GIT BLEEDING.pdf

Gastrointestinal Bleeding
Rajeev Jain, M.D.

GI Bleeding
• Clinical Presentation
• Acute Upper GI Bleed
• Acute Lower GI Bleed

Core Principles in
GI Bleeding Management
• Assessment and stabilization of
hemodynamic status
• Determine the source of bleeding
• Stop active bleeding
• Treatment of underlying abnormality
• Prevent recurrent bleeding

Definitions
Hematemesis: bloody vomitus (bright red or
coffee-grounds)
Melena: black, tarry, foul-smelling stool
Hematochezia: bright red or maroon blood
per rectum
Occult: positive stool occult test
Symptoms of anemia: angina, dyspnea, or
lightheadedness

Patient Assessment
• Hemodynamic status
• Localization of bleeding source
• CBC, PT, and T & C
• Risk factors
– Prior h/o PUD or bleeding
– Cirrhosis
– Coagulopathy
– ASA or NSAID’s

Initial Patient Assessment
Vital Signs Blood Loss
Severity of GI
Bleed
Shock
(resting hypotension)
20-25% Massive
Postural
(orthostatic hypotension)
10-20% Moderate
Normal <10% Minor

Resuscitation
• 2 large bore peripheral IV’s
• Normal saline or LR
• Packed RBCs
• Correct coagulopathy

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 UGIB
Demographics
• Over 400,000 admissions annually
• 80% self-limited
• Mortality 10-14%
• Continued or recurrent bleeding - mortality 30-
40%
• Nonvariceal UGIB w/o complication*
– Mean LOS 2.7 days, $3402 (2008 $)
• Nonvariceal UGIB with complication*
– Mean LOS 4.4 days, $5632 (2008 $)
Adam V, Barkun A. Value Health. 2008;11:1-3.

Risk
Stratification
Scoring
Systems

Blatchford Score
Rockall Score

UGIB Risk Stratification – AIMS65
• Albumin < 3.0 g/dL,
• INR > 1.5,
• Altered mental
status,
• Systolic blood
pressure 90 mm Hg
or lower, and
• Age older > 65
years.
Saltzman JR et al. Gastrointest Endosc 2011:1215-22.
• Large clinical
database -
CareFusion
• 187 US hospitals
• Recursive partitioning
• 2004-5 29,222 pts to
derive risk score
• 2006-7 32,504 pts to
validate

UGIB Risk Stratification – AIMS65
Saltzman JR et al. Gastrointest Endosc 2011:1215-22.

• Peptic ulcer disease
– Gastric ulcer
– Duodenal ulcer
• Mallory-Weiss tear
• Varices
• Esophagitis
• Dieulafoy’s lesion
• Vascular anomalies
• Malignancy
• Post-procedural
• Cameron’s lesions
• Hemobilia
• Hemorrhagic
gastropathy
• Aortoenteric fistula
Acute UGIB
Differential Diagnosis
Major Causes Minor Causes

Peptic Ulcer Disease
Forrest Class Stigmata
IA Arterial spurting
IB Arterial oozing
IIA Visible vessel
IIB Adherent clot
IIC Pigmented flat spot
III Clean based
Forrest JA, Finlayson ND, Shearman DJ: Endoscopy in gastrointestinal bleeding. Lancet 1974; 2:394-7

Endoscopic Appearance
of Ulcers
Clean based ulcer Nonbleeding visible vessel

Risk Stratification after
Endoscopy

Prognostic Features at Endoscopy in
Acute Ulcer Bleeding

• 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.

Risk of Recurrent Bleeding
after Endoscopic Therapy

Effect of Proton-Pump Inhibition
on Peptic Ulcer Bleeding
Gralnek et al. New Eng J Med 2008;359:928-37.

Management of PUD
after EGD in High Risk Pts
• Proton-pump inhibitor 80 mg IV bolus dose plus
continuous infusion for 72 hrs
• Admit to monitored bed or ICU setting
• Initiate oral intake of clear liquid diet 6 hrs after EGD
in pts with hemodynamic stability
• Transition to oral PPI after completing IV course
• Perform testing for H. pylori infection
• For selected patients, discuss need for NSAIDs and
antiplatelet therapy

Management of PUD
after EGD in Low Risk Pts
• Oral proton-pump inhibitor
• Initiate oral intake with a regular diet 6 hrs
after EGD in pts with hemodynamic stability
• Perform testing for H. pylori infection
• For selected patients, discuss need for
NSAIDs and antiplatelet therapy
• Consider early discharge in selected pts

