Download Gastrointestinal Bleeding

Gastrointestinal Bleeding
Case…
 Hassan is 45 y/o saudi gentleman,
presents to ED at KKUH early morning,
C/O vomiting blood.
 How would you approach?
 How would you manage?
Gastrointestinal Bleeding
PERSPECTIVE
Epidemiology
o relatively common problem
o requires early consultation and hospital
admission.
Gastrointestinal Bleeding
o Mortality rate for GI bleeding is approximately
10%.
o Diagnostic modalities have improved much
more than therapeutic techniques.
Gastrointestinal Bleeding
GI bleeding
o is often easy to identify
…….when there is clear evidence of vomiting
blood or passing blood in the stool.
o may be subtle,
………with
signs
and
symptoms
of
hypovolemia, such as dizziness, weakness,
or syncope.
Gastrointestinal Bleeding
o Management approach depends on whether
the hemorrhage is located in the proximal or
the distal segment of the GI tract (i.e., upper
or lower GI bleeding).
o These segments are anatomically defined by
the ligament of Treitz in the duodenum.
Gastrointestinal Bleeding
Lower GI bleeding (LGIB)
o affects a smaller portion of patients
o fewer hospital admissions than UGIB.
Gastrointestinal Bleeding
o Occur in persons of any age.
o Most commonly affects people in their 40s
through 70s.
o Most deaths in patients older than 60 years.
o UGIB is more common in men than in
women (in a 2 : 1 ratio)
o LGIB is more common in women.
Gastrointestinal Bleeding
o Significant UGIB requiring admission is more
common in adults.
o LGIB requiring admission is more common in
children.
Gastrointestinal Bleeding
DIAGNOSTIC APPROACH
Differential Considerations
o Peptic ulcer disease
o gastric erosions
o varices
oDiverticulosis
oangiodysplasia
three fourths of
adult patients
with UGIB.
80% of adults
with LGIB.
Gastrointestinal Bleeding
In children,
o Esophagitis
o Gastritis
most common
causes of UGIB
o peptic ulcer disease
o infectious colitis
o inflammatory bowel disease
most
common
causes of
LGIB.
Gastrointestinal Bleeding
Meckel’s diverticulum
& intussusception
most common cause
of massive LGIB in
children
younger
than 2 years of age
o At all ages, anorectal abnormalities are the
most common cause of minor LGIB.
Gastrointestinal Bleeding
o No source of bleeding is identified
in approximately 10% of patients
with GI bleeding.
Gastrointestinal Bleeding
o In abdominal aortic grafts pt with with GI
bleeding, the possibility of aortoenteric fistula
should be considered
o Prompt surgical consultation in the ED
should be obtained if this is suspected,
because bleeding can be massive and fatal.
Gastrointestinal Bleeding
Rapid Assessment and
Stabilization
o Most patients with GI bleeding
are easy to diagnose by history
+/- physical exam
Gastrointestinal Bleeding
o If hemodynamically unstable should
undergo
rapid
resuscitation.
evaluation
and
o should
be undressed quickly with
placement of cardiac and oxygen
saturation monitors.
o supplemental oxygen should be given
as needed.
Gastrointestinal Bleeding
o At least two large-bore (minimum 18-
gauge);
o Send samples for
o CBC, for hg, plat, hematoc.
o Coagulation profile
o type and screen or type and crossmatch
o crystalloid
initiated.
resuscitation
should
be
Gastrointestinal Bleeding
o NS 2-L bolus in adults or 20 mL/kg
in children until the patient’s vital
signs have stabilized or the patient
has received 40 mL/kg of
crystalloid in an adult or 60 mL/kg
as a child.
Gastrointestinal Bleeding
o If remain unstable give type O, type-specific,
or cross matched blood, depending on
availability.
o Persistently unstable patients should receive
immediate
consultation
with
a
gastroenterologist for UGIB and with a
surgeon for LGIB.
Gastrointestinal Bleeding
History
In 50%
o Patients typically complain of vomiting
red blood or coffee grounds–like
material, or passing black or bloody
stool.
o Hematemesis (vomiting blood) occurs
with bleeding of the esophagus,
stomach, or proximal small bowel.
Gastrointestinal Bleeding
History
o Hematemesis may be bright red or
darker (i.e., coffee grounds–like) as
a result of the conversion of
hemoglobin to hematin or other
pigments by hydrochloric acid in
the stomach.
