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emergency approach & management of lower gastrointestinal bleed
This document discusses the approach and management of acute lower gastrointestinal bleeding. It begins by defining upper, mid, and lower GI bleeding based on their origins. Stool color and characteristics can provide clues to the source and pace of bleeding. The case presented is of a 68-year-old male with a large amount of maroon colored bleeding from the rectum. His history, physical exam, and labs are discussed. The differential diagnosis and risk stratification for upper vs lower GI bleeding are reviewed. Initial resuscitation priorities like IV access, fluid resuscitation, blood transfusion thresholds and strategies, and coagulopathy correction are outlined. Risk factors, diagnostic modalities, and the role of colonoscopy versus surgery for lower GI
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emergency approach & management of lower gastrointestinal bleed
- 1. Approach & management Acutelower Gastrointestinal Bleeding DR ABDUL RUB PGY3 MEM
- 2. Definitions Upper GIbleed – 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
- 3. Stool color andorigin/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)
- 4. APPROACH TO APATIENT 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
- 5. Case – PhysicalExam 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
- 6. Case - HPI Denies abdominal pain, nausea, vomiting, antecedent retching No history of heartburn, dysphagia, weight loss No history of diarrhea or constipation/hard stools
- 7. Case – PMHx,Meds Hepatitis C CAD – h/o MI AAA – s/p elective repair 3 years ago HTN Hypercholesterolemia Screening colonoscopy 10 years ago – no polyps, (+) diverticulosis • Medications: – Aspirin – Clopidogrel – Atorvastatin – Atenolol – Lisinopril
- 8. examination Anicteric Midline scar, benign abdomen, no tender liver edge palpable in epigastrium, no splenomegaly Rectal examination – no masses, dark maroon blood
- 9. 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
- 10. Case - Labs Labs Hct 21% (Baseline 33%) Plt 110K BUN 22, Cr 1.0 Alb 3.5 INR 1.6 ALT 51, AST 76
- 11. Initial Considerations Differentialdiagnosis? 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
- 12. 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 Rare, but cannot afford to miss Most commo n Most commo n
- 13. 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 Most common diagnosis
- 14. 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;12:500 Am J Gastroenterol 1997;92:1796 Am J Emerg Med 2006;24:280
- 15. Utility of NGTube 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;43:525 Arch Intern Med 1990;150:1381 Gastrointest Endosc 2004;59:172
- 16. Initial Assessment Alwaysremember to assess A,B,C’s Assess degree of hypovolemic shock
- 17. 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
- 18. 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
- 19. Transfusion Strategy Randomizedtrial: 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
- 20. Restrictive Strategy Superior RestrictiveLiberal P value Mortality rate 5% 9% 0.02 Rate of further bleeding 10% 16% 0.01 Overall complication rate 40% 48% 0.02 NEJM 2013;368;11-21 Benefit seen primarily in Child A/B cirrhotics
- 21. 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 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
- 22. 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
- 23. action Early resuscitation and supportivemeasures are critical to reduce mortality from GIB Early resuscitation and supportive measures are critical to reduce mortality from GIB
- 24. Resuscitation Early intensiveresuscitation 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
- 25. Risk Stratification Identifypatients at high risk for adverse outcomes Helps determine disposition (ICU vs. floor vs. outpatient) May help guide appropriate timing of endoscopy
- 26. 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
- 27. Lower GI Bleed Differential Diagnosis - Diverticulosis (# 1 cause) - Angioectasias - Hemorrhoids - Colitis (IBD, Infectious, Ischemic) - Neoplasm - Post-polypectomy - Dieulafoy’s lesion - Diverticulosis (# 1 cause) - Angioectasias - Hemorrhoids - Colitis (IBD, Infectious, Ischemic) - Neoplasm - Post-polypectomy - Dieulafoy’s lesion Large volume, painless Large volume, painless Smaller volume, pain, diarrhea Smaller volume, pain, diarrhea
- 28. LGIB – RiskStratification 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 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% 0 factors: ~6% risk 1-3 factors: ~40% >3 factors: ~80% Arch Intern Med 2003;163:838 Am 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
- 29. LGIB – RiskFactors 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
- 30. 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
- 31. Radiographic Studies Tagged RBCscan 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 Coordinate with IR so that positive scan is followed closely by angiography
- 32. 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
- 33. Algorithmic Evaluation ofPatient with Hematochezia Hematochezi a Hematochezi a Assess activity of bleed Assess activity of bleed NG lavageNG lavage Prep for Colonoscopy Prep for Colonoscopy PositivePositive EGDEGD NegativeNegative active inactive Risk for UGIB Hemodynamic ally stable? Hemodynamic ally stable? No risk for UGIB negative Treat lesion Treat lesion positiv e
- 34. Evaluation ACUTE LOWERGI 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.
- 35. 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
- 36. 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
- 37. Always get objectivedescription of stool Always get objective description of stool Take Home Point Avoid noninformative terms such as “grossly guaiac positive” Avoid noninformative terms such as “grossly guaiac positive”
- 38. If you needa card to tell you whether there’s blood in the stool, it’s NOT an acute GIB If you need a card to tell you whether there’s blood in the stool, it’s NOT an acute GIB Take Home Point
- 39. Take Home Point UpperGI bleed must still be considered in patients with severe hematochezia, even if NG aspirate negative Upper GI bleed must still be considered in patients with severe hematochezia, even if NG aspirate negative
- 40.
Editor's Notes
- #3 Ligament of trietz connects diaphragm to 4th portion of duodenum
- #4 Guaiac :stool mixed with hydrogenperoxide on guaiac paper ..if heam present then paper turns blue
- #6 Orthostatic hypotention:fall in systolic of &gt;20&diastolic &gt;10..causes low blood,vasodilators,dehydration,diabetes ,pheochromocytoma
- #8 Acute hep 80%---75%cld-----20%cirrhosis----1to5% death due to liver cancer
- #10 Symptoms of gi bleed.fatigue,weakness,syncope,epigastric pain,heamatemesis,malena,haematochezia,…vital signs for assessment of hypovolemic shock
- #11 Haematocrit is % rbc in blood 40-50% in Asian population..bun7-20..urea production occurs in liver & excreted by kidney. Elevated BUN to creatinine ration &gt;20 indicates prerenal injury or hypo perfusion.warfarin treatment…1st dose omission 2nd iv vitamin k 3rd FFP
- #23 Each pack of platelets will increase count by 15K