DESCRIPTION

• Bleeding from GI tract:
  • Upper GI tract: Proximal to ligament of Treitz
  • Lower GI tract: Distal to ligament of Treitz to anus
• Mortality rate:
  • 10% overall; from < 5% in children up to 25% for adults of age > 70
  • Upper GI bleed (UGIB) 6–8%; variceal 30–50%
  • Lower GI bleed (LGIB) 2–4%

ETIOLOGY

Upper GI Bleed (UGIB):

• Ulcerative disease of upper GI tract:
  • Peptic ulcer disease (40%):
    • Helicobacter pylori infection
    • Drug-induced (NSAIDs, aspirin, glucocorticoids, K⁺ supplements, Fe supplements)
  • Gastric or esophageal erosions (25%):
    • Reflux esophagitis
    • Infectious esophagitis (Candida, HSV, CMV)
    • Pill-induced esophagitis
    • Esophageal foreign body
  • Gastritis and stress ulcerations:
    • Toxic agents (NSAIDs, alcohol, bile)
    • Mucosal hypoxia (trauma, burns, sepsis)
    • Cushing ulcers from severe CNS damage
    • Chemotherapy
• Portal HTN:
  • Esophageal or gastric varices (10%)
  • Portal hypertensive gastropathy
• Arteriovenous malformations:
  • Aortoenteric fistula (s/p aortoiliac surgery)
  • Hereditary hemorrhagic telangiectasia (Osler—Weber–Rendu syndrome)
  • Dieulafoy vascular malformations
  • Gastric antral vascular ectasia (GAVE or watermelon stomach)
  • Idiopathic angiomas
• Mallory–Weiss tear (5%)
• Gastric and esophageal tumors
• Pancreatic hemorrhage
• Hemobilia
• Strongyloides stercoralis infection

Lower GI Bleed (LGIB):

• Diverticulosis (33%)
• Cancer or polyps (19%)
• Colitis (18%):
  • Ischemic, inflammatory, infectious, or radiation
• Vascular:
  • Angiodysplasia (8%)
  • Radiation telangiectasia
  • Aortocolonic fistula
• Inflammatory bowel disease:
  • Crohn's disease and ulcerative colitis
• Postpolypectomy
• Anorectal (4%):
  • Hemorrhoids (internal and external)
  • Anal fissures
  • Anorectal varices
  • Rectal ulcer
  • Foreign body

Pediatric Considerations

Meckel diverticulum and intussusception are the most common causes of LGIB in children.

[Outline]

• DESCRIPTION
• ETIOLOGY

SIGNS AND SYMPTOMS

• Both UGIB and LGIB may present with signs/symptoms of hypovolemia
• UGIB classic presentation:
  • Hematemesis or coffee ground emesis
  • Melena: Black tarry stool
• LGIB classic presentation:
  • Hematochezia: Bright red or maroon stool

ALERT

History

• Hematemesis and melena most common
• Coffee ground emesis
• Black stools
• Bright red blood per rectum
• Abdominal pain
• Weakness or lightheadedness
• Dyspnea
• Confusion or agitation

Physical Exam

• Tachycardia
• Hypotension
• Pale conjunctiva
• Dry mucous membranes
• Bloody, melanotic, or heme-positive stools
• Shock