Gastrointestinal Bleeding
o The color of vomited or aspirated blood from
the stomach does not differentiate between
arterial and venous bleeding.
o Melena, or black tarry stool, will result from
the presence of approximately 150 to 200
mL of blood in the GI tract for a prolonged
period.
Gastrointestinal Bleeding
o Melena is seen in approximately
o 70% of patients with UGIB
o one third of patients with LGIB.
o Blood from the duodenum or jejunum must
remain in the GI tract for approximately 8
hours before turning black.
Gastrointestinal Bleeding
o Occasionally, black stool may follow bleeding
into the lower portion of the small bowel and
ascending colon.
o Stool may remain black and tarry for
several days, even though bleeding has
stopped.
Gastrointestinal Bleeding
Hematochezia, or bloody stool (bright red or
maroon)
o most often signifies LGIB
o Could be due to a brisk UGIB with rapid
transit time through the bowel in 10 to 15% of
patients.
o a more proximal source of significant
bleeding must be excluded before assuming
the bleeding is from the lower GI tract.
Gastrointestinal Bleeding
o Approximately two thirds of patients with
LGIB present with red blood from bleeding
per rectum.
o Small amounts of red blood (5 mL) from
rectal bleeding, such as bleeding due to
hemorrhoids, may cause the water in the
toilet bowl to appear bright red.
Gastrointestinal Bleeding
DDX
o Bright red stools also can be seen after
ingestion of a large quantity of beets
o Hemoccult testing would be negative and the
patient also will report pink colored water in
the toilet bowl.
Gastrointestinal Bleeding
Important qs
o duration and quantity of bleeding
o associated symptoms
o previous history of bleeding
o current medications,
o alcohol
o NSAID ASA
o allergies
o associated medical illnesses
o previous surgery
Gastrointestinal Bleeding
symptoms of hypovolemia
…..dizziness,
weakness,
or
loss
of
consciousness, most often after standing up.
o Other
nonspecific
complaints
include
dyspnea, confusion, and abdominal pain.
Gastrointestinal Bleeding
o Rarely an elderly patient may present with
ischemic chest pain precipitated by
significant anemia due to a GI bleed.
o One in five patients with GI bleeding may
have only nonspecific complaints.
Gastrointestinal Bleeding
o The history is of limited help in predicting the
site or quantity of bleeding.
o Patients with a previously documented GI
lesion bleed from the same site in only
of cases.
60%
Gastrointestinal Bleeding
o Gross estimates of blood loss based on the
volume and color of the vomitus or stool are
inaccurate.
Gastrointestinal Bleeding
Physical Examination
o Vital signs and postural changes in heart rate
and blood pressure are insensitive and
nonspecific, with the exception of significant,
sustained
heart
rate
increase
and
hypotension.
Gastrointestinal Bleeding
o All patients hypotensive and tachycardic
should be assumed to have a significant
hemorrhage.
Gastrointestinal Bleeding
o Normal vital signs do
significant hemorrhage
not
exclude
a
o postural changes in heart rate and blood
pressure may occur in individuals who are
not bleeding
Gastrointestinal Bleeding
o general appearance
o vital signs
o mental status (including restlessness)
o skin signs (e.g., color, warmth, and moisture
to assess for shock, or presence of lesions
such as telangiectasia, bruises, or petechiae
to assess for vascular diseases or
hypocoagulable states)
o pulmonary and cardiac findings
o abdominal examination
Gastrointestinal Bleeding
o Frequent reassessment is important because
a patient’s status may change quickly.
Gastrointestinal Bleeding
o Rectal Examination Rectal and stool
examinations are often key to making or
confirming the diagnosis of GI bleeding.
o The finding of red, black, or melenic stool
early in the assessment is helpful in
prompting early recognition and management
of patients with GI bleeding.
Gastrointestinal Bleeding
o The absence of black or bloody stool,
however, does not exclude the diagnosis of
GI bleeding.
o Regardless of the apparent character and
color of the stool, occult blood testing is
indicated.
Gastrointestinal Bleeding
Ancillary Testing
Tests for Occult Blood
o The presence of hemoglobin in occult
amounts in stool is confirmed by tests such
as ( Hemoccult, HemaPrompt).
o Stool tests for occult blood may have positive
results 14 days after a single, major episode
of UGIB.
Gastrointestinal Bleeding
False-positive
o associated with the ingestion of
o certain fruits (e.g., cantaloupe, grapefruit, figs),
o uncooked vegetables (e.g., radish, cauliflower,
broccoli)
o red meat
o methylene blue, chlorophyll, iodide, cupric
sulfate, and bromide preparations.
