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Gastrointestinal bleeding - Rosen's emergency medicine, 2009

Gastrointestinal bleeding - Rosen's emergency medicine, 2009

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  • 1. Chapter 22   Gastrointestinal Bleeding Philip L. Henneman ■  PERSPECTIVE Epidemiology Gastrointestinal (GI) bleeding is a relatively common problem encountered in emergency medicine that often requires early consultation and hospital admission. The overall mortality rate for GI bleeding is approximately 10% and has not changed significantly since the 1960s. Diagnostic modalities have improved much more than therapeutic techniques. GI bleeding is often easy to identify when there is clear evidence of vomiting blood or passing blood in the stool, but the clinical presentation may be subtle, with signs and symptoms of hypovolemia, such as dizziness, weakness, or syncope. The approach to GI bleeding depends on whether the hemorrhage is located in the proximal or the distal segment of the GI tract (i.e., upper or lower GI bleeding). These segments are anatomically defined by the ligament of Treitz in the fourth section of the duodenum. In the United States, upper GI bleeding (UGIB) affects 50 to 150 people per 100,000 population each year and results in more than 300,000 admissions and about 30,000 deaths per year at an estimated annual cost of almost $1 billion. Lower GI bleeding (LGIB) affects a smaller portion of patients and results in proportionally fewer hospital admissions than UGIB.1 GI bleeding can occur in persons of any age but most commonly affects people in their 40s through 70s (mean age, 59 years). Most deaths caused by GI bleeding occur in patients older than 60 years. UGIB is more common in men than in women (in a 2 : 1 ratio), whereas LGIB is more common in women. Significant UGIB requiring admission is more common in adults, whereas LGIB requiring admission is more common in children.2 ■  DIAGNOSTIC APPROACH LGIB. Despite improved diagnostic techniques, no source of bleeding is identified in approximately 10% of patients with GI bleeding. In patients with abdominal aortic grafts who present to the emergency department (ED) with GI bleeding, the possibility of aortoenteric fistula should be considered. Prompt surgical consultation in the ED should be obtained if this is suspected, because bleeding can be massive and fatal. Rapid Assessment and Stabilization Most patients with GI bleeding are easy to diagnose because they present to the ED complaining of vomiting blood or passing black or bloody stool. The diagnosis is confirmed quickly by examination of the stool for the presence of blood. Patients with suspected GI bleeding who are hemodynamically unstable should undergo rapid evaluation and resuscitation. They should be undressed quickly to permit placement of cardiac and oxygen saturation monitors, and supplemental oxygen should be given as needed. At least two large-bore peripheral intravenous lines should be placed (minimum 18gauge); blood should be drawn for hemoglobin or hematocrit, platelet count, prothrombin time (PT), and type and screen or type and crossmatch studies; and crystalloid resuscitation should be initiated. Intravenous crystalloid fluid should be given as a 2-L bolus in adults or 20 mL/kg in children until the patient’s vital signs have stabilized or the patient has received 40 mL/kg of crystalloid in an adult or 60 mL/kg as a child. Patients who remain unstable after 40 to 60 mL/kg of crystalloid should be given type O, type-specific, or crossmatched blood, depending on availability. Persistently unstable patients should receive immediate consultation with a gastroenterologist for UGIB and with a surgeon for LGIB.3 Differential Considerations Pivotal Findings Peptic ulcer disease, gastric erosions, and varices account for approximately three fourths of adult patients with UGIB (Box 22-1). Diverticulosis and angiodysplasia account for approximately 80% of adults with LGIB. In children, esophagitis, gastritis, and peptic ulcer disease are the most common causes of UGIB, and infectious colitis and inflammatory bowel disease are the most common causes of LGIB (Box 22-2). In children younger than 2 years of age, massive LGIB is most often a result of Meckel’s diverticulum or intussusception. At all ages, anorectal abnormalities are the most common cause of minor History, physical examination, testing a stool sample for blood, and measuring hemoglobin or hematocrit are the keys to diagnosing GI bleeding in most patients. 170 History Patients typically complain of vomiting red blood or coffee grounds–like material, or passing black or bloody stool. Hematemesis (vomiting blood) occurs with bleeding of the esophagus, stomach, or proximal small bowel. Approximately