Management of
Acute Variceal Bleeding
Suspected Variceal Bleeding
Endoscopy
Band ligation or sclerotherapy
Continue Octreotide for 5 days
Early rebleeding
Failure to control TIPS or surgery
Octreotide 50 ug bolus, 50 ug/hr
Conservative blood volume resuscitation
Antibiotics

Antibiotic Prophylaxis in GI
Bleeding in Cirrhotic Patients
• Fluoroquinolones or amoxicillin +
clavulinic acid
• Meta-analysis 1
– Decrease rates of infection
• SBP, bacteremia
– Increased short-term survival
• RCT 2
– Reduction in early rebleeding
1.Bernard et al.Hepatology. 29(6):1655-61.1999.
2.Hou et al. Hepatology. 39(3):746-53.2004.

Transjugular Intrahepatic
Portosystemic Shunt (TIPS)
IVC
Portal Vein
Splenic Vein
Coronary Vein

Aortoduodenal Fistula
The picture can't be displayed.
Aorta
Duodenum
Graft
Fistula

Acute UGIB
Surgery
• Recurrent bleeding despite endoscopic
therapy
• > 6-8 units pRBCs

Management of Ulcer Bleeding: ACG
Guidelines
Initial Assessment and Risk Stratification
• Hemodynamic status should be assessed immediately upon presentation
and resuscitative measures begun as needed (Strong recommendation).
• Blood transfusions should target Hgb ≥ 7 g / dl, with higher Hgbs targeted in
patients with clinical evidence of intravascular volume depletion or
comorbidities, such as coronary artery disease (Conditional
recommendation).
• Risk assessment should be performed to stratify patients into higher and
lower risk categories and may assist in initial decisions such as timing of
endoscopy, time of discharge, and level of care (Conditional
recommendation).
• Discharge from the ED without inpatient endoscopy may be considered in
patients with urea nitrogen < 18.2 mg / dl; Hgb ≥ 13.0 g / dl for men (12.0 g /
dl for women), systolic blood pressure ≥ 110 mm Hg; pulse < 100 beats /
min; and absence of melena, syncope, cardiac failure, and liver disease, as
they have < 1 % chance of requiring intervention (Conditional
recommendation).
Laine & Jensen Am J Gastroenterol 2012; 107:345–360

Management of Ulcer Bleeding: ACG Guidelines
Pre-endoscopic interventions
• Intravenous infusion of erythromycin (250 mg ~ 30 min before
endoscopy) should be considered to improve diagnostic yield and
decrease the need for repeat endoscopy. However, erythromycin
has not consistently been shown to improve clinical outcomes
(Conditional recommendation).
• Pre-endoscopic intravenous PPI (e.g., 80 mg bolus followed by 8 mg
/ h infusion) may be considered to decrease the proportion of
patients who have higher risk stigmata of hemorrhage at endoscopy
and who receive endoscopic therapy. However, PPIs do not improve
clinical outcomes such as further bleeding, surgery, or death
• If endoscopy will be delayed or cannot be performed, intravenous
PPI is recommended to reduce further bleeding (Conditional
recommendation).
• Nasogastric or orogastric lavage is not required in patients with
UGIB for diagnosis, prognosis, visualization, or therapeutic effect

Timing of endoscopy
• Patients with UGIB should generally undergo endoscopy
within 24 h of admission, following resuscitative efforts to
optimize hemodynamic parameters and other medical
problems (Conditional recommendation).
• In patients who are hemodynamically stable and without
serious comorbidities endoscopy should be performed as
soon as possible in a non-emergent setting to identify the
substantial proportion of patients with low-risk endoscopic
findings who can be safely discharged (Conditional
recommendation).
• In patients with higher risk clinical features (e.g., tachycardia,
hypotension, bloody emesis or nasogastric aspirate in
hospital) endoscopy within 12 h may be considered to
potentially improve clinical outcomes (Conditional
recommendation).

- Endoscopy
• Stigmata of recent hemorrhage should be recorded as they predict risk
of further bleeding and guide management decisions. The stigmata, in
descending risk of further bleeding, are active spurting, non-bleeding
visible vessel, active oozing, adherent clot, fl at pigmented spot, and
clean base (Strong recommendation).
• Endoscopic therapy should be provided to patients with active spurting
or oozing bleeding or a non-bleeding visible vessel (Strong
recommendation).
• Endoscopic therapy may be considered for patients with an adherent
clot resistant to vigorous irrigation. Benefi t may be greater in patients
with clinical features potentially associated with a higher risk of
rebleeding (e.g., older age, concurrent illness, inpatient at time bleeding
began) (Conditional recommendation).
• Endoscopic therapy should not be provided to patients who have an
ulcer with a clean base or a fl at pigmented spot (Strong
recommendation).

