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 200mg IV can provide equal endoscopy conditions as lavage

Treatment

1. IVF
2. Blood
   1. Indications for tranfusion:
      1. Continued active bleeding
      2. Failure to improve perfusion and vital signs after infusion of 2L NS
3. FFP as needed
4. PPI
   1. Pantoprazole/esomeprazole 80mg x 1; then 8mg/hr
   2. Lansoprazole 60mg x 1; then 6mg/hr
5. Octreotide
   1. 25-50mcg x 1; then 25-50 mcg/hr
      1. Use lower dosage for elderly or severe liver disease
6. Ceftriaxone
7. Endoscopy
8. Surgery
9. Balloon tamponade (for life-threatening hemorrhage if endoscopy is not available)
   1. Sengstaken-Blakemore tube
      1. Tube consists of gastric and esophageal balloons
         1. First inflate gastric balloon; if bleeding continues inflate esophageal balloon
            1. Esophageal pressure must not exceed 40-50 mmHg
      2. Adverse reactions are frequent
         1. Mucosal ulceration
         2. Esophageal/gastric rupture
         3. Tracheal compression (consider intubation prior to balloon insertion)

Disposition

• Consider admission for:

1. Age >60yr
2. Transfusion required
3. Initial Sys BP < 100
4. Red blood in NG lavage
5. History of cirrhosis or ascites on exam
6. History of vomiting red blood

• Consider discharge for Glasgow-Blatchford Bleeding Score of 0 (ALL of the following)

1. BUN <18
2. Hb >13 (men), Hb >12 (women)
3. Sys BP >110
4. HR <100
5. Pt did NOT present w/ melena
6. Pt did NOT present w/ syncope
7. No hepatic disease
8. No cardiac failure

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. LGIB
2. Upper GI bleed
3. Diverticulosis (painless, voluminous)
4. Infectious (virus, bacteria, parasites, C. dif)
5. Ischemic Colitis 3-12% (acute onset; 90% > 70yo)
6. IBD (fistula-in-ano)
7. Mesenteric Vascular Insufficiency (abd pain out of proportion to PE)
8. Angiodysplasia
9. Cancer/polyps
10. Rectal dz
11. Hemorrhoids
    1. External (below pectinate); Internal (above)
12. Ulcer (HIV, syphilis, STDs)
13. Fissures (painful defecation)
14. 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

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)