  • 2. 171 Etiology of Significant Gastrointestinal (GI) Upper Peptic ulcer disease Gastric erosions Varices Mallory-Weiss tear Esophagitis Duodenitis Lower Diverticulosis Angiodysplasia Upper GI bleeding Cancer/polyps Rectal disease Inflammatory bowel disease *Potential causes listed in decreasing frequency. BOX 22-2 Etiology of Gastrointestinal Bleeding in Children* Upper Esophagitis Gastritis Ulcer Esophageal varices Mallory-Weiss tear Lower Anal fissure Infectious colitis Inflammatory bowel Polyps Intussusception *Potential causes listed in decreasing frequency. 50% of patients with UGIB present with this complaint. Hematemesis may be bright red or darker (i.e., coffee grounds– like) as a result of the conversion of hemoglobin to hematin or other pigments by hydrochloric acid in the stomach. The color of vomited or aspirated blood from the stomach does not differentiate between arterial and venous bleeding. Melena, or black tarry stool, will result from the presence of approximately 150 to 200 mL of blood in the GI tract for a prolonged period. Melena is seen in approximately 70% of patients with UGIB and in one third of patients with LGIB. Black stool that is not tarlike may result from presence of 60 mL of blood from the upper GI tract. Blood from the duodenum or jejunum must remain in the GI tract for approximately 8 hours before turning black. Occasionally, black stool may follow bleeding into the lower portion of the small bowel and ascending colon. Stool may remain black and tarry for several days, even though bleeding has stopped. Black stool also may be seen after ingestion of bismuth (e.g., PeptoBismol), which can confuse the situation because such preparations often are taken for UGI distress. In contrast with melena, stool rendered black by bismuth is not positive on Hemoccult testing. Hematochezia, or bloody stool (bright red or maroon), most often signifies LGIB but may be due to a brisk UGIB with rapid transit time through the bowel in 10 to 15% of patients. Because UGIB is much more common than LGIB, a more proximal source of significant bleeding must be excluded before assuming the bleeding is from the lower GI tract. Approximately two thirds of patients with LGIB present with red blood from bleeding per rectum. Small amounts of red blood (e.g., 5 mL) from rectal bleeding, such as bleeding due to hemorrhoids, may cause the water in the toilet bowl to appear bright red. Bright red stools also can be seen after ingestion of a large quantity of beets; in this case, Hemoccult testing would be negative and the patient also will report pinkcolored water in the toilet bowl. In taking the history, specific questions should address the duration and quantity of bleeding, associated symptoms, previous history of bleeding, current medications, alcohol, nonsteroidal anti-inflammatory drug use and long-term aspirin Physical Examination Vital Signs  Vital signs and postural changes in heart rate and blood pressure have been used to assess the amount of blood loss in patients with GI bleeding but are insensitive and nonspecific, with the exception of significant, sustained heart rate increase and hypotension. All patients with a history suggesting GI bleeding who are hypotensive, are tachycardic, or experience sustained posture-induced changes in heart rate of greater than 20 beats per minute should be assumed to have a significant hemorrhage. Normal vital signs do not exclude a significant hemorrhage, and postural changes in heart rate and blood pressure may occur in individuals who are not bleeding (e.g., elderly patients, many normal individuals, individuals on certain medications such as beta-blockers, individuals with hypovolemia from other causes). General Examination  The physical examination is valuable in establishing a specific diagnosis and assessing the severity of blood loss and the physiologic response to that loss. Careful attention is given to the patient’s general appearance, vital signs, mental status (including restlessness), skin signs (e.g., color, warmth, and moisture to assess for