Gastrointestinal Bleeding

Definition

• Intraluminal blood loss anywhere from the oropharynx to the anus

• Classification: upper above the ligament of Treitz: lower below the ligament of Treitz

• Signs: hematemesis blood in vomitus (UGIB); hematochezia bloody stools

(LGIB or rapid UGIB); melena black, tarry stools from digested blood (usually UGIB, but can be anywhere above and including the right colon) Etiologies of upper Gl bleed (UGIB)

• Oropharyngeal bleeding and epistaxis -* swallowed blood

• Erosive esophagitis (10%):GERD Barrett's esophagus, XRT

if immunocompromised also consider CMV. HSV. Candida

• Varices (10-30%; nejm 2001345:669): esophageal r gastric. 2° to portal HTN;

present in 40-60% cirrhotics; if isolated gastric need to r o splenic vein thrombosis

• Mallory-Weiss tear (10%; GE junction tear due to retching against closed glottis)

• Gastritis/gastropathy (15%; NSAIDs.ASA. alcohol, stress-related mucosal disease)

• Peptic ulcer disease (PUD) (50%; H. pylori. NSAIDs. gastric hypersecretory states)

• Vascular malformations (5%)

Dieulafoy s lesion: superficial ectatic artery usually in cardia -» sudden, massive UGIB vascular lesions: AVMs, angioectasias (submucosal, may involve any part of the gut) gastric antral vascular ectasia (GAVE): "watermelon stomach." tortuous, dilated vessels aorto-enteric fistula: AAA or aortic graft erodes into 3rd portion of duodenum;

p w "herald bleed"; if suspected, diagnose by endoscopy or CT vasculitis

• Neoplastic disease: esophageal or gastric carcinoma. GIST Etiologies of lower Gl bleed (LGIB)

• Diverticular hemorrhage (33%; 60% of diverticular bleeding localized to right colon)

• Angiodysplasia (8%; most commonly located in ascending colon and cecum)

• Neoplastic disease (19%; usually occult bleeding, rarely severe)

• Colitis (18%; infection, ischemic, radiation, inflammatory bowel disease [UC » CD])

• Anorectal (4%; hemorrhoids, anal fissure, rectal ulcer)

• Post-polypectomy

Clinical manifestations

• UGIB > LGIB: nausea, vomiting, hematemesis. coffee-ground emesis. epigastric pain.

vasovagal reactions, syncope, melena

• LGIB • UGIB: diarrhea, tenesmus. BRBPR or maroon stools Workup (performed concurrently with initial stabilization)

• Goal: where (anatomic location), why (etiology), and how much (amt of blood loss)

• History acute or chronic GIB. number of episodes, most recent episode hematemesis. vomiting prior to hematemesis. melena. hematochezia abdominal pain, weight loss, anorexia. A in stool caliber use of aspirin. NSAIDs, anticoagulants, or known coagulopathy alcohol abuse, cirrhosis, known liver disease, risk factors for liver disease abdominal rectal radiation, history of cancer prior Gl or aortic surgery

• Physical exam tachycardia at 10% volume loss; orthostatic hypotension at 20% loss; shock at 30% loss pallor, telangiectasias (alcoholic liver disease or Osier-Weber-Rendu syndrome) signs of liver disease: jaundice, spider angiomata. gynecomastia, testicular atrophy.

palmar erythema, caput medusae. Dupuytren s contractures, hepatosplenomega/y localizable abdominal tenderness or peritoneal signs, masses. LAN. signs of prior surgery rectal exam: appearance color of stools, presence of hemorrhoids or anal fissures

• Laboratory studies: Hct (may be normal early in acute blood loss before equilibration, which may take 24 h; i 2-3% - loss of 500 cc blood). MCV. platelet count. PT. PTT. BUN Cr (ratio -36 in UGIB due to Gl resorption of blood and or prerenal azotemia). LFTs

• Nasogastric tube: useful for localization. Most helpful if returns fresh blood active

UGIB; coffee grounds recent UGIB (but can be confused w bile); nonbloody bile suggests lower source, but does not exclude active UGIB;© Hemoccult of no value.

