Gastrointestinal (GI) BleedingRalph Lee, MMEd(Dist), MD, FRCPC

Gastroenterologist and Assistant ProfessorUniversity of Ottawa, September 18, 2015

Objectives

Define upper and lower gastrointestinal (GI) bleeding.

Outline the etiologies and clinical features of upper and lower GI bleeding

Apply a systematic clinical approach to GI bleeding.

Outline the investigation and management of GI bleeding

Recognize clinical indicators suggesting urgent versus non‐urgent assessment.

What is Gastrointestinal Bleeding? (1)

Bleeding from anywhere in the GI tractEsophagus to rectum

Traditionally, classified into two groups, based on presumed location of bleeding:UpperLower

3rd category, ‘Mid- GI’ bleeding, is present, but infrequently used

What is Gastrointestinal Bleeding? (2)

Upper GI (UGI) Bleeding Traditional: Proximal to

the Ligament of Treitz New: Proximal to the

Ampulla of Vater Lower GI (LGI) Bleeding

Traditional: Distal to Ligament of Treitz

New: Distal to terminal ileum

Mid GI bleeding New: Ampulla of Vater to

terminal ileum

UPPER GI BLEEDING

UGI Bleeding

75 – 80% of GI bleedingannual hospitalization rate = 160/100,000

(US)Mortality rate = 3.5 – 10%Sex – M:F – 2:1 incidence with ageMore likely to present with hemodynamic

instability due to rich blood supply of UGI tract

UGI BleedingCauses (Common)

Peptic Ulcer disease (20 - 50%)

Varices (5 - 20%) Mallory-Weiss tears (8

- 15%) Erosions (8 - 15%) AV Malformations (5%) Tumours (5%) Dieulafoy’s lesions

(1%)

UGI BleedingCauses (Other)

Other (11%) Gastric Antral Vascular

Ectasia (GAVE) AKA ‘Watermelon’

stomach Portal hypertensive

gastropathy Hemobilia Hemosuccus pancreatitis Aortoenteric fistulas Cameron’s lesions/ulcers

UGI BleedingHow Do They Present? (1)

Hematemesis Vomiting blood Bright red blood, clots, ‘coffee ground’

emesis Melena

Passage of black, tarry, foul-smelling stools Digested blood Appears with ≥ 50cc of bleeding from UGI

tract Things that mimick melena:

Iron pills - greenish Bismuth subsalicylate (Peptol Bismol™) - non-

foul smelling

UGI BleedingHow Do They Present? (2)

Bowel movement frequencyBlood is cathartic and a great laxativeRough indicator of rapidity of bleeding

Hemodynamic symptomsPre/SyncopeOrthostatic dizziness/lightheadednessChest pain, dyspnea

UGI BleedingHow Do They Present? (3)

(Hematochezia - red blood per rectum)Usually sign of LGI Bleeding, but can occur with

rapid UGI bleeding (i.e. ≥ 1000cc)patient usually hemodynamically unstable

Other symptomsDependent on cause

Abdominal pain, heartburn, dysphagia, nausea, vomiting

LOWER GI BLEEDING

LGI Bleeding

20 – 30% of gastrointestinal bleedingUsually less hemodynamically significant,

higher Hb level, less blood transfusion requirements than UGI bleeds

Increased incidence with ageMean age at presentation: 63 – 77

Mortality rate among hospitalized acute lower GI bleeds – 2 - 4%

LGI BleedingCauses

Diverticulosis (25 - 65%) Cancers/polyps (17%) Colitis/ulcers (18%)

IBD, ischemic, vasculitis, infectious, radiation-induced, NSAID-induced

Unknown (16%) Angiodysplasia (3 - 15%) Other (8%)

Post-polypectomy, stercoral ulcers, aorto-colonic fistulas

Anorectal (24 - 64%) Fissures, hemorrhoids

LGI BleedingHow Do They Present? (1)

Red Blood per Rectum Bright Red Blood Per Rectum (BRBPR) – left colonic? Dark/maroon – right colonic/lower small bowel?

Stool frequency – blood is cathartic form – diarrhea Location of blood

Surface/side of stool/dripping – perianal source? Mixed in stool – R colonic?

(Melena)* Usually sign of UGI bleeding, but can occur with distal small

bowel, cecum or R-sided colonic bleeding source Typically, hemodynamically stable with less rapid bleeding

LGI BleedingHow Do They Present? (2)

Other SymptomsDependent on causeFecal urgency, tenesmus, incontinenceAbdominal pain/crampsFevers/chillsWeight loss

GI BLEEDING

GI BleedingOther important historical items

Past medical history: GI

Previous PUD/H. Pylori infection? GI Malignancy?

Previous endoscopies Previous polypectomy

Diverticulosis IBD Cirrhosis?

Varices?