Gastrointestinal Bleeding
False-negative
o uncommon but can be caused by bile or
ingestion of magnesium containing antacids
or ascorbic acid.
o Tests to evaluate gastric contents for occult
blood (e.g., Gastroccult) can be unreliable
and should not be used for this purpose.
Gastrointestinal Bleeding
Clinical Laboratory
o The initial hematocrit may be misleading in
patients with preexisting anemia or
polycythemia.
Gastrointestinal Bleeding
o Changes in the hematocrit may
significantly behind actual blood loss.
lag
o rapid infusion of crystalloid in nonbleeding
patients also may cause a decrease in
hematocrit by hemodilution.
Gastrointestinal Bleeding
o hemoglobin concentration of 8 g/dL or less
(hematocrit <25%) from acute blood loss
usually require blood therapy.
o After transfusion and in the absence of
ongoing blood loss, the hematocrit can be
expected to increase approximately 3% for
each unit of blood administered (hemoglobin
level increases by 1 mg/dL).
Gastrointestinal Bleeding
o The PT should be used to determine whether
a patient has a preexisting coagulopathy.
An elevated PT may indicate
o vitamin K deficiency
o liver dysfunction
o warfarin therapy
o consumptive coagulopathy.
Gastrointestinal Bleeding
o Patients with anticoagulants or with an
elevated PT and evidence of active bleeding
should receive sufficient FFP to correct the
PT.
o Serial platelet counts are used to determine
the need for platelet transfusions (i.e., less
than 50,000/mm3).
Gastrointestinal Bleeding
Blood Bank Blood
o should be sent for “type and hold” or type
and crossmatch studies early in the patient’s
care.
o Immediate transfusion needs in unstable
patients can be met with O-positive packed
red blood cells (O-negative packed red blood
cells in women of childbearing age whose Rh
status is unknown).
Gastrointestinal Bleeding
o Type-specific blood is usually available within
10 to 15 minutes.
o Group O blood and type-specific blood are
safe for patients and cause few transfusion
reactions.
o Fully crossmatched blood may take 60
minutes to prepare.
Gastrointestinal Bleeding
Other Laboratory Tests
o Electrolytes usually normal
o Urea and creatinin
Gastrointestinal Bleeding
Patients with repeated vomiting,
may develop,
oHypokalemia
oHyponatremia
ometabolic alkalosis
correct with adequate hydration
and the resolution of vomiting.
Gastrointestinal Bleeding
o Patients with shock often have
metabolic acidosis from lactate
accumulation.
o High Urea as a result of
oabsorption of blood from the GI tract
ohypovolemia causing prerenal azotemia
Gastrointestinal Bleeding
ECG in all patients with a GI bleed who are
o older than 50 years
o preexisting ischemic cardiac disease,
o significant anemia
o chest pain
o shortness of breath
o persistent hypotension.
Asymptomatic myocardial ischemia
develop in the setting of GI bleeding.
may
Gastrointestinal Bleeding
o Patients with GI bleeding and myocardial
ischemia should receive packed red blood
cells as soon as possible
Gastrointestinal Bleeding
Imaging
o No need for plain abdominal radiography
unless aspiration or with signs and symptoms
of bowel perforation.
o air consistent with bowel perforation is a rare
finding with UGIB
o Need immediate surgical consultation and
operative repair.
Gastrointestinal Bleeding
DIFFERENTIAL DIAGNOSIS
o Swallowing blood during epistaxis or from the
oral cavity may cause hematemesis or
melena.
o Red vomitus may be due to food products
(e.g., Jell-O, tomato sauce, wine), and black
stool may be due to iron therapy or bismuth
(e.g., Pepto-Bismol).
Gastrointestinal Bleeding
MANAGEMENT
o Quick identification
o Aggressive resuscitation
o Prompt consultation
Gastrointestinal Bleeding
After initial resuscitation of the patient,
o it is important to identify whether the
hemorrhage is proximal or distal to the
ligament of Treitz (i.e., UGIB or LGIB).
o If the patient’s vomitus demonstrates blood,
then the diagnosis of UGIB is confirmed.
Gastrointestinal Bleeding
o If a patient reports bloody or “coffee grounds”
emesis or if melenic stool is present, an
upper GI bleed is more likely.
Emergency management of patients with gastrointestinal bleeding. ED, emergency department; IV,
intravenous; LGIB, lower gastrointestinal bleeding; UGIB, upper gastrointestinal bleeding.