• Dx studies in UGIB: EGD (potential Rx as well; consider erythro 250 mg IV x1

30-60 min prior to promote gastric emptying of blood and t Dx Rx yield)

• Diagnostic studies in LGIB (r o UGIB before attempting to localize presumed LGIB)

bleeding spontaneously stops — colonoscopy (identifies cause in >70%, potential Rx) stable but continued bleeding — colonoscopy after rapid purge (GoLYTELY 4-6 L) unstable - arteriography (detects bleeding rates ^0.5 ml min; therapeutic potential [intraarterial vasopressin or embolization]); tagged RBC scan (bleeding rates -0.1 ml min, but localization unreliable) often used as screening prior to angio exploratory laparotomy Treatment

• Acute treatment of GIB is hemodynamic resuscitation with IV fluid and blood establish access with 2 large-bore (18-gauge or larger) intravenous lines volume resuscitation with normal saline or lactated Ringer's solution transfusion (blood bank sample for type & cross; use O-neg blood if Pt exsanguinating) correct coagulopathies (FFP to normalize PT. platelets to keep count -50,000 mm1) nasogastric tube lavage if hematemesis intubation for emergent EGD if shock, poor resp status, ongoing hematemesis. AMS

Etiology

Options

Varices

Pharmocologic octreotide 50 pg IVB — 50 pg h infusion (84% success; lanat

1993:341637). Usually X 5 d. but most benefit w in 24-48 h. Antibiotics in Pts w ascites for SBP prophylaxis (norfloxacin 400 mg

PO bid or Bactrim DS PO bid x 7 d) (Heterology 2004.39:746) Non-pharmocologic endoscopic band ligation (>90% success) has replaced sclerotherapy (88% success) b c J compl. (ne/m 1991326:1S27) octreotide endoscopic Rx (>95% success; ne/m 199s:333:5ss) balloon tamponade (Sengstaken-Blakemore) if bleeding severe; mainly used as rescue procedure and bridge to TIPS TIPS for esophageal variceal hemorrhage refractory to above, or for gastric varices (main side effect: encephalopathy) surgery (portocaval splenorenal shunts. Sugiura procedure)

PPI (omeprazole 80 mg IVB 8 mg h) before EGD accelerates resolution of bleeding, i need for Rx during EGD. and J LOS

(nejm 2007:356:1631)

? octreotide 50 pg IVB — 50 p.g h if unstable and EGD not immediately available (Ann* 1997:127:1062) Non-pharmocologic endoscopic therapy (epinephrine inj. bipolar cautery, hemoclip) arteriography with infusion of vasopressin or embolization surgery if endoscopic and pharmacologic therapy fails

Mallory-Weiss

Esophagitis

Gastritis

Usually stops spontaneously, endoscopic therapy if active PPI. Hj-antagonists

Diverticular disease

Usually stops spontaneously ( 75%)

Endoscopic therapy (eg. epinephrine injection, cautery, banding, or hemoclip). arterial vasopressin or embolization, surgery

Angiodysplasia

Usually stops spontaneously (-85%)

Endoscopic Rx (cautery), arterial vasopressin embolization, surgery

Poor prognostic signs in UGIB

• Demographics: age 60. comorbidities, variceal or neoplastic etiology

• Severity: bright red blood in NGT. t transfusion requirement, hemodynamic instability Obscure GIB

• Etiologies: angiodysplasia. small intestinal tumors. Meckel's diverticulum (congenital ileal abnormality, incomplete obliteration of vitelline duct w/ heterotopic gastric mucosa that can lead to peptic ulceration). Crohn's disease, mesenteric ischemia, vasculitis

• Workup: repeat EGD. push enteroscopy, bleeding scan, angiography (to look for abnormal

"vascular blush"). I c-pertechnetate scan ("Meckel's scan"), video capsule endoscopy, double-ballon enteroscopy

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