Gastrointestinal Bleeding

Prof. Dr. Orhan TarçınYeditepe Üniversitesi, Gastroenteroloji Bölümü

Gastrointestinal Bleeding

• The annual rate of hospitalization for any type of gastrointestinal (GI) hemorrhage in the United States is estimated to be 350 hospital admissions/100,000 population, with more than 1,000,000 hospitalizations annually.

• Approximately 50% of admissions for GI bleeding are for upper GI (UGI) bleeding (from the esophagus, stomach, duodenum), 40% are for lower GI (LGI) bleeding (from the colon and anorectum), and 10% are for obscure bleeding (from the small intestine).

• The source of most GI bleedings can be suspected by the clinical symptoms and physical examination and confirmed by upper or lower endoscopy.

• Initial management focuses on medical resuscitation, followed by endoscopic diagnosis and interventions to stop acute bleeding and prevent recurrent bleeding.

Gastrointestinal Bleeding

• Pharmacologic therapy is playing an increasingly important role in the management of UGI bleeding from peptic ulcers and varices.

• Optimal patient outcomes depend on successful medical resuscitation, precise endoscopic diagnosis, and appropriate use of therapeutic endoscopy

Gastrointestinal Bleeding

• Severe gastrointestinal bleeding is defined as documented gastrointestinal bleeding (i.e., hematemesis, melena, hematochezia, or positive nasogastric lavage) ;accompanied by shock or orthostatic hypotension, a decrease in the hematocrit value by at least 6% (or a decrease in the hemoglobin level of at least 2 g/dL), or transfusion of at least two units of packed red blood cells.

Defining of GI Bleeding

Hematemesis

• Hematemesis is defined as vomiting of blood, which is indicative of bleeding from the esophagus, stomach, or duodenum. Hematemesis includes vomiting of bright red blood, which suggests recent or ongoing bleeding, and dark material (coffee-ground emesis), which suggests bleeding that stopped some time ago.

Melena

• Melena is defined as black tarry stool and results from degradation of blood to hematin or other hemochromes by intestinal bacteria.

• Melena can signify bleeding that originates from UGI, small bowel, or proximal colonic source.

• Melena generally occurs when 50 to 100 mL or more of blood is delivered into the GI tract (usually the upper tract), with passage of characteristic stool occurring several hours after the bleeding event.

Hematochezia

• Hematochezia refers to bright red blood per rectum, and suggests active UGI or small bowel bleeding, or distal colonic or anorectal bleeding.

Obscure gastrointestinal bleeding

• Obscure gastrointestinal bleeding is bleeding from a site that is not apparent after routine endoscopic evaluation with esophagogastroduodenoscopy (upper endoscopy) and colonoscopy, and possibly small bowel radiography.

• Occult gastrointestinal bleeding refers to subacute bleeding that is not clinically visible.

Causes Of Upper GI BleedingCAUSE FREQUENCY (%)

Peptic ulcer 38

Gastric or esophageal varix 16

Esophagitis 13

No cause found 8

Upper gastrointestinal tract tumor 7

Angioma* 6

Mallory-Weiss tear 4

Erosions 4

Dieulafoy's lesion 2

Other 2

Causes of Severe Hematochezia (%)

LESIONStudy

REFERENCE 218 REFERENCE 219 UCLA CURE

Diverticulosis 30 33 30

Colon cancer or polyps 18 21 6

Colitis 17 17 21

Ischemic colitis NP( not provided) 7 12

IBD NP 4 9

Noninfectious colitis NP 5 0

Infectious colitis NP 1 0

Angioectasia 7 6 3

Postpolypectomy 6 NP 8

Rectal ulcer NP 1 6

Hemorrhoids NP 20 14

Anorectal source (unspecified) 4 3 0

Radiation colitis 0 0.5 3

Other 8 3 6

Unknown 16 0 0

History Taking

• Initial assessment of the patient with acute GI bleeding includes medical history taking, obtaining vital signs, performing a physical examination, including a rectal examination, and nasogastric lavage.

• During history taking, patients should be questioned about risk factors and historical features that help identify diagnostic possibilities for the bleeding source.

PHYSICAL EXAMINATION

• On initial evaluation, physical examination should focus on the patient's vital signs, with attention to signs of hypovolemia such as hypotension, tachycardia, and orthostasis.

• The abdomen should be examined for surgical scars, tenderness, and masses.

• Signs of chronic liver disease include spider angiomata, palmar erythema, gynecomastia, ascites, splenomegaly, caput medusae, and Dupuytren's contracture.