Gastrointestinal Bleeding
Anoscopy/Proctosigmoidoscopy
o Patients with mild rectal bleeding who do not
have obviously bleeding hemorrhoids should
undergo anoscopy or proctosigmoidoscopy.
o If bleeding internal hemorrhoids are
discovered, and the patient does not have
portal hypertension, the patient may be
discharged with appropriate treatment and
follow-up evaluation for hemorrhoids.
Gastrointestinal Bleeding
o If hemorrhoids are not detected, it is
important to determine if the stool above the
rectum contains blood.
o absence of blood above the rectum in a
patient who is actively bleeding indicates that
the source of bleeding is in the rectum.
Gastrointestinal Bleeding
o Presence of blood above the anoscope or
sigmoidoscope does not invariably indicate a
proximal source of bleeding, because
retrograde passage of blood into the more
proximal colon commonly occurs.
o Such patients need further evaluation.
Gastrointestinal Bleeding
Endoscopy
o Endoscopy is the most accurate diagnostic
tool available for the evaluation of UGIB.
o It identifies a lesion in 78% to 95% of patients
with UGIB if it is performed within 12 to 24
hours of the hemorrhage.
Gastrointestinal Bleeding
o Endoscopy-for upper GI bleeding.
o Colonoscopy is an effective tool for diagnosis
and selected treatment of LGIB.
Gastrointestinal Bleeding
Angiography and Tagged Red Blood
o Cell Scan Angiography can detect the
location of UGIB in two thirds of patients
studied.
o Since the advent of endoscopy, however, the
use of angiography has decreased
significantly, and today angiography is used
in only 1% of patients with UGIB.
Gastrointestinal Bleeding
Nuclear isotope–tagged red blood cell scan
o In some patients with more indolent or
elusive bleeding,
o Usually performed from the inpatient unit,
may identify the bleeding site.
Gastrointestinal Bleeding
Gastric Acid Secretion Inhibition
o All patients with peptic ulcer disease
documented by endoscopy should receive
therapy with a proton-pump inhibitor (e.g.,
omeprazole).
o There is no documented benefit to initiating
this
therapy
or
administering
H2
antihistamines in the ED for patients with
UGIB.
Gastrointestinal Bleeding
Octreotide (Somatostatin Analogues)
o IV infusion of octreotide at 25–50 μg/hour for
a minimum of 24 hours
o In patients with documented esophageal
varices and acute upper GI bleeding
o should receive in monitored bed.
Gastrointestinal Bleeding
o Octreotide is a useful addition to endoscopic
sclerotherapy and decreases rebleeding
occurrences.
o Octreotide may also reduce the incidence of
lower
GI
rebleeding
angiodysplasia.
secondary
to
Gastrointestinal Bleeding
Sengstaken-Blakemore Tube
o Rarely used in tertiary care centre.
o Should not be used without endoscopic
documentation of the source of bleeding
because complications are common and
significant (14% major, 3% fatal).
Gastrointestinal Bleeding
o A trial of balloon tamponade should be
considered in an exsanguinating patient with
probable variceal bleeding in whom
endoscopy is not immediately available.
o Consultation
with
a
surgeon
gastroenterologist is advisable.
or
Gastrointestinal Bleeding
Surgery
o For all hemodynamically unstable patients
with active bleeding who do not respond to
medical therapy.
o Mortality rate for patients undergoing
emergency procedures for GI bleeding is
approximately 23%.
Gastrointestinal Bleeding
Emergency surgical consultation for :
o blood replacement exceeds 5 units
within the first 4 to 6 hours
or
o 2 units of blood is needed every 4
hours
Gastrointestinal Bleeding
DISPOSITION
Risk Stratification
o Risk
stratification
involves
combining
historical, clinical, and laboratory data to
determine the risk of death and rebleeding in
patients presenting to an ED with GI
bleeding.
Gastrointestinal Bleeding
o patients present to the ED with a vague
complaint of vomiting blood or passing blood
from the rectum in whom detailed history and
examination
allows
a
diagnosis
of
hemorrhoid, or anal fissure, or there may be
little or no objective evidence of significant GI
bleeding…..Discharge pt with education
patients should be educated about the signs and
symptoms of significant GI bleeding and when to
return to the ED
Gastrointestinal Bleeding
o Patents should undergo specific follow-up
evaluation within 24 to 36 hours.
o They should be instructed to avoid aspirin,
nonsteroidal anti-inflammatory drugs, and
alcohol.
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