleed

• Age of the patient

• Comorbid conditions

• Onset of bleeding during hospitalization

Acute UGIBPrognostic Indicators

NASOGASTRIC ASPIRATE

STOOL COLOR

MORTALITY RATE (%)

Clear Red, brown, or black 10

Coffee Grounds Brown or black 10

Red 20

Red Blood Black 10

Brown 20

Red 30

Acute UGIBPrognostic Indicators

Tedesco et al. ASGE Bleeding Survey. Gastro Endo. 1981.

Acute UGIBDifferential Diagnosis

• Peptic ulcer disease– Gastric ulcer– Duodenal ulcer

• Mallory-Weiss tear• Portal hypertension

– Esophagogastric varices

– Gastropathy

• Esophagitis

• Dieulafoy’s lesion• Vascular anomalies• Hemobilia• Hemorrhagic

gastropathy• Aortoenteric fistula• Neoplasms

– Gastric cancer– Kaposi’s sarcoma

Acute UGIBDifferential Diagnosis

DIAGNOSES % OF TOTAL

Duodenal ulcer 24Gastric erosions 23Gastric ulcer 21Varices 10Mallory-Weiss tear 7Esophagitis 6

Acute UGIBFinal Diagnoses of the Cause in 2225

Patients

Tedesco et al. ASGE Bleeding Survey. Gastro Endo. 1981.

DIAGNOSES % OF TOTAL

Peptic ulcer 55 Varices 14 Angioma 6 Mallory-Weiss tear 5 Erosions 4 Tumor 4

Acute UGIBCauses in CURE Hemostasis Studies

(n=948)

Savides et al. Endoscopy 1996;28:244-8.

Acute UGIBCORI Database: 7822 EGDs b/n 1999-2001

Boonpongmanee S. et al. Gastrointest Endosc 2004;59:788-94.

Peptic UlcersStigmata of Recent Hemorrhage (SRH)

Acute Peptic Ulcer BleedingPrognosis by SRH

Laine and Peterson. New Eng J Med 1994;331:717-27.

• Thermal– Bipolar probe– Monopolar probe– Argon plasma

coagulator– Heater probe

• Mechanical– Hemoclips– Band ligation

• Injection– Epinephrine– Alcohol– Ethanolamine– Polidocal

Endoscopic Therapy of PUD

Endoscopic Therapy of PUD

Laine and Peterson New Eng J Med 1994;331:717-27.

Peptic Ulcer BleedingAdjuvant Medical Therapy

• Erythromycin– 250 mg IV 30 minutes before

endoscopy decreases blood in stomach

• Proton pump inhibitor therapy– 80 mg IV bolus followed by 8

mg/hr continuous infusion for 72 hrs

– Reduced risk:• Rebleeding (NNT 12)• Surgery (NNT 20)

Leontiadis, G. et al. BMJ 2005;330:568

Mallory-Weiss Tear

Esophageal Varices

Variceal Band Ligation

Variceal Band Ligation

Variceal Band Ligation

• Octreotide• Cyclic octapeptide analog of

somatostatin• Longer acting than somatostatin• Equivalent to sclerotherapy and

improves endoscopic results

MEDICAL THERAPYAcute Variceal Bleeding

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

IVC

Portal Vein

Splenic Vein

Coronary Vein

Aortoduodenal Fistula

Aorta

Duodenum

Graft

Fistula

Acute UGIB Surgery

• Recurrent bleeding despite endoscopic therapy

• > 6-8 units pRBCs

Acute LGIBDifferential Diagnosis

• Diverticulosis• Colitis

– IBD (UC>>CD)– Ischemia– Infection

• Vascular anomalies• Neoplasia• Anorectal

– Hemorrhoids– Fissure

• Dieulafoy’s lesion• Varices

– Small bowel– Rectal

• Aortoenteric fistula• Kaposi’s sarcoma

• UPPER GI BLEED

Acute LGIBDifferential Diagnosis

DIAGNOSES % OF TOTAL

Diverticulosis 40Vascular anomalies 30Colitis 21Neoplasia 14Anorectal 10Upper GI sites 10

Acute LGIBDiagnoses in pts with hemodynamic

compromise.

Zuccaro. ASGE Clinical Update. 1999.

Etiology of Acute LGIB

Strate LL. Gastroenterol Clin North Am. 2005 Dec;34(4):643-64.

Outcomes of Acute LGIB

Strate LL. Gastroenterol Clin North Am. 2005 Dec;34(4):643-64.

Diverticulosis

Diverticular Bleeding

Urgent Colonoscopy for the Diagnosis and Treatment of Severe Diverticular

Hemorrhage

• 121 pts with severe bleeding (>4 hrs after hospitalization)

• 1st 73 pts: no colonoscopic tx

• Last 48 pts eligible for colonoscopic tx

• Colonoscopy w/in 6-12 hrs

Urgent Colonoscopy for the Diagnosis and Treatment of Severe Diverticular Hemorrhage

Jensen DM, et al. New Eng J Med 2000:342:78-82.

Ischemic Colitis

• Most common form of intestinal ischemia

• Transient and reversible

• Abdominal pain• Watershed areas

– Splenic flexure– Rectosigmoid junction

Hemorrhoids

Bleeding AVM

Radiation Proctitis

• Incidence 0.3 - 3.0 %• Etiology Incomplete obliteration of

the vitelline duct.• Pathology50% ileal, 50% gastric,

pancreatic, colonic mucosa• Complications

– Painless bleeding (children, currant jelly)– Intussusception

Acute LGIBMeckel’s Diverticulum

Study Yield

% Comments

Colonoscopy 69-80 Therapeutic

Arteriography 40-78 1 ml/min,

risks

Tagged RBC Scan 20-72 Localization

Acute LGIBEvaluation

Zuccaro. ASGE Clinical Update. 1999.

• Annual incidence of hospitalization: – 20-30/100,000 persons

• Resuscitation• Exclude an UGI source• Most bleeding ceases• Colonoscopy• No role for barium studies

Acute LGIBKey Points