• The skin, lips, and buccal mucosa should be examined for telangiectasias, which are suggestive of hereditary hemorrhagic telangiectasia (HHT), or Osler-Weber-Rendu disease.

• Pigmented lip lesions may suggest Peutz-Jeghers syndrome. • Purpuric skin lesions may suggest Henoch-Schönlein purpura. • Acanthosis nigricans may suggest underlying malignancy,

especially gastric cancer. • The patient's feces should be observed to identify melena or

maroon (kesteane rengi) and red stool; however, the subjective description of stool color varies greatly among patients and physicians.[4]

PHYSICAL EXAMINATION

• Nasogastric or orogastric tube placement to aspirate and visually characterize gastric contents can be useful to determine the presence or absence of large amounts of red blood, coffee-ground material, or nonbloody fluid.

PHYSICAL EXAMINATION-2

LABORATORY STUDIES• Blood from the patient with acute GI bleeding

should be sent for standard hematology, chemistry, liver biochemical, and coagulation studies and for typing and crossmatching for packed red blood cells.

• The hematocrit value immediately after the onset of bleeding may not reflect blood loss accurately because over 24 to 72 hours there is equilibration of red blood cells in the vascular space with extravascular fluid and hemodilution resulting from intravenous administration of saline.

MCV –WBC-Platelet

• The mean corpuscular volume (MCV) is an important indicator of the chronicity of blood loss; an MCV lower than 80 fL suggests chronic GI blood loss and iron deficiency, which can be confirmed by the finding of low blood iron, total iron-binding capacity (TIBC), and ferritin levels.

• A low MCV and negative fecal occult blood test result raise the possibility of celiac disease. A high MCV (>100 fL) suggests chronic liver disease or folate or vitamin B12 deficiency.

• An elevated white blood cell count may occur in more than half of patients with UGI bleeding and has been associated with greater severity of bleeding.[

• A low platelet count can contribute to the severity of bleeding and suggests chronic liver disease or a hematologic disorder.

LABORATORY STUDIES

• The blood urea nitrogen (BUN) and serum creatinine levels can help assess the patient for hemoconcentration (elevated levels) or chronic kidney disease, which may lead to chronic anemia because of decreased erythropoietin production.

• In patients with UGI bleeding, the BUN level typically increases to a greater extent than the serum creatinine level because of increased intestinal absorption of urea after the breakdown of blood proteins by intestinal bacteria.

PT-INR and Others

• The prothrombin time (PT) and international normalized ratio (INR) assess whether a patient has impairment of the extrinsic coagulation pathway.

• Values can be elevated in chronic liver disease or with the use of warfarin.

• Liver biochemical test levels may indicate the presence of acute or chronic liver disease; a low serum albumin level suggests possible chronic liver disease, malnutrition, or protein loss via the intestine or kidney.

CLINICAL DETERMINATION OF THE BLEEDING SITE

• Presentation with hematemesis, coffee-ground emesis, or nasogastric lavage with return of a large amount of blood or coffee-ground emesis indicates an UGI source of bleeding.

• A small amount of coffee-ground material or pink-tinged fluid that clears easily may represent mucosal trauma from the nasogastric tube rather than active bleeding from an UGI source.

• A clear (nonbloody) nasogastric aspirate does not necessarily indicate a more distal GI source bleeding, because 16% of patients with actively bleeding UGI lesions have a clear nasogastric aspirate.

• The presence of bile in the nasogastric aspirate makes UGI bleeding unlikely but can be seen with an intermittently bleeding UGI source.

• Melena generally indicates an UGI source but can be seen with small intestinal or proximal colonic bleeding.

• Hematochezia generally implies a colonic or anorectal source of bleeding unless the patient is hypotensive, which could indicate a severe, brisk UGI bleed with rapid transit of blood through the GI tract.

• Maroon-colored stool can be seen with an actively bleeding UGI source or a small intestinal or proximal colonic source

CLINICAL DETERMINATION OF THE BLEEDING SITE-2

HOSPITALIZATION

• Patients with severe GI bleeding require hospitalization, • Whereas those who present with only mild acute

bleeding (self-limited hematochezia or infrequent melena) and who are hemodynamically stable (not suspected to be volume depleted), have normal blood test results, and can be relied on to return to the hospital if symptoms recur may be candidates for semiurgent outpatient endoscopy rather than direct admission to the hospital.

• %80 of GI bleeding stop spontaneously.

• On the other hand, patients should be hospitalized in an intensive care unit if they have large amounts of red blood in the nasogastric tube or per rectum, have unstable vital signs, or have had severe acute blood loss that may exacerbate other underlying medical conditions.

• Patients who have had an acute GI bleed but are hemodynamically stable can be admitted to a monitored bed (step-down unit) or standard hospital bed, depending on their clinical condition.