Cardiac CAD, angina, MI, CHF

Previous aortic

aneurysms/grafts/vascular

surgery? Previous radiation therapy? Bleeding episodes

Medications Anti-platelet agents (i.e.

ASA, Plavix),

anticoagulants (i.e.

warfarin, pradaxa) NSAIDs

Habits – EtOH Family history:

PUD, gastric cancer Colonic polyps, cancer IBD

GI BleedingPhysical Exam (1)

Look for: Hemodynamic instability Intravascular depletion Potential etiologies of bleeding

General: Altered mentation, jaundice

Vitals Hypotension Tachycardia Orthostatic changes

in BP and/or HR with position change from supine to standing

Suggests intravascular volume depletion of ≥ 2L

Head and Neck: Conjunctival pallor Scleral icterus Dry mucous membranes,

furrowed tongue, ↓ JVP Chest:

↓skin turgor at sternal angle Axilla: dry or moist

Abdomen: Tenderness, masses,

hepatosplenomegaly, stigmata of chronic liver disease

Digital rectal exam: Red blood? Melena? Hemorrhoids, fissures Masses

GI BleedingShock

SHOCK Class I Class II Class III Class IV

Blood Loss (mL) Up to 750 750-1500 1500-2000 >2000

Blood Loss (%) Up to 15 15-30 30-40 >40

HR (bpm) <100 >100 >120 >140

BP (mmHg) Normal Normal ↓ ↓

RR (breaths/min) 14-20 20-30 30-40 >35

Urine Output (cc/h) >30 20-30 5-15 Insig.

CNS Slightly anxious Mild anxious Anxious, confused Confused/ lethargic

GI BleedingManagement (Overview)

ABC’sResuscitationFocused History and Physical Exam

Upper vs. lower GI bleed InvestigationsTreatment

GI BleedingInitial Management

ABC’s Resuscitation

Intravenous (IV) accessMonitoring

Need for monitored area ? (i.e. ICU)Cardiac, respiratory (i.e pulse oximetry)

Volume re-expansionIV fluids

Keep patient NPO (nil per os) Focused history and physical exam

Upper vs. lower GI Bleed

GI BleedingInvestigations (1)

BloodworkType and crossmatch - PRBC’s, blood productsComplete Blood Cell Count

Hemoglobin MCV – mean corpuscular volume

MCV Fe deficiency chronic blood loss?Platelets

Clotting abilityElectrolytes

GI BleedingInvestigations (2)

Blood Urea Nitrogen (BUN), CreatinineIntravascular dehydration renal perfusion BUN, Cr

UGI bleed blood digestion in stomach/duodenum protein absorption urea nitrogen

[BUN x 10]: Cr > 1.5:1 May suggest UGI bleed

Liver enzymes and liver function testsINR - Coagulation status (i.e. INR)Liver disease (i.e. cirrhosis)

Albumin INR AST > ALT Platelets, MCV

(Nasogastric aspirate)

GI BleedingInitial Treatment (1)

Fluid ManagementIV crystalloids (i.e. normal saline); colloids (i.e.

volume expanders)Transfusion - Packed red blood cells

Reverse anti-coagulation INR - Vitamin K, fresh frozen plasma,

prothrombin complex concentrate (i.e. Octaplex) Platelets – Platelets transfusion

GI BleedingInitial Treatment (2)

Pharmacotherapy UGI Bleeds:

IV Proton Pump Inhibitor Mechanism: ↑ pH > 6 Promotes clot stability

↓ acid/pepsin on lesion ↑ platelet aggregation + fibrin formation

Empirically started to treat possible PUD until EGD performed IV PPI before endoscopy:

Lau et al. (2007): ↓ need for endoscopic therapy + accelerated

healing of ulcers Cochrane Meta-analysis (Sreedharan et al., 2010):

DOESN’T: mortality, rebleeding or progression to surgery DOES: high risk stigmata, need for endoscopic therapy

IV PPI after endoscopic therapy: rebleeding, mortality Dose: Pantoprazole 80mg IV bolus, then 8mg/h x 72 hours

GI BleedingInitial Treatment (3)

IV Somatostatin (i.e. octreotide) For possible variceal bleeds (i.e. patients with cirrhosis) –

started empirically Mechanism: splanchnic vasoconstriction portal

hypertension bleedingProkinetics (20 – 120 minutes before)

i.e. metoclopramide (Maxeran) or IV erythromycin To clear UGI tract of blood for better visualization Meta-analysis (Barkun et al., 2010): need for repeat

endoscopyLGI Bleeds: No specific medications

Urgent vs. Non-urgent Management

Urgent Hematemesis Serious co-morbid illness

Malignancy, cirrhosis Hemodynamic instability

Shock SBP < 100mmHg HR > 100bpm (Orthostatic hypotension)

