GI Bleed

[Also see Pedi GI Bleed ]


The Call

  • Vital signs: postural vitals
  • Any history of bleeding? Obvious site of bleeding?
  • Estimate quantity of blood lost?
  • Last Hgb, INR, PTT; good IV access?
  • Meds: heparin, warfarin, clopidogrel, ASA

Overview

  • It is important to stabilize the patient so that the appropriate investigations can be performed ASAP by the appropriate team (surgery, GI, IVR, etc.) if necessary.
  • Melena: > 50–100 mL of blood has been lost.
  • False alarm: Bismuth, iron supplement, red wine, etc.
  • Hematochezia: can occur with UGIB after > 1 L of blood has been lost
  • Shock: clinical diagnosis: SBP < 90 mmHg + evidence of inadequate tissue perfusion–urine output < 20 mL/h is a good indicator.

Etiology

Upper GI
  • Bleeding ulcer (peptic or duodenal); esophageal varices may present with hematemesis or coffee ground emesis.
  • It is not necessarily associated with nausea or pain.
  • Melena is often present.
  • NG tube aspiration of coffee-ground-like material is highly suggestive of this diagnosis, although not always present (bleeding from duodenal ulcer, etc.) Try to differentiate between variceal- and ulcer-related bleed, as management differs.

Lower GI

  • Suspected when the patient is having hematochezia.
  • Melena, although suggestive of UGIB, can be present if the bleeding is coming from the cecal region (or more distal).
  • It is also useful to try to quantify the amount of blood in the feces; blood being an irritant, a patient can possibly have numerous small bowel movements.

Gross hematuria (in the absence of kidney disease)

  • Traumatic urethral catheter and infection are common in-hospital causes, especially for anticoagulated patients (but anticoagulation alone is not responsible for hematuria)

Evaluation

Rapid History
  • Assess bleeding site
    • Upper GI source
      • Hematemesis, coffee ground emesis
      • Melena: usually bleed above ligament of Trietz
         
    • Lower GI source (or large upper bleed)
      • Hematochezia
      • Bright red blood per rectum
         
  • Ask about
    • Previous bleeds
      • Pt w/known varices will bleed from a nonvariceal source 20% of the time
    • Bleeding diathesis
      • Easy bruising, prolonged bleed after minor trauma
    • Medications
      • Anticoagulants
      • NSAIDs
      • Steroids, iron, bismuth, methotrexate
      • Anticoagulant toxins, EtOH
    • Predisposing factors
      • Alcohol use
      • Liver dz
        • Hepatitis
      • Chronic renal failure
      • Diabetes, COPD, peripheral vascular dz
      • Valvular heart dz
Rapid Physical Exam
  • ABCs: assess for hemodynamic stability; make sure you have adequate, large bore x 2 IV access.
  • Signs of liver disease
    • Jaundice, cutaneous angiomata
    • Palmar erythema, gynecomastia, testicular atrophy
  • Signs of coagulopathy
    • Multiple ecchymoses, petechiae, telangiectasia
  • Abdominal exam
    • Check masses, ascites & hepatosplenomegaly
    • Look for surgical scars, listen for bruit
      • Aorticoenteric fistula
    • Rectal exam
      • Masses, stool color, hemoccult
    • Assessment of anemia
  • Signs of hypovolemia
    • Dizziness
    • Weakness
    • Syncope
Laboratory
  • Blood work: STAT: CBC, CMP, Lactic Acid, INR, PTT; Type & cross + match 6 U PRBC.
    • CBC
      • Hgb & Hct may be normal during acute bleed
        • May take up to 6 hrs to equilibrate
    • PT/PTT
      • Increase PT
        • Coumadin, liver dz, fat malabsorption, abxs
      • Increase PTT
        • Congenital (factor VIII deficiency, von Willebrand's dz) or acquired (DIC)
    • Electrolytes
      • Lactic acidosis
        • From hypotension and shock
      • Hypochloremic alkalosis
        • From vomiting or NG tube
      • BUN
      • Creatinine > 20:1 suggests upper GI source or severe dehydration
      • LFT's
    • Type & Cross x 6U PRBC if
      • Active bleed, signs of shock, elderly
      • Transfuse type-specific blood if possible
      • If not possible
        • O- for fertile women
        • All others O+
  • ECG/monitoring, CK, trops, depending on the severity
  • Try to localize the source of the bleeding from the history + findings; consider NG tube.
  • Hematuria: send urine for C+S, urinalysis.
  • Give 2-4 Unit FFP if PT increased and actively cause bleeding
  • Transfuse platelets if <50,000

 

Differential

GI Bleed Overview
Blood in Vomit

GI Consult
Upper Endoscopy
 
Blood in Stool

NG Tube
(+) Blood in NG (-) Blood in NG

Upper GI Bleed

> 2 L/min

< 2 L/min

Arteriogram
or
Tag Red cell study

Wait till bleeding stops & do Colonoscopy


 
 
Blood in Vomit? 