shock, or presence of lesions such as telangiectasia, bruises, or petechiae to assess for vascular diseases or hypocoagulable states), pulmonary and cardiac findings, abdominal examination, and rectal and stool examination. Frequent reassessment is important because a patient’s status may change quickly. Rectal Examination  Rectal and stool examinations are often key to making or confirming the diagnosis of GI bleeding. The finding of red, black, or melenic stool early in the assessment is helpful in prompting early recognition and management of patients with GI bleeding. The absence of black or bloody stool, however, does not exclude the diagnosis of GI bleeding. Regardless of the apparent character and color of the stool, occult blood testing is indicated. Ancillary Testing Tests for Occult Blood  The presence of hemoglobin in occult amounts in stool is confirmed by tests such as guaiac assays (e.g., Hemoccult, HemaPrompt). Stool tests for occult blood may have positive results 14 days after a single, major episode of UGIB. False-positive results have been associated with the ingestion of certain fruits (e.g., cantaloupe, grapefruit, figs), uncooked vegetables (e.g., radish, cauliflower, broccoli) and red meat, methylene blue, chlorophyll, iodide, cupric sulfate, and bromide preparations. False-negative results are uncommon but can be caused by bile or ingestion of magnesiumcontaining antacids or ascorbic acid. Tests to evaluate gastric contents for occult blood (e.g., Gastroccult) can be unreliable Chapter 22 / Gastrointestinal Bleeding BOX 22-1 Bleeding in Adults* ingestion, allergies, associated medical illnesses, previous surgery, treatment by nonhospital personnel, and the response to that treatment.4,5 Patients with GI bleeding may report symptoms of hypovolemia, such as dizziness, weakness, or loss of consciousness, most often after standing up. Other nonspecific complaints include dyspnea, confusion, and abdominal pain. Rarely an elderly patient may present with ischemic chest pain precipitated by significant anemia due to a GI bleed. One in five patients with GI bleeding may have only nonspecific complaints. The history is of limited help in predicting the site or quantity of bleeding. Patients with a previously documented GI lesion bleed from the same site in only 60% of cases. Gross estimates of blood loss based on the volume and color of the vomitus or stool (e.g., brown or black, pink or red) or the number of episodes of hemorrhage are notoriously inaccurate.
  • 3. PART I  ■  Fundamental Clinical Concepts / Section Two • Cardinal Presentations 172 and should not be used for this purpose. In newborns, maternal blood that is swallowed may cause bloody stools; the Apt test may show that it is maternal in origin. Clinical Laboratory Tests  Blood should be drawn for evaluation of baseline hematocrit or hemoglobin, coagulation studies (PT and platelet count), and type and crossmatch studies (or type and screen studies if the patient is stable). The initial hematocrit may be misleading in patients with preexisting anemia or polycythemia. Changes in the hematocrit may lag significantly behind actual blood loss. Infusion of normal saline speeds equilibration of the hematocrit; however, rapid infusion of crystalloid in nonbleeding patients also may cause a decrease in hematocrit by hemodilution. The optimal hematocrit with respect to oxygen-carrying capacity and viscosity in critically ill patients has been reported to be 33%. In general, patients with a hemoglobin concentration of 8 g/dL or less (hematocrit <25%) from acute blood loss usually require blood therapy. After transfusion and in the absence of ongoing blood loss, the hematocrit can be expected to increase approximately 3% for each unit of blood administered (hemoglobin level increases by 1 mg/dL). The PT should be used to determine whether a patient has a preexisting coagulopathy. An elevated PT may indicate vitamin K deficiency, liver dysfunction, warfarin therapy, or consumptive coagulopathy. Patients receiving therapeutic anticoagulants or patients with an elevated PT and evidence of active bleeding should receive sufficient fresh frozen plasma to correct the PT. Serial platelet counts are used to determine the need for platelet transfusions (i.e., less than 50,000/mm3). Blood Bank  Blood should be sent for “type and hold” or type and crossmatch studies early in the patient’s care. Immediate transfusion