Gastrointestinal Bleeding Jeffery A. Baker, MD Key Points ‘© Agaressive resuscitative measures (intravenous access, crystalloid bolus, and blood products) are necessary in unstable patients with gastrointestinal (G1) bleeding. ‘© A negative nasogastric lavage does nct completely exclude an upper Gi bleed. ‘© Abrisk upper Gi bleed should be considered in the differential of patients who present with hematochezia. INTRODUCTION Gastrointestinal (G1) bleeding accounts for 5% of admis- sions from the emergency department (ED). An interven- tion is required to stop ongoing hemorrhage in 10% of patients. Bleeding can occur anywhere along the GI tract, and can be grossly divided into upper and lower sources. Upper GI bleeding is defined as occurring proximal to the ligament of Treitz (the suspensory ligament of the duode- ‘num). Lower Gl bleeding is defined as occurring distal to the ligament of Treitz. Upper GI bleeding is 4-8 times ‘more common than lower GI bleeding. Itis not always possible to clinically distinguish between, ‘upper and lower GI bleeding in the ED, but appearance of the gastric contentsand stool can provide cluesto the source of the hemorrhage. Hematemesis is the vomiting of blood and indicates an upper GI bleed. “Coffee ground” emesis ‘suggests that the blood has partially digested and that bleed- ing is either slow or has stopped. A nasogastric (NG) tube aspirate positive for blood also indicates an upper GI source of bleeding. NG lavage can be negative in 25% of patients with an upper GI source of bleeding because the nasogastric tube does not reliably pass the pylorus. ‘Melena is black, tarry stool that reflects the presence of blood in the GI tract for more than 8 hours. At least ‘© Octreotide should be administered in patients with liver disease and significant upper Gl bleeding, even when the diagnosis of esophageal varices has not been ‘confirmed ‘© Emergent endoscopy should be arranged when active upper GI bleeding Is present. 300 mL of blood must be present to produce melena. Melena is 4 times more likely to be from an upper GI source of bleeding and almost always reflects bleeding proximal to the right side of the colon, Hematochezia is, bright red or maroon-colored blood per rectum. It is 6 times more likely to be from a lower GI source. An excep- tion is a rapid upper GI source of bleeding Hematochezia, is present in 10% of upper GI bleeds. ‘The three most common causts of upper GI bleeding are peptic ulcer disease, gastritis, and varices (Table 30-1). Lower GI bleeding may be due to multiple causes, but Table 30-1. Causes of upper Gi bleeding. cause Percentage Peptic ulcer (duodenal 2/3) 40% Frosve gastits 25% ‘Varices (esophageal and gastric) 20% ‘Mallory Weiss tear 5% ‘Other (epistans, aartoenerc stu, carcino, 10% ‘caustic ingestion) 128GASTROINTESMNAL BUEED@CG Fe Table 30-2. Causes of lower Gi bleeding. (Cause Percentage Divertiaulsis so Inflammatory bowel disease 13% ‘Hemorthois, ana fissure 11% Neoplasia ™ Coagulpathy * ‘terovenous mattcmation 3 diverticulosis is most common (Table 30-2). Less common causes include pseudomembranous colitis, infectious diar- rhea, aortoenteric fistula, radiation colitis, mesenteric ischemia, and Meckel diverticulum. CLINICAL PRESENTATION > History In most cases, patients will report hematemesis, coffee- ‘ground emesis, hematochezia, or melena. The duration and frequency of these symptoms should be elicited. For hematemesis, itis important to determine whether blood was present initially or appeared after several episodes of vomiting. The latter history suggests a Mallory-Weiss tear. ‘A history compatible with cirrhosis (chronic alcohol use, hepatitis, IV drug use) suggests varices. These patients may abo have a coagulopathy, making control of hemor- rhage more difficult. When bleeding has been slow but chronic, the patient may present with lightheadedness, fatigue, chest pain, or shortness of breath owing to anemia without any knowledge of GI bleeding, Patients with pep- tic ulcer disease may report epigastric abdominal pain related to cating. Agents that increase the risk of peptic ulcer disease include nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, and cigarettes. Elderly patients with acute hemorrhage may initially present with syncope ornear-syncope. > Physical Examination Vital signs should be obtained immediately. When abnor~ malities are present, treatment is frequently necessary before obtaining 2 thorough history. Tachycardia and hypotension indicate hypovolemic shock and require immediate resuscitation. Cool, pale, and clammy skin is evidence of anemia or shock. The abdomen should be thoroughly examined, noting areas of tenderness or perito- nitis. Rectal examination should be performed with Hemoccult testing. The presence of hemorrhoids should be documented. They may or may not be the source of lower GI bleeding. Examination should also elicit any evi- dence of the stigmata of cirthosis including ascites, spider angioma, jaundice, or palmar erythema. DIAGNOSTIC STUDIES > Laboratory Complete blood count, electrolytes, renal function, and coagulation studies should be obtained. Itis important to remember that a normal hemoglobin valve does not rule out a massive acute hemorrhage. Compensatory hemodi- lution may not occur for 2-3 hours. Blood bank should be contacted for immediate type and screen. Blood products should be ordered for patients with unstable vital signs oF significant blood loss. Upper Gl bleeding may elevate blood urea nitrogen because of the digestion and absorp- tion of hemoglobin. > Imaging Upright chest x-ray is indicated