This document discusses the basics of gastrointestinal bleeding. It begins by describing a case of a patient admitted for hematemesis and melena. It then discusses initial steps like assessing vital signs, intravenous access, considering proton pump inhibitors or looking for varices. It provides definitions and the magnitude of GI bleeding. It discusses differential diagnoses for upper and lower GI bleeding. It also covers risk stratification, endoscopic findings and therapies, post-endoscopy management, and other options if endoscopy fails like interventional radiology, surgery or repeat endoscopy.

1. Basics of GI Bleeding
Ron Thomas, MD
Fellow
Division of Gastroenterology and
Hepatology

2. Early July on ART 6W…
• Overnight admit
– 69 yo male with recent melena and Hgb to 5 g/dl
– Prior perforated gastric ulcer with Graham patch
– Recent hemicolectomy for colonic signet ring
adenoCA
– EGD two days prior with large nonbleeding ulcer
extending from lesser curvature to incisura
– Was in rehab for a few hours before hematemesis

3. During Rounds
• “This patient was admitted for hematemesis”
• [Pause, quick glance at patient in room]
• “And he’s having active hematemesis now!!”

4. What do you do now?
• Assess hemodynamics
• Ensure large bore IV access
• Consider PPI infusion
• Could we be dealing with varices?
• Key labs: CBC, INR, BUN
• Think about NG lavage
• Don’t think about Fecal Occult

5. His EGD

10. Definitions
• Inpatient
– Overt
• Outpatient
– Occult
– Obscure
• UGIB
• LGIB

11. Magnitude
• Acute UGIB estimated to be 400,000 U.S.
hospital admissions per year1
• 80-90% of UGIB is nonvariceal2
• Peptic ulcer bleeding
– Affects patients > 60 years old3
– 5-10% mortality 2,4
– $2B in U.S. health care spending per year5
1Lewis JD et al. Am J Gastroenterol 2002; 97.
2Barkun A et al. Am J Gastroenterol 2004;99.
3Ohmann C et al. Scand J Gastroenterol 2005; 40.
4Lim CH et al. Endoscopy 2006;38.
5Viviane A et al. Value Health 2008;11.

12. Initial Steps
• Estimate hemodynamics
• Volume resuscitate
• Rectal exam
• Identify high risk patients
• Early endoscopy is key
– Within 24 hours
– High risk window 72 hours from presentation

13. Initial Steps
• Understand anti-coagulation history
• Assess level of care and airway
• Make a differential diagnosis
• Find old endoscopy reports

14. Melena
Courtesy of Joseph Thomas, MD

15. Hematochezia
Courtesy of Joseph Thomas, MD

16. Maroon Stools
Courtesy of Joseph Thomas, MD

17. UGIB: Brief DDx
• Peptic ulcer disease
– H. pylori
– NSAIDs
– Malignancy
• Mallory-Weiss tear
• Erosive esophagitis
• Erosive gastritis
• Esophageal ulcers

18. UGIB: Brief DDx
• Vascular malformations
– Angiodysplasia in CRI
– Dieulafoy’s lesion (submucosal arteriole)
– GAVE
– PHG
• Miscellaneous
– AE fistula
– Pancreatic pseudoaneurysm
– Hemobilia

19. Varices
• Some adjustments to protocol
– Octreotide drip
• Decrease splanchnic blood flow
• Reduce portal pressure
– Antibiotics
– Lower transfusion requirement
– Correcting coagulopathy if appropriate
– Intubate

20. LGIB: Brief DDx
• Diverticulosis
• Angiodysplasia
• Neoplastic disease
• Colitis
– Ischemia, infection, XRT, IBD
• Internal hemorrhoids
• Solitary rectal ulcer
• UGIB

21. Risk Stratification
• Important way to predict who might do poorly
• Rockall Score
– Age
– Shock (HR, BP)
– Coexisting illness
– Add endoscopic component
• Diagnosis
• High risk stigmata

22. Gralnek IM et al. NEJM 2008; 359.

23. Endoscopic Stigmata of Bleeding Peptic Ulcer, Classified as High Risk or Low Risk.
Gralnek IM et al. N Engl J Med 2008;359:928-937.
Gralnek IM et al. NEJM 2008; 359.

24. Basic Endoscopic Therapy
• Injection AND
– Thermal (e.g. heater probe, APC) OR
– Mechanical (e.g. clip)
• Thermal or mechanical alone
• For varices,
– Band ligation

25. Why PPI’s?
• Goal of PPI therapy is to raise the gastric PH
• High dose PPI infusion decreases basal and stimulated
acid secretion by parietal cells
• Cochrane meta-analysis that included 6 RCT from 1992-
2007 found that IV PPI prior to endoscopy did NOT
experience any statistically significant differences in
outcomes of mortality, rebleeding, or progression to
surgery.
• However, analysis did show that PPI therapy resulted in
significantly reduced rates of high risk stigmata
identified on endoscopy and need for endoscopic
therapy.
Courtesy of Joseph Thomas, MD

26. Post-Endoscopy
• High risk lesions
– PPI infusion for 72 hours after endoscopic
hemostasis
– Technically
• Can advance diet to clears after 6 hours (if
hemodynamic instability)
• Can go to oral PPI after infusion complete
• Discuss with GI consultant
– No role for repeat endoscopy in 24 hours; relook if
rebleed

27. Post-Endoscopy
• Varices
– Octreotide infusion for up to 5 days in conjunction
with band ligation1
• Result of meta-analysis
• 5 day period highest for re-bleed
– Antibiotics for 1 week
• For non-variceal bleeding
– H pylori testing (preferably from mucosal biopsy)
1Banales R et al. Hepatology 2002; 305.

28. What if Endoscopy Fails?
• IR
– Tagged RBC scan
• Bleeding > 0.1 ml/min
– Angiography
• Need localization
• Renal contrast load
• Bleeding 0.5-1.5 ml/min (CT angiography)
• Can be therapeutic
– Embolization

29. What if Endoscopy Fails?
• Surgery
– Uncontrolled bleeding
– Recurrent diverticular bleeding
– Get on board early

30. GastroHep Slide Atlas, www.gastrohep.com

31. GastroHep Slide Atlas, www.gastrohep.com

32. GastroHep Slide Atlas, www.gastrohep.com

33. GastroHep Slide Atlas, www.gastrohep.com

34. GastroHep Slide Atlas, www.gastrohep.com

35. GastroHep Slide Atlas, www.gastrohep.com

36. GastroHep Slide Atlas, www.gastrohep.com

37. Summary
While “all bleeding eventually stops…”
• Assess
• Resuscitate
• Risk-stratify
• Form a differential diagnosis
• Be particularly vigilant in the first 24 hours