ESSENTIAL WORKUP

• CBC, coagulation studies, electrolytes
• Perform ENT exam. Distinguish between hemoptysis and hematemesis:
  • Pulmonary source:
    • Bright red and frothy in appearance
    • Sputum mixed with blood is likely pulmonary
    • pH > 7
  • GI source:
    • Dark red/brown blood, ± gastric contents
    • Associated with nausea/vomiting
    • pH < 7
• Consider nasogastric lavage:
  • Might help determine if bleeding is ongoing and facilitate endoscopy
  • Controversialstudies have failed to demonstrate outcome benefit. False-negatives, if bleeding beyond pylorus.
• Rectal exam:
  • Inspect for hemorrhoids and anal fissures
  • Examine stool color
  • False-positive Hemoccult result:
    • Raw red meat
    • Iron supplements
    • Fruits: Cantaloupe, grapefruit, figs
    • Vegetables: Raw broccoli, cauliflower, radish
    • Methylene blue, chlorophyll
    • Iodide, bromide
  • False-negative Hemoccult result:
    • Bile
    • Mg-containing antacids
    • Ascorbic acid
  • Agents causing black stools, but negative Hemoccult:
    • Iron
    • Charcoal
    • Bismuth (i.e., Pepto-Bismol)
    • Food dyes
    • Beets

Pediatric Considerations

Bloody stool in newborns may be caused by the infant swallowing maternal blood.

DIAGNOSIS TESTS & INTERPRETATION

Lab

• CBC:
  • Anemia (low mean corpuscular volume seen with chronic blood loss)
  • Thrombocytopenia
• Electrolytes, BUN, creatinine, glucose
• Coagulation profile
• Lactate
• LFTs, if upper GI bleeding suspected
• Type and screen/cross for active bleeding or unstable vital signs
• BUN/Cr ratio > 36 has a high sensitivity but low specificity for UGIB

ALERT

Imaging

• Upright CXR if concern for aspiration or perforation
• Angiography/arterial embolization:
  • Effective for identifying large, active bleeding
• Radionucleotide (tagged red blood cell) scan:
  • Effective for identifying slow, active bleeding

Diagnostic Procedures/Surgery

• Anoscopy:
  • For suspected internal hemorrhoids or fissures
• Esophagogastroduodenoscopy (EGD):
  • Diagnostic and possibly therapeutic
• Colonoscopy:
  • Diagnostic only
  • Best after adequate bowel prep
• Bowel resection:
  • Reserved for refractory bleeding

DIFFERENTIAL DIAGNOSIS

• Epistaxis
• Oropharyngeal bleeding
• Hemoptysis
• Hematuria
• Vaginal bleeding
• Visceral trauma

[Outline]

• SIGNS AND SYMPTOMS
• ESSENTIAL WORKUP
• DIAGNOSIS TESTS & INTERPRETATION
• DIFFERENTIAL DIAGNOSIS

PRE-HOSPITAL

• Stabilize airway
  • Intubate for massive UGIB, if patient unable to protect airway
• Establish access
  • Insert large-bore IV (16–18g) and administer crystalloid to keep SBP > 90 mm Hg
  • Attempt 2nd IV line en route to hospital

INITIAL STABILIZATION/THERAPY

• Assess airway, breathing, and circulation
• Control airway in unstable patients, with massive bleeding, or unable to protect airway
• Initiate 2 large-bore (16 g) IVs and place on cardiac monitor
• Provide volume:
  • Administer 1 L NS bolus (peds: 20 mL/kg) and repeat once, if necessary
  • Transfuse RBCs if significant anemia or unstable after crystalloid boluses
    • Cross-matched or type-specific blood, if available
    • Otherwise, O negative for premenopausal women, O positive for others
    • Provide fresh frozen plasma (FFP) along with RBC transfusion in ratio of 1:2–4. For patients requiring massive transfusion, consider adding FFP and platelets in 1:1:1 ratio with RBCs
  • For coagulopathy, administer FFP and vitamin K (if INR > 1.5) and platelets (if platelets < 50,000/uL)

ED TREATMENT/PROCEDURES

• Consult gastroenterology for any significant GI bleeding
• Consider surgical consult and/or interventional radiology for massive active bleeding, unstable patient, or evidence of perforation
• Place Foley catheter to monitor urine output
• Consider nasogastric tube (NGT), as above
• Blood transfusion indications:
  • Significant anemia:
    • Hemoglobin < 7 g/dL
    • Hemoglobin < 10 g/dL when at increased risk of ischemia (e.g., CAD and CVA)
    • Evidence of end-organ ischemia
    • Ongoing chest pain/ischemic EKG changes
  • Unstable vital signs despite crystalloid bolus