needs in unstable patients can be met with Opositive packed red blood cells (O-negative packed red blood cells in women of childbearing age whose Rh status is unknown). Type-specific blood is usually available within 10 to 15 minutes. Group O blood and type-specific blood are safe for patients and cause few transfusion reactions. Fully crossmatched blood may take 60 minutes to prepare. Stable patients can be managed more cost-effectively by ordering “type and hold” without crossmatching for units of blood. Other Laboratory Tests  Electrolytes usually are normal in patients with GI bleeding. However, determination of electrolytes, blood urea nitrogen, and creatinine may be useful in a small percentage of patients with GI bleeding when indicated. For example, in patients with repeated vomiting, hypokalemia, hyponatremia, and metabolic alkalosis may develop, which usually correct with adequate hydration and the resolution of vomiting. Patients with shock often have metabolic acidosis from lactate accumulation. The blood urea nitrogen is elevated in many patients with UGIB as a result of the absorption of blood from the GI tract and hypovolemia causing prerenal azotemia. After 24 hours, hypovolemia probably is the sole determinant of azotemia unless there has been recurrent bleeding or there is baseline renal insufficiency. Electrocardiogram  An electrocardiogram (ECG) should be obtained in all patients with a GI bleed who are older than 50 years of age or have preexisting ischemic cardiac disease, significant anemia, or chest pain, shortness of breath, or persistent hypotension. Asymptomatic myocardial ischemia (ST segment depression greater than 1 mm) or injury (ST segment elevation greater than 1 mm) may develop in the setting of GI bleeding. Patients with GI bleeding and clinical or ECG evidence of myocardial ischemia should receive packed red blood cells as soon as possible, as well as appropriate treatment for myocardial ischemia. Imaging  GI hemorrhage is not an indication for plain ab­­ dominal radiography. An upright chest radiograph should be obtained in patients with UGIB suspected of aspiration or with signs and symptoms of bowel perforation (shock with significant abdominal or peritoneal tenderness). Subdiaphragmatic air consistent with bowel perforation is a rare finding with UGIB, but it is an indication for immediate surgical consultation and operative repair. ■  DIFFERENTIAL DIAGNOSIS Not all patients complaining of vomiting blood or passing blood in the stool have GI bleeding. Swallowing blood during epistaxis or from the oral cavity may cause hematemesis or melena. Red vomitus may be due to food products (e.g., Jell-O, tomato sauce, wine), and black stool may be due to iron therapy or bismuth (e.g., Pepto-Bismol). Hypovolemia (and its symptoms) may be due to vomiting and diarrhea without bleeding. Poor oral intake with or without fever also may result in hypovolemia. Usually the patient’s hemoglobin or hematocrit is normal or elevated until hemodilution can occur. There are many causes of anemia other than GI bleeding. In the absence of suggestive symptoms or blood in the stool, GI bleeding is less likely to be the cause of observed anemia.3 ■  MANAGEMENT Quick identification, aggressive resuscitation, risk stratification, and prompt consultation are the keys to appropriate emergency management. When the diagnosis of GI bleeding is made, emergency management of patients can proceed (Fig. 22-1). Reassurance Patients who present to the ED with symptoms and signs of GI bleeding are often frightened by their symptoms. They may be concerned about the possibility of painful procedures and of the real or perceived risk of death. These patients and their families should be treated in a supportive and reassuring manner. They should be provided with accurate information about their problem, and all aspects of the care they are receiving should be explained in a way that they understand. Nasogastric Tube and Gastric Lavage After initial resuscitation of the patient, it is important to identify whether the hemorrhage is proximal or distal to the ligament of Treitz (i.e., UGIB or LGIB). If the patient’s vomitus demonstrates blood, then the diagnosis of UGIB is confirmed. If a patient reports bloody or “coffee grounds” emesis or if melenic stool is present, an upper GI bleed is more likely. Placement of a nasogastric (NG) tube formerly was widely undertaken in the