Author:
Czarina E.Sánchez
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 age >70
- Upper GI bleed (UGIB) 6-8%
- Lower GI bleed (LGIB) 2-4%
Etiology
Upper GI Bleed (UGIB):
- Ulcerative disease of upper GI tract:
- Peptic ulcer disease (40%):
- Gastric or esophageal erosions (25%):
- Reflux esophagitis
- Infectious esophagitis (Cand ida, 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 (8%):
- Angiodysplasia
- Radiation telangiectasia
- Aortocolonic fistula
- Inflammatory bowel disease:
- 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 |
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 |
| Hematochezia classically signals an LGIB, but can also be seen with brisk UGIB |
History
- Hematemesis and melena most common
- Coffee ground emesis
- Black stools
- Bright red blood per rectum
- Abdominal pain
- Weakness or lightheadedness
- Syncope
- Dyspnea
- Confusion or agitation
Physical Exam
- Tachycardia
- Hypotension
- Pale conjunctiva
- Dry mucous membranes
- Bloody, melanotic, or heme-positive stools
- Shock
- Signs of portal hypertension:
- Splenomegaly
- Abdominal wall collateral vessels
- Ascites
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
- Controversial: No outcome benefit has been shown and can have 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:
- Agents causing black stools, but negative hemoccult:
Pediatric Considerations |
| Hematemesis and bloody stool in newborns may be caused by the infant swallowing maternal blood during delivery or breastfeeding |
Diagnostic Tests & Interpretation
Lab
- CBC:
- Anemia (low mean corpuscular volume seen with chronic blood loss)
- Thrombocytopenia
- Electrolytes, BUN, creatinine, glucose
- Coagulation profile
- Lactate
- LFTs, if UGIB 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 |
| Hematocrit can remain normal for a period after acute blood loss; a drop may not be seen initially |
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
Prehospital
- Stabilize airway:
- Intubate for massive UGIB, if patient unable to protect airway
- Establish access:
- Insert large-bore IV (16-18 g) and administer crystalloid to keep SBP >90 mm Hg
- Attempt second IV 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
- If unstable, provide volume:
- Administer 1 L crystalloid bolus (peds: 20 mL/kg) and repeat once, if necessary
- Transfuse RBCs if unstable after crystalloid boluses or significant anemia:
- Cross-matched or type-specific blood, if available
- Otherwise, O-negative for premenopausal women, O-positive for others
- Transfusion goal Hgb 7-9 g/dL
- Provide fresh frozen plasma (FFP) along with RBC transfusion in ratio of 1:2-4. For patients requiring massive transfusion, add FFP and platelets in 1:1:1 ratio with RBCs
- For coagulopathy, administer (if INR >2) vitamin K and prothrombin complex concentrate (PCC) or if not available FFP (15-30 mL/kg) and platelets (if platelets <50,000/μL)
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
- Blood transfusion indications:
- Significant anemia:
- Hemoglobin <7 g/dL
- Hemoglobin <9 g/dL when at increased risk of ischemia (e.g., CAD and CVA)
- Evidence of end-organ ischemia
- Ongoing chest pain/ischemic ECG changes
- Unstable vital signs despite crystalloid bolus
- Massive bleeding
ALERT |
Avoid overtransfusion in variceal bleeding; it can precipitate further bleeding- UGIB treatment:
- IV proton pump inhibitor (PPI) (e.g., pantoprazole)
- High risk for active bleeding with 2 out of 3 risk factors:
- Bright blood from NGT
- Hemoglobin <8 g/dL
- WBC >12,000/uL
- Emergent endoscopy
- Therapeutic options:
- Cauterization of bleeding ulcers/vessels
- Endoscopic sclerotherapy
- For variceal bleeding:
- Octreotide
- Vasopressin:
- No mortality benefit. Bleeding cessation benefits may be counterbalanced by increased mortality due to ischemia
- Administer with IV nitroglycerin to reduce tissue ischemia
- Balloon tamponade with Blakemore tube is a last resort for varices
- In cirrhotics with UGIB, prophylactic antibiotics reduce bacterial infections and all cause mortality
- LGIB treatment:
- Consider angiography for massive, active bleeding with directed vasopressin infusion
- Bowel resection for massive bleeding refractory to medical management
- Tranexamic acid (TXA) for massive bleeding
|
Medication
- Vitamin K: 10 mg (peds: 1-5 mg) PO/SC/IV q24h
- Pantoprazole: 80 mg (peds: Dosing not approved) IV bolus followed by an infusion of 8 mg/hr for 72 hr or intermittent bolus doses
- Octreotide: 50 mcg (peds: 1-2 mcg/kg) bolus, then 50 mcg/hr (peds: 1-2 mcg/kg/hr) IV
- Somatostatin: 250 mcg (peds: Not established) IV bolus and 250-500 mcg/hr for 2-5 d (not available in the U.S.)
- Vasopressin: 0.4-1 IU/min (peds: 0.002-0.005 IU/kg/min) IV
- Nitroglycerin: 10-50 mcg/min (peds: Not established) IV
- TXA: 1,000 mg over 10 min (peds: 20 mg/kg over 10 min)
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
- FeinmanM, HautER. Upper gastrointestinal bleeding . Surg Clin North Am. 2014;94:43-53.
- GhassemiKA, JensenDM. Lower GI bleeding: Epidemiology and management . Curr Gastroenterol Rep. 2013;15:333-342.
- NadlerJ, StankovicN, UberA, et al. Outcomes in variceal hemorrhage following the use of a balloon tamponade device . Am J Emerg Med. 2017;35:1500-1502.
- SacharH, VaidyaK, LaineL. Intermittent vs continuous proton pump inhibitor therapy for high-risk bleeding ulcers: A systematic review and meta-analysis . JAMA Intern Med. 2014;174:1755-1762.
- VillanuevaC, ColomoA, BoschA, et al. Transfusion strategies for acute upper gastrointestinal bleeding . N Engl J Med. 2013;368:11-21.
The authors gratefully acknowledge Leon D. Sánchez for his contribution to the previous edition of this chapter.