Gastrointestinal Bleeding

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Gastrointestinal Bleeding

• Rajeev Jain, M.D.

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GI Bleeding

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

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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

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GI Bleeding ManagementDefinitions

• 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

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GI Bleeding ManagementPatient Assessment

• Hemodynamic status
• Localization of bleeding source
• CBC, PT, and T C
• Risk factors
• Prior h/o PUD or bleeding
• Cirrhosis
• Coagulopathy
• ASA or NSAIDs

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GI Bleeding ManagementInitial Patient Assessment
Vital Signs Blood Loss Severity of GI Bleed
Shock (resting hypotension) 20-25 Massive
Postural (orthostatic hypotension) 10-20 Moderate
Normal lt10 Minor
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GI Bleeding ManagementResuscitation

• 2 large bore peripheral IVs
• Normal saline or LR
• Packed RBCs
• Correct coagulopathy

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GI Bleeding ManagementLocation of Bleeding

• Upper
• Proximal to Ligament of Treitz
• Melena (100-200 cc of blood)
• Azotemia
• Nasogastric aspirate
• Lower
• Distal to Ligament of Treitz
• Hematochezia

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Acute UGIBDemographics

• 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. 2008111-3.
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Risk Stratification Scoring Systems
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Blatchford Score
Rockall Score
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UGIB Risk Stratification AIMS65

• Albumin lt 3.0 g/dL,
• INR gt 1.5,
• Altered mental status,
• Systolic blood pressure 90 mm Hg or lower, and
• Age older gt 65 years.

• 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

Saltzman JR et al. Gastrointest Endosc
20111215-22.
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UGIB Risk Stratification AIMS65
Saltzman JR et al. Gastrointest Endosc
20111215-22.
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Acute UGIBDifferential Diagnosis
Major Causes
Minor Causes

• Peptic ulcer disease
• Gastric ulcer
• Duodenal ulcer
• Mallory-Weiss tear
• Varices
• Esophagitis
• Dieulafoys lesion
• Vascular anomalies
• Malignancy

• Post-procedural
• Camerons lesions
• Hemobilia
• Hemorrhagic gastropathy
• Aortoenteric fistula

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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 2394-
7
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Endoscopic Appearanceof Ulcers
Clean based ulcer
Nonbleeding visible vessel
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Risk Stratification after Endoscopy
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Prognostic Features at Endoscopy in Acute Ulcer
Bleeding
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Endoscopic Therapy of PUD

• Thermal
• Bipolar probe
• Monopolar probe
• Argon plasma coagulator
• Heater probe
• Mechanical
• Hemoclips
• Band ligation

• Injection
• Epinephrine
• Alcohol
• Ethanolamine
• Polidocal

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Endoscopic Therapy of PUD
Laine and Peterson New Eng J Med 1994331717-27.
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Risk of Recurrent Bleeding after Endoscopic
Therapy
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Effect of Proton-Pump Inhibition on Peptic Ulcer
Bleeding
Gralnek et al. New Eng J Med 2008359928-37.
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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

Gralnek et al. New Eng J Med 2008359928-37.
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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

Gralnek et al. New Eng J Med 2008359928-37.
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Mallory-Weiss Tear
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Esophageal Varices
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Management of Acute Variceal Bleeding
Suspected Variceal Bleeding
Octreotide 50 ug bolus, 50 ug/hr Conservative
blood volume resuscitation Antibiotics
Band ligation or sclerotherapy Continue
Octreotide for 5 days
Endoscopy
Early rebleeding
Failure to control
TIPS or surgery
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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.
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Variceal Band Ligation
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Transjugular Intrahepatic Portosystemic Shunt
(TIPS)
Coronary Vein
IVC
Splenic Vein
Portal Vein
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Aortoduodenal Fistula
Aorta
Duodenum
Fistula
Graft
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Acute UGIB Surgery

• Recurrent bleeding despite endoscopic therapy
• gt 6-8 units pRBCs

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Management of Ulcer Bleeding ACG
GuidelinesInitial 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
  lt 18.2 mg / dl Hgb 13.0 g / dl for men (12.0 g
  / dl for women), systolic blood pressure 110 mm
  Hg pulse lt 100 beats / min and absence of
  melena, syncope, cardiac failure, and liver
  disease, as they have lt 1 chance of requiring
  intervention (Conditional recommendation).

Laine Jensen Am J Gastroenterol 2012
107345360
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Management of Ulcer Bleeding ACG
GuidelinesPre-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 (Conditional
  recommendation).
• 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 (Conditional
  recommendation).

Laine Jensen Am J Gastroenterol 2012
107345360
35
Management of Ulcer Bleeding ACG
GuidelinesTiming 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).

Laine Jensen Am J Gastroenterol 2012
107345360
36
Management of Ulcer Bleeding ACG Guidelines -
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).

Laine Jensen Am J Gastroenterol 2012
107345360
37
Management of Ulcer Bleeding ACG Guidelines -
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).

Laine Jensen Am J Gastroenterol 2012
107345360
38
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).

Laine Jensen Am J Gastroenterol 2012
107345360
39
International Consensus on Nonvariceal Upper
Gastrointestinal BleedingPostdischarge 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.
• In patients with previous ulcer bleeding who
  require 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.
2010152101-113.
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International Consensus on Nonvariceal Upper
Gastrointestinal BleedingPostdischarge 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.
• In patients with previous ulcer bleeding who
  require 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.
2010152101-113.
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Acute LGIBDifferential Diagnosis

• Diverticulosis
• Colitis
• IBD (UCgtgtCD)
• Ischemia
• Infection
• Vascular anomalies
• Neoplasia
• Anorectal
• Hemorrhoids
• Fissure

• Dieulafoys lesion
• Varices
• Small bowel
• Rectal
• Aortoenteric fistula
• Kaposis sarcoma
• UPPER GI BLEED

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Acute LGIBDiagnoses in pts with hemodynamic
compromise.
Zuccaro. ASGE Clinical Update. 1999.
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Diverticulosis
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Diverticular Bleeding
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Hemorrhoids
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Bleeding AVM
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Radiation Proctitis
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Acute LGIBMeckels Diverticulum

• 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

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Acute LGIBEvaluation
Zuccaro. ASGE Clinical Update. 1999.
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Acute LGIBKey Points

• Resuscitation
• UGI source
• Most bleeding ceases
• Colonoscopy
• No role for barium studies

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SUMMARYGI Bleeding Management

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