Hb < 80 Transfusion requirement

> 2u PRBC’s Severe, ongoing bleeding

Non-urgent Young, healthy, minimal

bleeding

GI BleedingEndoscopy

UGI Bleed – EGD Timing: Within 24 hours of presentation To:

Diagnose cause of bleeding (high sensitivity/specificity)Stratify risk of rebleeding/adverse eventsPotentially treat underlying pathology

LGI Bleed – Colonoscopy Timing: Controversial

Severe bleeds: Within 8 – 24 hours Generally, LGI bleeds less severe than UGI bleeds Often, more difficult to identify source; therefore, mostly

diagnostic rather than therapeutic Unclear: EGD Colonoscopy

Upper vs. Lower EndoscopyPresumed Upper GI Bleed

Hematemesis

EGD

Upper vs. Lower EndoscopyPresumed Lower GI Bleed

Upper vs. Lower EndoscopyMassive Rectal Bleeding

Upper vs. Lower EndoscopyOccult Bleeding

Occult bleeding Stool testing positive for

occult blood Unexplained Fe

deficiency anemia

GI BleedingEndoscopic Hemostasis (1)

Injection i.e. Vasoconstrictors (i.e.

epinephrine), saline, sclerosants, tissue adhesives

Creates submucosal cushion of fluid which tamponades site +/- vasoconstriction

Thermal therapy i.e. Mono/bipolar

electrocoagulation, Argon Plasma Coagulation (APC), Laser Photocoagulation

Cauterizes vessel closed

GI BleedingEndoscopic Hemostasis (2)

Mechanical therapy i.e. Hemoclips, rubber

bands Closes and

tamponades vessel Animation

http://www.youtube.com/watch?v=59uO-8UVC2A

Hemospray New therapy Nano particle spray

UGI BleedingPeptic Ulcer Disease (1)

Most commonly due to NSAIDS, H.

Pylori 75 – 80% stop spontaneously Ulcer appearance indicates risk of

rebleeding and determines whether

therapy required Forrest Classification

UGI BleedingPeptic Ulcer Disease (2)

Endoscopic intervention: Risk of rebleeding Need for surgery Mortality

UGI BleedingVarices

Often unstable UGI bleeds Esophageal – Options:

Ligated with rubber bands (band ligation)

Injection with sclerosants Gastric – Options:

Injected with ‘glue’ (cyanoacrylate)

Band Ligation If endoscopy unsuccessful:

Transjugular intrahepatic portosystemic shunt (TIPS)

Liver transplant

LGI BleedingDiverticular Bleeding

Complicates 3 – 15% with colonic

diverticulae Pathophysiology:

Trauma of vasa recta at neck or

dome of diverticulum

Presentation: Painless hematochezia

Treatment: 75 - 80% resolve spontaneously

Recurrence within 4 years 25 – 40%

Endoscopic hemostasis If site can be identified < 30d rebleeding: Uncommon

Angiography (85% effective) < 30d rebleeding: 22%

Surgical resection

LGI BleedingAngiodysplasia

Increases with age Pathophysiology

Degenerative changes Chronic, intermittent obstruction

of submucosal vessels Presentation

Usually asymptomatic Overt or occult bleeding

Usually in right colon Treatment

Iron replacement Cauterization if bleeding or Fe

deficiency anemia (Estrogen/progesterone)

GI BleedingOther Options (1)

If endoscopy fails to identify source or fails to stop the bleeding

Mesenteric angiography Performed by interventional radiology Catheter introduced through femoral artery, passed to celiac

trunk, SMA, IMA + branches to: Diagnose bleeding site

Requires blood loss of ≥ 0.5-1mL/min Low sensitivity (47%) but high specificity (100%)

Perform therapy Feeding arteries can be embolized with microscopic gel foam, microcoils or

EtOH particles Success rate: 52 – 94% http://www.youtube.com/watch?v=jvi2WwvXIew

Complications (17%): Nephrotoxicity, bowel infarction, hematomas

GI BleedingOther Options (2)

RBC scan Patient infused with technetium

tagged RBC’s to locate site of

bleeding Disadvantages:

Not therapeutic Only localizes bleeding to

generalized area of abdomen

Requires blood loss ≥

0.1mL/min Higher sensitivity; lower

specificity Surgery

Intraoperative enteroscopy Oversew, resection

Summary (1)

Upper GI Bleed Hematemesis Melena Hemodynamic instability Elevated BUN x 10: Cr

Lower GI Bleed Dark/bright red blood per

rectum (hematochezia)

Longer course Tend to be more

hemodynamically stable

Summary (2)

PUD is most common cause of UGIB bleeding Diverticular disease is the most common cause of significant LGIB Approach includes

ABC’s Resuscitation History and Physical Exam Initial Investigations Initial Treatment Endoscopy Radiology Surgery

IV PPI’s are started empirically if UGIB is suspected Endoscopy is the primary diagnostic and therapeutic tool for GI

bleeds

Questions?