HOSPITALIZATION-2

RESUSCITATION

• Resuscitation efforts should be initiated at the same time as initial assessment in the emergency department and continue during the patient's hospitalization.

• At least one large-bore (14- or 16-gauge) catheter should be placed intravenously, and two should be placed when the patient has ongoing bleeding.

• Normal saline is infused as fast as needed to keep the patient's systolic blood pressure higher than 100 mm ‘Hg and pulse lower than 100/min.

RESUSCITATION-2

• Patients are transfused with packed red blood cells, platelets, and fresh-frozen plasma as necessary to keep the hematocrit value higher than 24%, platelet count higher than 50,000/mm3, and prothrombin time less than 15 seconds, respectively.

• A GI endoscopist should be consulted as soon as possible to expedite the patient's assessment and determine the optimal timing of endoscopy.

• The patient's vital signs should be monitored frequently, as appropriate to the level of hospitalization.

• Laboratory-determined hematocrit values (not fingerstick hematocrit values, which are less reliable) should be obtained every four to eight hours until the hematocrit value is stable.

• In patients with active bleeding, an indwelling urinary catheter should be placed to monitor the patient's urine output.

RESUSCITATION-3

• Endotracheal intubation should be considered in patients with active ongoing hematemesis or with altered mental status to prevent aspiration pneumonia.

• Patients who are older than 60 years, have chest pain, or have a history of cardiac disease should be evaluated for myocardial infarction with electrocardiography and serial troponin measurements.

• A chest x-ray should also be considered.

RESUSCITATION-4

INITIAL MEDICAL THERAPY

• Administration of a proton pump inhibitor (PPI) is useful for reducing rebleeding rates in patients with peptic ulcer disease .

• Starting a PPI in the emergency department or intensive care unit (ICU) before endoscopy is performed in patients with severe UGI bleeding has become a common practice but is still controversial.

• It reduces the need for endoscopic therapy but does not result in improved clinical outcomes in the transfusion requirement, rebleeding rate, need for surgery, or death rate.

Suspicion of Variceal Bleeding

• Patients with a strong suspicion of portal hypertension and variceal bleeding should be started empirically on intravenous octreotide (which can reduce the risk of rebleeding to a rate similar to that associated with endoscopic therapy.

Medical Management of Acute Variceal Bleeding

• Somatostatin and its long-acting analog octreotide cause selective splanchnic vasoconstriction and lower portal pressure, without causing the cardiac complications seen with vasopressin (even in combination with nitroglycerin).

• A meta-analysis has shown that vasoactive drugs (e.g., octreotide, somatostatin, terlipressin [a long-acting vasopressin analog]) are as effective as sclerotherapy for controlling variceal bleeding and cause fewer adverse events

Figure 19-1. Algorithm for the initial management of severe upper gastrointestinal (UGI) bleeding. The steps in the algorithm may take place simultaneously or in varying

orders and in the emergency department depending on the clinical situation.

Algorithm for the endoscopic and medical management of severe ulcer hemorrhage following hemodynamic stabilization.

(IV, intravenous; NBVV, nonbleeding visible vessel; PPI, proton pump inhibitor; UGIB, upper gastrointestinal bleed.)

Endoscopy• Ideally, the patient should be hemodynamically stable, with a

heart rate of less than 100 beats/min and a systolic blood pressure higher than 100 mm Hg.

• Respiratory insufficiency, altered mental status, or ongoing hematemesis indicates the need for endotracheal intubation before emergency upper endoscopy to stabilize the patient and protect the airway.

• Coagulopathy and thrombocytopenia should be corrected with transfusions prior to endoscopy.

• Proper medical resuscitation will not only allow safer endoscopy, but also ensure a better diagnostic examination for lesions, such as varices, that are volume dependent and will allow more effective hemostasis because of the correction of coagulopathy.

Endoscopic Stigmata of Recent Ulcer Hemorrhage

ENDOSCOPIC APPEARANCE FREQUENCY (%) RISK OF REBLEEDING

(%)RISK OF REBLEEDING AFTER ENDOSCOPIC HEMOSTASIS (%)*

Active arterial bleeding 12 90 15-30

Visible vessel 22 50 15-30

Adherent clot 10 33 0-5

Oozing without stigmata 14 10 0-5

Flat spot 10 7 NA

Clean ulcer base 32 3 NA

Figure 19-7. Endoscopic stigmata of recent peptic ulcer bleeding. A, Active bleeding with spurting. B, Visible vessel (arrow) with an adjacent clot. C, An adherent clot. D, Slight oozing

of blood after washing in the center of an ulcer without a clot or visible vessel.