- Endoscopy
• Epinephrine therapy should not be used alone. If used, it should be
combined with a second modality (Strong recommendation).
• Thermal therapy with bipolar electrocoagulation or heater probe and
injection of sclerosant (e.g., absolute alcohol) are recommended
because they reduce further bleeding, need for surgery, and mortality
(Strong recommendation).
• Clips are recommended because they appear to decrease further
bleeding and need for surgery. However, comparisons of clips vs. other
therapies yield variable results and currently used clips have not been
well studied (Conditional recommendation).
• For the subset of patients with actively bleeding ulcers, thermal therapy
or epinephrine plus a second modality may be preferred over clips or
sclerosant alone to achieve initial hemostasis (Conditional
recommendation).

Management of Ulcer Bleeding: ACG
Guidelines - Therapy after initial endoscopy
• After successful endoscopic hemostasis, intravenous PPI therapy with 80 mg
bolus followed by 8 mg/h continuous infusion for 72 h should be given to
patients who have an ulcer with active bleeding, a non-bleeding visible vessel,
or an adherent clot (Strong recommendation).
• Patients with ulcers that have flat pigmented spots or clean bases can receive
standard PPI therapy (e.g., oral PPI once daily) (Strong recommendation).
• Routine second-look endoscopy, in which repeat endoscopy is performed 24 h
after initial endoscopic hemostatic therapy, is not recommended (Conditional
recommendation).
• Repeat endoscopy should be performed in patients with clinical evidence of
recurrent bleeding and hemostatic therapy should be applied in those with
higher risk stigmata of hemorrhage (Strong recommendation).
• If further bleeding occurs after a second endoscopic therapeutic session,
surgery or interventional radiology with transcathether arterial embolization is
generally employed (Conditional recommendation).

International Consensus on Nonvariceal
Upper Gastrointestinal Bleeding:
Postdischarge ASA and NSAIDs
• In patients with previous ulcer bleeding who require
an NSAID, it should be recognized that treatment
with a traditional NSAID plus PPI or a COX-2 inhibitor
alone is still associated with a clinically important risk
for recurrent ulcer bleeding.
an NSAID, the combination of a PPI and a COX-2
inhibitor is recommended to reduce the risk for
recurrent bleeding from that of COX-2 inhibitors
alone.
Barkun AN, et al. Ann Intern Med. 2010;152:101-113.

International Consensus on Nonvariceal
Upper Gastrointestinal Bleeding:
Postdischarge ASA and NSAIDs
• In patients who receive low-dose ASA and develop
acute ulcer bleeding, ASA therapy should be
restarted as soon as the risk for cardiovascular
complication is thought to outweigh the risk for
bleeding.
cardiovascular prophylaxis, it should be recognized
that clopidogrel alone has a higher risk for rebleeding
than ASA combined with a PPI.
Barkun AN, et al. Ann Intern Med. 2010;152:101-113.

• 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 LGIB
Differential Diagnosis

DIAGNOSES % OF TOTAL
Diverticulosis 40
Vascular anomalies 30
Colitis 21
Neoplasia 14
Anorectal 10
Upper GI sites 10
Acute LGIB
Diagnoses in pts with hemodynamic compromise.
Zuccaro. ASGE Clinical Update. 1999.

• Incidence 0.3 - 3.0 %
• Etiology Incomplete obliteration of
the vitelline duct.
• Pathology 50% ileal, 50% gastric,
pancreatic, colonic mucosa
• Complications
– Painless bleeding (children, currant jelly)
– Intussusception
Acute LGIB
Meckel’s Diverticulum

Study
Yield
%
Comments
Colonoscopy 69-80 Therapeutic
Arteriography 40-78
1 ml/min,
risks
Tagged RBC Scan 20-72 Localization
Acute LGIB
Evaluation
Zuccaro. ASGE Clinical Update. 1999.

• Resuscitation
• UGI source
• Most bleeding ceases
• Colonoscopy
• No role for barium studies
Acute LGIB
Key Points

SUMMARY
• Assessment and stabilization of
hemodynamic status
• Determine the source of bleeding
• Stop active bleeding
• Treatment of underlying abnormality
• Prevent recurrent bleeding

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