belief that it had both diagnostic and therapeutic benefit. Although in some cases, an NG tube may help to establish or confirm the diagnosis of UGIB, it is not useful for risk stratification. Aspiration of bloody contents from the NG tube diagnoses UGIB (or bleeding from nasal or oral passageways), but it does not determine if the bleeding is ongoing or has already stopped. Earlier assertions that gastric lavage “until clear” demonstrated that the bleeding had stopped have been refuted by findings at endoscopy. There is a 10% incidence of failure to aspirate blood through the NG tube in established UGIB. False-negative results are possible if the bleeding is intermittent or has already stopped and the stomach is cleared, or if the bleeding is in the duodenum, and edema or spasm of the pylorus has prevented reflux of
  • 4. 173 Chief complaint History Physical examination IV access (if not done earlier) Laboratory Examination of gastric contents Initial ED risk stratification UGIB LGIB ED disposition Anoscopy Proctosigmoidoscopy Endoscopy ED/final disposition ED disposition Angiography Nuclear imaging study Colonoscopy Figure 22-1.  Emergency management of patients with gastrointestinal bleeding. ED, emergency department; IV, intravenous; LGIB, lower gastrointestinal bleeding; UGIB, upper gastrointestinal bleeding. blood into the stomach. The presence of bile in an otherwise clear aspirate excludes the possibility of active bleeding above the ligament of Treitz, but should not be used to exclude UGIB in a patient with documented melena. False-positive results may occur from nasal bleeding. Gastric contents should not be tested for occult blood; visual inspection of the vomitus or aspirate is insufficient to diagnose subtle bleeding, and testing is unreliable. In patients who have hematochezia, an upper GI origin for the bleeding often is associated with signs and symptoms of shock, because rapid transit time of large quantities of blood is producing the hematochezia. Because up to 10 to 15% of patients with hematochezia have UGIB, it has been recommended that an NG tube Anoscopy/Proctosigmoidoscopy Patients with mild rectal bleeding who do not have obviously bleeding hemorrhoids should undergo anoscopy or proctosigmoidoscopy. If bleeding internal hemorrhoids are discovered, and the patient does not have portal hypertension, the patient may be discharged with appropriate treatment and follow-up evaluation for hemorrhoids. If hemorrhoids are not detected, it is important to determine if the stool above the rectum contains blood. The absence of blood above the rectum in a patient who is actively bleeding indicates that the source of bleeding is in the rectum. The presence of blood above the anoscope or sigmoidoscope does not invariably indicate a proximal source of bleeding, because retrograde passage of blood into the more proximal colon commonly occurs. Such patients need further evaluation. Endoscopy Endoscopy is the most accurate diagnostic tool available for the evaluation of UGIB. It identifies a lesion in 78% to 95% of patients with UGIB if it is performed within 12 to 24 hours of the hemorrhage. Accurate identification of the bleeding site allows for risk stratification with respect to predicting rebleeding and mortality. Endoscopy-based triage significantly reduces hospitalization rates and costs of treating upper GI bleeding.8,9 Significant advances in endoscopic hemostasis also make it of therapeutic value in select patients (e.g., for banding or sclerosing of varices). Colonoscopy is an effective tool for diagnosis and selected treatment of LGIB.10,11 Chapter 22 / Gastrointestinal Bleeding Initial resuscitation be inserted in most cases of LGIB, but there is no evidence to support an improved outcome related to this practice.2,6 Typically, a clinical decision is made regarding the likelihood of an upper versus lower GI origin for the bleeding, and endoscopy is then performed based on that determination. If the first endoscopy approach fails to identify the bleeding site, often endoscopy of the other end of the GI tract is necessary. Gastric tubes are safe in most patients, but pharyngeal and esophageal perforation, cardiac arrest, ethmoid sinus fracture with brain trauma, and bronchial intubation have been reported. No evidence exists that gastric tube placement aggravates hemorrhage from varices or Mallory-Weiss tears. Gastric lavage may be helpful to prepare