in patients with suspicion of perforation oraspiration. The presence of free air under the diaphragm is diagnostic of perforation and is a surgical emergency. Routine imaging otherwise offers little clinical value in GI bleeding. > Electrocardiogram ‘An electrocardiogram shouldbe obtained on patients with risk factors for coronary artery disease, patient with known heart disease, or patients with symptoms concerning for coronary ischemia. Silent ischemia can occur asa result of decreased oxygen delivery related to biood loss. PROCEDURES Nasogastric aspiration should be performed on patients suspected of having an upper GI bleed. Aspirate appearing like gross blood or “coffee grounds” is evidence of an upper Gl source. The stomach may then be lavaged with 200-300 mL. saline to see if the aspirate clears. Note that false negatives ‘may occur with bleeding distal to the pylorus, and false positives may occur from nasal trauma. NG aspiration is, an especially uncomfortable and anxiety-provoking proce- dure for the patient, and the use of topical anesthetic is, advised. Although NG aspiration in GI bleeding is rou- tinely performed, it will only yield a useful diagnostic, result in a minority of cases. MEDICAL DECISION MAKING ‘The exact location of GI bleedingis usually not determined in the initial ED evaluation. Examination of any emesis, stocl, or NG aspirate mey help to determine the general location of the hemorrhage and direct further diagnostic and treatment strategies (Figure 30-1). TREATMENT Patients with active GI bleeding should be placed on a car- diac monitor with supplemental oxygen. Large peripheral TV catheters should be inserted in unstable patients. If these130 CHAPTER 30 Suspected GI bleeding Hematemesis/ positive NG aspirate Hematochezia/ negative NG aspirate A Figure 30-1. GI bleeding diagnostic algorithm. GI, gastrointestinal; NG, nasogastric. lines cannot be inserted, a large-bore (8F) central line should bbe placed to maximize volume resuscitation. IV fluid bolus of 1-2 L of normal saline should be administered. If the patient remains unstable after the fluid bolus, administra tion of packed red blood cells (RBCs) is indicated. Uncross- ‘matched type O blood is ordered for patients with unstable vital signs and significant blood loss. If ¢ coagulopathy is suspected, fresh-frozen plasma is also ordered. For upper GI bleeding, histamine? antagonists are fre- ‘quently administered, although they have not been shown to eof any benefit inthe acute setting. Proton pump inhibitors decrease the rate of re-bleeding, Pantoprazcle 80 mgIV bolus followed by 5 ma/hr infusion is recommended. Octreotide is beneficial in decreasing the rate of bleeding, the incidence of rebleeding, and morality by decreasing portal hypertension. It is particularly useful in variceal bleeding, but may also reduce bleeding from nonvariceal sources. Administer a '50-meg IV bolus followed by 50 meg/hr IV drip. Emergent endoscopy is indicated for patients with fresh blood in the ING aspirate and hematochecia from an upper Gl source. Patients with liver disease also benefit from early endoscopic intervention. Surgical intervention may be required in patients with uncontrolled hemorrhage, perforation, or patients with liver disease and portal hypertension. In the setting of « suspected lower GI source of bleeding, consult gastroenterology and surgical services early in unsta- ble patients. Diagnostic and therapeutic options include angiography, technetium-labeled RBC scan, colonoscopy, or surgical intervention for partial colectomy. Angiography allows for localization and arterial embolization, whereas a technetium-labeled RBC scan localizes the bleeding site only. In emergent cases, colonoscopy misses the diagnosis in 409% ‘of cases because of poor bowel preparation. When the siteof bleeding is identified during colonoscopy, it mey allow for therapeutic interventions to stop bleeding, but is unsuccess- ful in 20%6 of cases. Surgical intervention is required in cases ‘of massive lower GI bleeding when other therapies fal DISPOSITION D> Admission Upper GI bleed. Mest patients with an upper GI bleed require admission. Admission to an intensive care unit, (ICU) setting should be strongly considered for patients with unstable vital signs, age >75 years, persistent bleeding that does not clear with NG lavage, presence of coagulopa- thy or severe anemia (hematocrit <20%), evidence of portal hypertension, or unstable comorbid conditions. ‘Lower GI blesd. Most patients with lower GI bleeding will require admission. ICU admission is appropriate for unstable patients, Mortality is higher in elderly patients ‘with comorbidities, and these features should prompt con- sideration for admission to an intensive care setting. > Discharge Upper GI bleed. Discharge with clos: follow-up can be arranged for reliable patients who meet al of the following criteria: age <65 years, no comorbidities including coagulopa- thy, no significant liver disease, normal vital signs, negative NG lavage and no melena, and a hemoglobin >10 gm/dL. Recent clinical scoring systems (Glasgow-Blatchford bleeding, score) may help predict which patients can be safely dis- charged from the ED without endoscopy. Lower GI bleed. Young stable patients with normal hemoglobin, no active bleeding, evidence of hemorrhoids fr fissures as a possible source, and no evidence of portal hypertension, coagulopathy, or other significant comor- bidities may be discharged with close follow-up. BMetsis ss Lo BM. Lower gastrointestinal bleeding. 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