(-)
Blood in vomit

(+)
Blood in vomit
Think Lower GI Bleed, Get stool guiac. ↑↑ BUN: Cr
Tests:
- Sigmoidoscopy
- Colonoscopy
- Nuclear labled RBC Scan - Can localize the site of bleed
- Angiogram - Requires Active Bleed.
DDx:
-PUD most common
-Gastric erosions
-Mallory-Weiss tears
-Esophagitis
-Varices --> Octreotide, Propranolol
-Duodenitis
 
Adult Child
Hemmaroids:
 - Anoscopy or Sgmoidoscopy
Meckle's (> 2yo)
- PainLESS or Acute abdominal pain
- Dx: Tc 99 scan
- Tx: Surgery
Diverticulosis:
- Colonscopy
Intussusepiton (< 2 yo)
- CRAMPY, Normal between episodes
- Post Rotavirus, Adenovirus
- Sausage- shaped mass
- Dx/Tx: Barrium
- Complication: Intussuseption.
AVM:
- Ascending Colon (RIGHT Side)
Angiodysplasia:
- Sigmoid Colon (LEFT side)
- ESRD associated
- Aortic Stenosis

Management

Initial Assessment

  1. ABCs
    • Ensure airway adequate, ventilation OK
    • Supplemental O2
    • Consider intubation (RSI) if
      • Lethargic/altered mental status
      • Intractable vomiting of blood
        • Aspiration risk
  2. Assess hemodynamic stability
    • Shock Stages (and Symptoms)
      • Class I: (0-15% blood loss)
        • Normal or minimally elevated HR
        • No other changes
      • Class II: (15-30% blood loss)
        • Tachycardia, tachypnea, cool skin, delayed capillary refill
        • Decreased pulse pressure
        • Slight agitation
      • Class III: (30-40% blood loss)
        • Tachycardia, tachypnea, hypotension
        • Confusion
      • Class IV: (>40% blood loss)
        • Marked tachycardia, tachypnea, decr UO
        • Decr SBP (DBP may be undetectable)
        • Lethargy/LOC, cool skin, pallor
  3. Fluid resuscitation
    • 2 large-bore IVs
      • Peripheral lines preferred
    • NS or LR
      • If hypotensive, run wide open until stable
      • Consider CVP in elderly w/CHF and decreased cardiac reserve
    • If still unstable after 2L fluid
      • Consider PRBC's or blood
      • Type-specific if possible
      • O(+) if not
      • O(-) for fertile women
    • Rx coagulopathy w/FFP
  4. Further measures
    • Endoscopy if rapidly available
    • NG tube (if endo not readily available)
      • Diagnostic use or to relieve emesis only
        • Bile stained gastric aspirate will r/o most profound GI bleeds
      • Will not treat upper GI bleed
      • Best done with large-bore tube (Ewald)
      • Lavage w/room temp H2O or NS
      • May dislodge clots
  5. Early consultation
    • ALL unstable/actively bleeding patients
      • Upper GI bleed
        • GI (endoscopy) consult AND
        • Surgical consult
      • Lower GI bleed
        • Surgical consult

Severe bleeding

  • Fluid replacement if any sign of instability (bolus NS PRN).
  • Transfer patient to a monitored setting.
  • THINK:
    • Consider Intubation for UGIB for airway protection
    • Pantoprazole 80 mg IV bolus, followed by 8 mg/hr
    • Octreotide 50 mcg bolus, followed by 25-50 mcg/hr infusion x1-5 days (Alcoholics)
       
  • Call for help—senior resident, fellow, attending, etc. The patient may (will likely) need urgent intervention.
  • STOP anticoagulant therapy:
    • HOLD heparin, warfarin, clopidogrel, ASA, etc.
  • STOP BP meds if hemodynamically unstable
  • Reverse INR (if necessary). 2–4 units of FFP can be a good starting point; the correction obtained with FFP is proportional to the INR (the higher the INR, the more correction you’re likely to get).
  • Three- or four-factor prothrombin complex concentrate (if available) for life-threatening bleeding
  • Vitamin K:
    • 10 mg IV over 20 to 60 minutes, can be repeated q12h; risk of anaphylaxis—to sustain the reversal obtained by the FFP.
  • Make sure the patient is NPO (for intervention).
  • Follow hemoglobin/hematocrit PRN (at least q6h)—Transfuse PRN:
    • Don’t forget that those values are not necessarily representative of the patient’s "true" values when there’s an acute bleed, so plan your transfusions accordingly.

Moderate bleeding

  • Follow hemoglobin / hematocrit q6h x 24h then R/A.
  • Consider reversing INR if necessary: low-dose vitamin K: 1 mg PO x 1—the effects of this treatment will take a few hours.