a patient for endoscopy. Before gastric lavage, patients with evidence of a possible perforated viscus (e.g., severe pain, peritoneal signs) should undergo radiologic assessment looking for free air. Lavage should not be performed in the presence of pneumoperitoneum. Gastric lavage does not reduce blood loss in patients with UGIB, and use of iced lavage fluid is not recommended. Gastric lavage in preparation for endoscopy is best performed with a large-bore Ewald tube, passed orally while the patient is in the left lateral decubitus position with the bed in Trendelenburg position. Additional holes may be cut in the distal portion of the Ewald tube to improve aspiration of blood and clots. Clots that cannot be aspirated continue to cause pink return, giving the false impression of continued bleeding. The irrigant need not be sterile; regular tap water may be used. The irrigant should be delivered and removed by gravity in volumes of 200 to 300 mL until the return is clear. Little irrigant is absorbed by the patient. Gastric rupture has been reported as a rare complication of gastric lavage.7,8
  • 5. 174 PART I  ■  Fundamental Clinical Concepts / Section Two • Cardinal Presentations Angiography and Tagged Red Blood   Cell Scan Angiography can detect the location of UGIB in two thirds of patients studied. Since the advent of endoscopy, however, the use of angiography has decreased significantly, and today angiography is used in only 1% of patients with UGIB. Angiography is used more commonly in patients with LGIB and usually in consultation with a general surgeon. Although angiography rarely diagnoses the cause of bleeding, it does identify the site of bleeding in approximately 40% of patients who have LGIB and in 65% of patients who eventually require surgical intervention. Angiography ideally is performed during active bleeding; this may be apparent from persistently unstable vital signs or continued transfusion requirements to establish or maintain an optimal hemoglobin or hematocrit level. Arterial embolization can be used in selected cases of LGIB.12 In some patients with more indolent or elusive bleeding, a nuclear isotope–tagged red blood cell scan, usually performed from the inpatient unit, may identify the bleeding site. Gastric Acid Secretion Inhibition All patients with peptic ulcer disease documented by endoscopy should receive therapy with a proton-pump inhibitor (e.g., omeprazole).13–15 There is no documented benefit to initiating this therapy or administering H2 antihistamines in the ED for patients with UGIB, however. Octreotide (Somatostatin Analogues) Patients with documented esophageal varices and acute upper GI bleeding should receive an intravenous infusion of octreotide at 25–50 µg/hour for a minimum of 24 hours while being observed in the intensive care unit (ICU). Octreotide is a useful addition to endoscopic sclerotherapy and decreases rebleeding occurrences.16,17 (See Chapter 87.) Octreotide may also reduce the incidence of lower GI rebleeding secondary to angiodysplasia.18 Vasopressin Intravenous vasopressin has been used in the treatment of UGIB, most commonly in patients with variceal hemorrhage. Controlled studies have not shown a positive effect of vasopressin on overall mortality, however. These results, combined with a relatively high rate of serious complications (9% major and 3% fatal), suggest that use of vasopressin should be limited. A trial of vasopressin may be warranted in an exsanguinating patient with suspected variceal bleeding, especially if endoscopy is not immediately available. The recommended dose of vasopressin is 20 units given intravenously over 20 minutes and then 0.2 to 0.4 unit per minute. Consultation with a gastroenterologist is advisable. Sengstaken-Blakemore Tube Placement of a Sengstaken-Blakemore tube stops hemorrhage in approximately 80% of patients bleeding from esophageal varices. The Linton tube may be superior to the SengstakenBlakemore tube in patients with bleeding gastric varices; however, either of these tubes is rarely used. In general, these tubes should not be used without endoscopic documentation of the source of bleeding because complications are common and significant (14% major, 3% fatal). A trial of balloon tamponade should be considered, however, in an exsanguinating patient with probable variceal bleeding in whom endoscopy is not immediately available and vasopressin has not slowed the