After EUS –İİAB Oozing Bleeding in the Stomach and Endoscopic Therapy

Algorithm for the management of severe hematochezia. (RBC, red blood cell)

The frequencies of the sources of severe hematochezia in patients seen at the University of California, Los Angeles, Center for Ulcer Research Education. Note that in most cases (75%),

severe hematochezia is from the colon, 17% is from an upper gastrointestinal (UGI) (esophagus, stomach, or duodenum) source, and 5% is from a small intestinal source.

Endoscopic stigmata of recent colonic diverticular bleeding. A, Active bleeding (arrow).

B, Adherent clot (arrow) C, Nonbleeding visible vessel

Endoscopy• In patients with severe UGI bleeding, gastric lavage with a large

(34-Fr) orogastric tube should be performed to evacuate blood and clots from the stomach to prevent aspiration and allow good endoscopic visualization.

• In patients with severe hematochezia and suspected active colonic bleeding, urgent colonoscopy can be undertaken after a rapid purge.

• Patients should receive 4 to 8 L of polyethylene glycol purge orally or via a nasogastric tube over four to six hours until the rectal effluent is clear of stool, blood, and clots.

• Metoclopramide, 10 mg, may be given intravenously before the purge and repeated every four to six hours to facilitate gastric emptying and reduce nausea.

Maroon Stool

• Patients with maroon stool in whom there is pretest uncertainty about the bleeding source should be considered for an urgent polyethylene bowel preparation as well.

• Colonoscopy immediately after push enteroscopy

Algorithm for the management of severe overt obscure gastrointestinal bleeding.*Deep enteroscopy includes double-balloon enteroscopy, single-

balloon enteroscopy, and spiral enteroscopy

Endoscopic Therapy

• Injection Therapies• Coagulation with contact methods (heater

prob, multipolar (bipolar) coagulation prob )• Coagulation with non-contact methods (Argon

Plasma coagulation, laser)• Clipping

RADIOLOGIC IMAGING

• Angiography may be used to diagnose and treat severe bleeding, especially when the cause cannot be determined by upper and lower endoscopy. Angiography generally is diagnostic of extravasation into the intestinal lumen only when the arterial bleeding rate is at least 0.5 mL/min.

• An advantage of angiography is that it permits therapeutic intra-arterial infusion of vasopressin or transcatheter embolization for hemostasis if active bleeding is detected, without the need for bowel cleansing

• A disadvantage of angiography is that it usually does not identify the specific cause of bleeding, only its location.

Radionuclide imaging

• Radionuclide imaging is occasionally helpful for patients with unexplained GI bleeding, although it is used less frequently now.

• Radionuclide imaging can be performed relatively quickly and may help localize the general area of bleeding .

• The technique involves injecting a radiolabeled substance intravenously into the patient's bloodstream and then performing serial scintigraphy to detect focal collections of radiolabeled material. Radionuclide imaging has been reported to detect bleeding at a rate of 0.04 mL/min.

• Up to 25% of bleeding scans suggest a site of bleeding that proves to be incorrect

Surgery

• Most patients admitted for acute GI bleeding have bleeding of mild to moderate severity and do not need surgical consultation.

• In selected patients with severe, ongoing GI bleeding in whom a diagnosis is not made by urgent endoscopy or colonoscopy, surgical consultation during the hospitalization is recommended.

THE END

Independent Risk Factors for Persistent or Recurrent Gastrointestinal Tract Bleeding

RISK FACTOR RANGE OF ODDS RATIOS FOR INCREASED RISK

Clinical FactorsHealth status (ASA class 1 vs. 2-5) 1.94-7.63

Comorbid illness 1.6-7.63Shock (systolic blood pressure < 100 mm Hg) 1.2-3.65

Erratic mental status 3.21

Ongoing bleeding 3.14

Age ≥ 70 yr 2.23

Age > 65 yr 1.3

Transfusion requirement NA

Presentation of Bleeding

Hematemesis 1.2-5.7

Red blood on rectal examination 3.76

Melena 1.6

Laboratory Factors

Coagulopathy 1.96

Initial hemoglobin ≤ 10 g/dL 0.8-2.99

Endoscopic Factors

Ulcer location on superior wall of duodenum 13.9

Ulcer location on posterior wall of duodenum 9.2

Active bleeding 2.5-6.48

High-risk stigmata 1.91-4.81

Ulcer size ≥ 2 cm 2.29-3.54

Ulcer location high on lesser curve 2.79

Diagnosis of gastric or duodenal ulcer 2.7

Clot over ulcer 1.72-1.9