Acute GI Bleeding

• Upper GI hemorrhage occurs proximal to the Ligament of Treitz and is commonly caused by Peptic Ulcer Disease (PUD) and variceal hemorrhage
• Management of acute gastrointestinal hemorrhage involves a multidisciplinary approach including emergency medicine, gastroenterology, intensive care, surgery, and interventional radiology
• Occult Gastrointestinal Bleeding refers to anemia that persists or recurs after negative endoscopic evaluation and imaging workup
• Lower Gastrointestinal Bleeding (LGIB) accounts for 30% to 40% of all bleeds and is defined as distal to the Ligament of Treitz
• 15% of gastrointestinal bleeding stops spontaneously, while 15% persists requiring surgery
• Gastrointestinal bleeding involves the gastrointestinal tract, pancreas, liver, and biliary tree
• Trivial to massive bleeding can occur in Upper Gastrointestinal Bleeding (UGIB) and Lower Gastrointestinal Bleeding (LGIB) with a ratio of 5:1
• Massive Gastrointestinal Bleeding refers to intestinal blood loss leading to hemodynamic instability or transfusion requirement
• Management of Acute GI Hemorrhage

  1. Rapid Initial Assessment

  2. Resuscitation

  3. History & PE

  4. Investigate

  5. Therapeutic measures

  6. Control

  7. Prevention
• In patients without shock, postural changes can help determine the extent of blood loss
• Obscure bleeding is hemorrhage that persists or recurs after negative evaluation with endoscopy
• Lower GI hemorrhage, which is distal, often originates from the colon, specifically from Diverticula and angiodysplasia
• Improvements in the management of gastrointestinal bleeding, primarily through endoscopy and directed therapy, have significantly reduced hospitalization length and overall mortality
• Severity of hemorrhage can be determined based on clinical parameters such as obtundation, agitation, hypotension, heart rate, and pulse pressure
• Classification of Hemorrhagic Shock based on clinical parameters
• Fluid resuscitation strategy should be guided by the severity of hemorrhage
• Important characteristics of bleeding include time of onset, volume, frequency, and character
• Massive transfusion protocols


  • Make universal donor blood products rapidly available in prespecified ratios with proven survival benefit in bleeding patients
• Characteristics of hematemesis

  • Vomiting of blood
  • Bright red or older appearance
  • May be caused by bleeding from upper GI tract or nasal/oropharyngeal space
• Serum lactate


  Utilized as an endpoint of resuscitation when elevated
• Elderly patients with GI hemorrhage need central venous catheter for close monitoring
• Foley catheter


  Used for urine output (hydration) and assessment of end organ perfusion
• Stabilization


  Place two large bore IV lines (PLR/PNSS)
• Blood transfusion


  Threshold based on underlying condition, hemodynamic status, markers of tissue hypoxia; use PRBC, WB, FFP, Platelet (1:1:1) if needed (>6 units of blood)
• Simultaneous Blood tests


  Type and crossmatch, hematocrit, platelet count, coagulation profile, routine chemistries, & liver function tests
• Emergency room patient management


  Secure the breathing, airway, and circulation (ABC’s)
• Fluid resuscitation strategy

  Guided by the severity of hemorrhage
• Characteristics of hematochezia

  • Bright red blood from the rectum, suggestive of colonic origin
• History and physical examination help in diagnosing the source of bleeding
• Critical patients need ICU admission
• Characteristics of melena


  • Passage of malodorous, black, tarry, and foul-smelling stool indicative of a proximal source of bleeding
  • Melanotic appearance due to gastric acid degradation
  • Byproduct of hemoglobin degradation by digestive enzymes and luminal bacteria in the small intestine
• Localization of bleeding site


  Subsequent management depends on this
• Nasogastric Tube Insertion

  First steps in differentiating upper GI bleeding from lower GI bleeding
• Localization

  Subsequent management of the patient with acute GI haemorrhage depends on localization of the site of the bleeding
• Nasogastric Tube Insertion

  1. The first steps in differentiating a UGIB from a LGIB is aided by a nasogastric tube (NGT) lavage

  2. Most useful situation: Patients with severe hematochezia, and unsure if UGIB vs. LGIB

  3. It can detect the presence of blood above the ligament of Treitz while also irrigating the stomach in preparation for an endoscopy

  4. Positive aspirate (blood/coffee grounds) indicates UGIB

  5. Can provide prognostic info: Red blood per NGT is predictive of high-risk endoscopic lesion, coffee grounds indicate less severe/inactive bleeding

  6. NGT is unreliable in localizing the bleeding site

  7. All patients with significant bleeding should undergo upper endoscopy for direct visualization
• Endoscopy in Upper Bleeding

  1. ESOPHAGOGASTRODUODENOSCOPY (EGD) is the gold standard investigation for the diagnosis and management of upper GI bleeding

  2. Advantages: Identify the source of bleeding, etiology, achieve hemostasis, and provide prognostic information for risk stratification. Ideal timing is within 24 hrs

  3. Issues: Mucosal visibility is impaired in active bleeding, complications include perforation and aspiration. Aggressive lavage of the stomach with room temperature normal saline solution before the procedure can be helpful. Use of promotility agents to enhance endoscopic visualization is not recommended

  4. COLONOSCOPY is recommended for patients 50 years old with hematochezia or iron deficiency anemia. Diagnostic yield is 89-97%. If bleeding cannot be localized with imaging or angiography and UGIB has been ruled out, a colonoscopy should be performed if the patient is stable and can tolerate a full bowel preparation

  5. FLEXIBLE ENDOSCOPY is for younger patients with convincing benign conditions

  6. CAPSULE ENDOSCOPY is for patients who cannot tolerate endoscopy, small bowel (obscure bleeding), normal EGD and colonoscopy. It is noninvasive and designed for imaging of the small bowel. It is the diagnostic modality of choice for overt GIB in a stable patient when upper and lower sources have been ruled out. Bleeding is the most common indication for capsule endoscopy
• Not all patients with GI bleeding require hospital admission or emergent evaluation. For example, a patient with a small amount of rectal bleeding that has stopped can generally be evaluated on an outpatient basis
• Scoring systems are used to identify patients at high risk for adverse outcomes
• Angiography


  Insensitive, able to detect bleeding only at a rate of 0.5mL to 1mL/min. Role in massive GI bleeding precluding endoscopic evaluation or in patients with negative endoscopies. Therapeutic gold standard for identifying the source of bleeding, particularly in unstable and high-risk operative patients. Multidetector computed tomography angiogram (CTA) is emerging as the first-line study for localization of GIB in patients whose hemodynamics can support further work-up
• Red Cell Labelling (Nuclear Scintigraphy)

  Sensitive: 0.1m/min. Repeat images can be acquired up to 24 hours after the initial labeling of RBCs. Localization is in the area of the abdomen rather than a portion of the GI tract. More often used to identify a potential role for subsequent angiography. In a stable patient with a slow intermittent bleed, RBC scintigraphy can sometimes provide a valuable estimation of bleeding site that can guide endoscopic or angiographic interventions