hemorrhage. Consultation with a surgeon or gastroenterologist is advisable. Surgery Surgery is indicated for all hemodynamically unstable patients with active bleeding who do not respond to appropriate intravascular volume replacement, correction of any coagulopathy, and endoscopic intervention (if available). The mortality rate for patients undergoing emergency procedures for GI bleeding is approximately 23%. Generally, surgery is indicated whenever the risk of ineffective medical therapy and continued hemorrhage outweighs that of surgical morbidity and mortality.19 Emergency surgical consultation should be considered when blood replacement exceeds 5 units within the first 4 to 6 hours or when 2 units of blood is needed every 4 hours (after replacement of initial losses) to maintain normal cardiac output. ■  DISPOSITION Risk Stratification Risk stratification involves combining historical, clinical, and laboratory data to determine the risk of death and rebleeding in patients presenting to an ED with GI bleeding. Patients can be sorted into four risk categories: very low, low, moderate, and high risk. Some patients present to the ED with a vague complaint of vomiting blood or passing blood from the rectum in whom detailed history and examination allows a diagnosis of hemorrhoid, or anal fissure, or there may be little or no objective evidence of significant GI bleeding. These patients can be categorized as very low risk and can be sent home without further diagnostic tests2,7,20 (Box 22-3). Before discharge, patients should be educated about the signs and symptoms of significant GI bleeding and when to return to the ED or when to call their primary care physician. They should be given specific education about the possible or actual cause of the bleeding and specific treatment for that disorder. They should be educated about the side effects of any medications. Patents should undergo specific follow-up evaluation within 24 to 36 hours. They should be instructed to avoid aspirin, nonsteroidal anti-inflammatory drugs, and alcohol.2,21,22 Patients with low-risk, moderate-risk, and high-risk criteria are more complicated and require further assessment. Historically, nearly all patients with significant GI bleeding were admitted to the hospital. As health care has changed, a greater emphasis has been placed on outpatient management of select BOX 22-3 ■ ■ ■ ■ ■ ■ ■ Very-Low-Risk Criteria for Patients Complaining of Gastrointestinal Bleeding Who Can Be Discharged Home No comorbid diseases Normal vital signs Normal or trace positive result on stool guaiac testing Negative findings on gastric aspiration, if done Normal or near-normal hemoglobin/hematocrit Good support systems Proper understanding of signs and symptoms of significant bleeding ■ Immediate access to emergent care if needed ■ Follow-up arranged within 24 hr
  • 6. 175 Table 22-1 Initial Emergency Department Risk Stratification for Patients with Gastrointestinal Bleeding MODERATE RISK HIGH RISK Age < 60 yr Initial SBP ≥ 100 mm Hg Normal vital signs for 1 hr No transfusion requirement No active major comorbid diseases No liver disease Age > 60 yr Initial SBP < 100 mm Hg Mild ongoing tachycardia for 1 hr Transfusions required, ≤4 units Stable major comorbid diseases Mild liver disease—PT normal or near-normal No high-risk clinical features Persistent SBP < 100 mm Hg Persistent moderate/severe tachycardia Transfusion required, >4 units Unstable major comorbid diseases Decompensated liver disease—e.g., coagulopathy, ascites, encephalopathy No moderate-risk or high-risk clinical features PT, prothrombin time; SBP, systolic blood pressure. Data from Terdiman JP, Lindenauer GF: Acute gastrointestinal bleeding. In Wachter RM, Goldman L, Hollander H (eds): Hospital Medicine. Philadelphia, Lippincott Williams & Wilkins, 2005, pp. 767–779. Table 22-2 Management by Risk Category for Patients with Upper Gastrointestinal Bleeding after Endoscopy Recommended Management RISK STRATIFICATION LOW RISK MODERATE RISK HIGH RISK Low risk Immediate discharge* 23-hr observation (floor)† Moderate risk 48-hr inpatient stay† 48- to 72-hr inpatient stay (floor)† High risk ICU monitoring for 48 hr (48- to 72-hr hospitalization) ICU monitoring for 24 to 48 hr (72-hr hospitalization) ICU monitoring for 24 hr‡ (48- to 72-hr hospitalization) ICU monitoring for 24 hr (48- to 72-hr hospitalization) ICU monitoring for 72 hr (≥72-hr hospitalization) *Patients