ALERT

MEDICATION

• Pantoprazole: 80 mg (peds: Dosing not approved) IV bolus followed by an infusion of 8 mg/h for 72 hr
• Octreotide: 50 µg (peds: 1–2 µg/kg) bolus, then 50 µg/h (peds: 1–2 µg/kg/h) IV
• Somatostatin: 250 µg (peds: Not established) IV bolus and 250–500 µg/h for 2–5 days (not available in US)
• Vasopressin: 0.4–1 IU/min (peds: 0.002–0.005 IU/kg/min) IV
• Nitroglycerin: 10–50 µg/min (peds: Not established) IV
• Vitamin K: 10 mg (peds: 1–5 mg) PO/SC/IV q24h

[Outline]

• PRE-HOSPITAL
• INITIAL STABILIZATION/THERAPY
• ED TREATMENT/PROCEDURES
• MEDICATION

DISPOSITION

Admission Criteria

• Active bleeding
• Age > 65 or comorbid conditions
• Coagulopathy
• Decreased hematocrit
• Unstable vital signs at any time

Discharge Criteria

• Resolution of UGIB with negative nasogastric lavage and EGD
• Minor or resolved LGIB
• Stable hematocrit > 30 or hemoglobin > 10 g/dL
• Otherwise healthy patient

Issues for Referral

Consider referral to gastroenterologist for outpatient colonoscopy and/or EGD

FOLLOW-UP RECOMMENDATIONS

• Patients discharged from the ED should have close follow-up within 24–36 hr
• Give strict discharge instructions to return if further bleeding or other concerning symptoms (lightheadedness, dyspnea, chest pain, etc.) occur
• Patients with UGIB should be discharged on a PPI, and advised to avoid caffeine, alcohol, tobacco, NSAIDs, and aspirin

[Outline]

• DISPOSITION
• FOLLOW-UP RECOMMENDATIONS

• 10–15% of UGIB present with hematochezia
• Consider GIB in patients presenting with signs of hypovolemia or hypovolemic shock
• Common pitfall: Failure to adequately resuscitate with crystalloid and blood products

Geriatric Considerations

PUD is the predominant cause of GIB in elderly and has a higher associated mortality.

ICD9

• 533.40 Chronic or unspecified peptic ulcer of unspecified site with hemorrhage, without mention of obstruction
• 535.51 Unspecified gastritis and gastroduodenitis, with hemorrhage
• 578.9 Hemorrhage of gastrointestinal tract, unspecified

ICD10

• K27.4 Chronic or unsp peptic ulcer, site unsp, with hemorrhage
• K29.71 Gastritis, unspecified, with bleeding
• K92.2 Gastrointestinal hemorrhage, unspecified

[Outline]

• ICD9
• ICD10

• Das AM, Sood N, Hodgin K, et al. Development of a triage protocol for patients presenting with gastrointestinal hemorrhage: A prospective cohort study. Crit Care. 2008;12:R57.
• Gralnek IM, Barkun AN, Bardou M. Management of acute bleeding from a peptic ulcer. N Engl J Med. 2008;359(9):928–937.
• Johansson PI, Stensballe J. Hemostatic resuscitation for massive bleeding: The paradigm of plasma and platelets—a review of the current literature. Transfusion. 2010;50(3):701–710.
• Pallin DJ, Saltzman JR. Is nasogastric tube lavage in patients with acute upper GI bleeding indicated or antiquated? Gastrointest Endosc. 2011;74(5):981–984.
• Wolfson AB, Hendey GW, Ling LJ, et al., eds. Harwood-Nuss' Clinical Practice of Emergency Medicine. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009.

Czarina E. Sànchez

Leon D. Sànchez