Gastrointestinal bleeding

Background

• Bleeding originating proximal to ligament of Treitz

Diagnosis

History

• Hematemesis
• Coffee-ground emesis
• Melena + age <50 suggests upper GI bleed
• Vomiting + retching followed by hematemesis = Mallory-Weiss
• Aortic graft = aortoenteric fistula
• Meds
  • ASA, steroids, NSAIDs, anticoagulants
• ETOH abuse
  • Peptic ulcer disease, gastritis, varices
• Pseudo-melena
  • Iron or bismuth use

Physical Exam

• Tachycardia, hypotension
• Liver disease
  • Spider angiomata, palmar erythema, jaundice, gynecomastia
• Coagulopathy
  • Petechiae/purpura
• ENT exam
  • Swallowed blood may result in coffee-ground emesis or melena
• Rectal exam

DDX

1. Peptic ulcer disease (most common cause)
2. Gastritis/esophagitis
3. Gastric/esophageal varices
4. Mallory-Weiss Syndrome
5. Stress ulcer
6. Malignancy
7. ENT sources of bleeding
8. Aortoenteric fistula

Workup

1. 2 large bore IV
2. Type and cross
3. CBC & serial Hb
4. Chemistry
   1. BUN/Cr >30 suggests UGI if no hx of renal failure (incr absorption/digestion of hb)
5. Coags (if INR > 1.5 transfuse FFP)
6. LFTs
7. Guaiac
8. ?ECG (if >50 yo or if suspicious for silent MI)
9. ?CXR (if suspect perforation)
10. ?NG lavage
    1. Controversial
       1. Pros
          1. Positive aspirate proves strong evidence for an UGI source of bleeding
          2. Can assess presence of ongoing active bleeding
          3. Can prepare pt for endoscopy
       2. Cons
          1. Uncomfortable
          2. Negative aspirate does not conclusively exclude UGI source
          3. Provides useful information in only minority of pts w/o hematemesis
          4. Erythromycin can provide equal endoscopy conditions as lavage

1. IVF/blood
2. IV PPI (Protonix 40-80mg x 1, then 8mg/hr)
3. Octreotide (suspected varices: 50mcg bolus, then 25mcg/hr)
4. Ceftriaxone (if e/o ascites; decreases mortality)
5. ?Consider vasopressin/sengstaken-blakemore tube if no access to endoscopy

If aortic graft --> immed surg consult

Consider

1. Proctoscopy (22cm from anal verge)
2. Sigmoidoscopy (60cm from anal verge)
3. Angiography (requries arterial bledding >0.5cc/min)
4. CT angio

DDX

Adult

1. UGIB
   1. PUD (Gastric 21%, Duodenal 24%)
   2. Gastritis 23%
   3. Esophagitis/Duodenitis 6%
   4. Varicies
   5. Mallory-Weiss <15%
   6. Boerhaave's
   7. Dieulafoy lesion
   8. Angiodysplasia
   9. Hemobilia
   10. Aortoenteric fistula
2. LGIB
3. Upper GI bleed
4. Diverticulosis (painless, voluminous)
5. Infectious (virus, bacteria, parasites, C. dif)
6. Ischemic Colitis 3-12% (acute onset; 90% > 70yo)
7. IBD (fistula-in-ano)
8. Mesenteric Vascular Insufficiency (abd pain out of proportion to PE)
9. Angiodysplasia
10. Cancer/polyps
11. Rectal dz
12. Hemorrhoids
    1. External (below pectinate); Internal (above)
13. Ulcer (HIV, syphilis, STDs)
14. Fissures (painful defecation)
15. Abscess, prolapse, proctitis, impaction

Peds

1. UGIB
   1. Esophagitis
   2. Gastritis
   3. Ulcer
   4. Esophageal varices
   5. Mallory-Weiss
2. LGIB
   1. Anal fissure
   2. Infectious colitis
   3. IBD
   4. Polyps
   5. Intussusception

Disposition

Blatchford score

Rockall score

Home (very low risk)

1. No comorbid dz
2. Normal vitals
3. Norma/trace pos guiac
4. Normal/near-normal Hb
5. Home support
6. F/U within 24hrs

Ward/Stable (low risk)

1. Age <60
2. Initial SBP >100
3. Normal vitals x 1hr
4. No transfusion req
5. No major comorbid
6. No liver dz

ICU

1. Normal or dec Hct
2. Blood in NG doesn't clear
3. SBP<100, HR>100
4. Gauaic +/- stool

False Positive Guaiac

1. Red fruits and meats
   1. (Bananas, turnips, broccoli)
2. Methylene blue
3. Chlorophyll
4. Iodide
5. Cupric sulfate
6. Bromide
7. Iron (causes GI bleed by irritation)

Source

• Tintinalli
• Erythromycin infusion or gastric lavage for upper gastrointestinal bleeding: a multicenter randomized controlled trial. Pateron D et al. Ann Emerg Med. (2011)