with low-risk clinical and endoscopic findings can be discharged home with appropriate treatment based on diagnosis, scheduled follow-up evaluation within 24 hours, and proper patient education to ensure immediate return if signs of rebleeding appear. † Patients may be discharged after 24 to 48 hours of in-hospital observation if there is no evidence of rebleeding, vital signs are normal, there is no need for further transfusion, and the hemoglobin or hematocrit has remained stable. They should be provided with appropriate treatment based on diagnosis, scheduled follow-up evaluation within 24 hours, and proper patient education to ensure immediate return if signs of rebleeding appear. ‡ Patients with high-risk clinical or endoscopic findings should be hospitalized and monitored closely for evidence of rebleeding. Data from Terdiman JP, Lindenauer GF: Acute gastrointestinal bleeding. In Wachter RM, Goldman L, Hollander H (eds): Hospital Medicine. Philadelphia, Lippincott Williams & Wilkins, 2005, pp. 767–779. low-risk patients with GI bleeding. Studies have shown that combining clinical and endoscopic criteria provides an accurate estimation of the risk of rebleeding and mortality in patients with UGIB. These combined criteria have been used to identify patients with UGIB at low risk, who can be discharged home, and patients at moderate or high risk, who need to be admitted to an appropriate care site in the hospital. Risk stratification for patients with LGIB is less well studied, so nearly all patients with significant LGIB are admitted. Risk stratification can be used for patients with LGIB, however, to decide an appropriate inpatient care site. Table 22-1 presents an initial risk stratification tool for patients with upper and lower GI bleeding. Combining clinical and endoscopic findings allows for final risk stratification, as shown in Table 22-2, to decide disposition, inpatient care site, and treatment.1,2,6,20,23-25 Patients with clinical evidence of GI bleeding should undergo endoscopy as soon as it is available for final risk stratification, inpatient triage, and determination of appropriate treatment (see Table 22-2). If endoscopy is not immediately available, patients with low clinical risk may be admitted to an ED observation unit or short-stay hospital bed until endoscopy can be performed. Patients with moderate clinical risk criteria may be admitted to an inpatient floor, intermediate care unit, or ICU, as indicated by specific patient management needs and depending on the capabilities of the institution. Patients with high clinical risk should be admitted to a closely monitored step-down unit or an ICU. The timing of endoscopy depends on availability, the acuity of the patient, the need for emergent therapy, the need to determine final care site, and the need to minimize length of stay.3,26 Patients with LGIB that is not clearly due to hemorrhoids, fissure, or proctitis should be admitted to an inpatient bed. Patients with low risk may be admitted to an inpatient floor bed and prepared for a nuclear medicine imaging study (e.g., red blood cell–labeled study) or colonoscopy. Patients with high-risk criteria should be admitted to a step-down unit or ICU and considered for angiography to identify the site of LGIB. Patients with moderate-risk criteria require individualized determination of the most appropriate inpatient care site (floor, intermediate care bed, or ICU) and the most useful diagnostic studies (nuclear imaging or angiography). Consultation with a surgeon should be obtained if it appears that more than 5 units of blood is required to achieve hemodynamic stability or if there is reasonable suspicion that operative intervention may be needed. This is especially true of patients older than 65 years of age. In general, the older the patient, the more aggressive the surgical management ought to be. Patients with a history of varices, persistent postural changes in heart rate, or significant bleeding of bright red blood per rectum are more likely to require surgery than are patients without these findings. Emergent vascular surgical consultation is needed for patients who have abdominal aortic grafts who present to the ED with GI bleeding, because of the possibility of an aortoenteric fistula. The references for this chapter can be found online by accessing the accompanying Expert Consult website. Chapter 22 / Gastrointestinal Bleeding LOW RISK