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Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.

Terms of Use
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Copyright Annals of Internal Medicine, 2012

Ann Int Med. 157 (3): ITC2-1.

in the clinic

Acute
Gastrointestinal
Bleeding
Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.

Who is at risk for acute GI bleeding?

Risks factors vary by site and cause
Upper GI bleeding
Peptic ulcer disease (risk factors: NSAIDs, H. pylori)
Increased gastric acid production
Smoking
Severe physiologic stress
Host factors (genetic polymorphisms affecting cyclooxygenase and prostaglandin production)
Varices, esophagitis, vascular abnormalities,
Mallory-Weiss tear, benign or malignant neoplasms
? Spicy foods (no convincing data they increase risk)

Copyright Annals of Internal Medicine, 2012

Ann Int Med. 157 (3): ITC2-1.

Who is at risk for acute GI bleeding?

Risks factors vary by site and cause
Lower GI bleeding
Diverticulosis (most common cause of hematochezia)
Inflammatory bowel disease
Infectious colitis
Neoplasia
Angioectasias
Benign anorectal disease
Upper GI sources

Copyright Annals of Internal Medicine, 2012

Ann Int Med. 157 (3): ITC2-1.

Obscure bleeding: 10-20% of GI bleeding

Unknown cause despite evaluation, tests, imaging
Recurrent or persistent bleeding (50%)
Obscure-overt (visible blood w/ melena / hematochezia)
Obscure-occult (recurrent iron-deficiency / positive FOBT)
Many from small intestine: Mid-GI bleeding (mostly from angioectasia)

Copyright Annals of Internal Medicine, 2012

Ann Int Med. 157 (3): ITC2-1.

Can acute GI bleeding be prevented?

Peptic ulcer disease
Reduce NSAID use
Administer antacid Rx with H2-inhibitors or PPIs

At-risk hospitalized pts

Coagulopathy or thrombocytopenia
Mechanical ventilation
Traumatic brain or spinal cord injury, burns
Prophylactic H2-inhibitors or PPIs

Copyright Annals of Internal Medicine, 2012

Ann Int Med. 157 (3): ITC2-1.

Can acute GI bleeding be prevented?

Chronic liver disease and portal hypertension
Nonselective -blockers + endoscopic
interventions

Diverticulitis or angioectasias
High-fiber diets may help
Surgical intervention (diverticulosis) after
1major episode

Copyright Annals of Internal Medicine, 2012

Ann Int Med. 157 (3): ITC2-1.

CLINICAL BOTTOM LINE: Prevention

Upper GI bleeding
Minimize use and appropriately prescribe NSAIDs,
antiplatelet agents, anticoagulants
Primary and secondary prophylactic acid suppression
Variceal bleeding
Nonselective beta-blockers and endoscopic therapy
Lower GI bleeding
Reduce exposure to NSAIDS, antiplatelet agents,
anticoagulants
Few measures help in prevention

Copyright Annals of Internal Medicine, 2012

Ann Int Med. 157 (3): ITC2-1.

What are symptoms of acute GI bleeding?

Hematemesis
Melena
Bloody diarrhea
Presyncope or syncope
Fatigue; dizziness; pallor (anemia)
Upper GI bleeding
Nausea, dyspepsia

Lower GI bleeding
Altered bowel habits, lower abdominal pain, rectal
discomfort

Copyright Annals of Internal Medicine, 2012

Ann Int Med. 157 (3): ITC2-1.

What are the signs of acute GI bleeding?

Hypotension (systolic BP < 90 mmHg)
Tachycardia (>120 bpm)
Orthostatic changes in BP (10mmHg), HR (30/min)
Blood or coffee-grounds-like material in nasogastric
aspirate: upper GI source
Pallor: poor indicator without corroborative evidence
Perioral telangiectasias: hereditary hemorrhagic
telangiectasia syndrome
Skin abnormalities: stigmata of cirrhosis, pigmented lip
lesions, acanthosis nigricans, vascular anomalies

Copyright Annals of Internal Medicine, 2012

Ann Int Med. 157 (3): ITC2-1.

What are the common causes of upper and

lower GI bleeding?
Inflammatory
PUD; esophagitis or esophageal ulceration
Diaphragmatic hernia; diverticular disease; IBD
Benign and malignant neoplasms

Vascular anomalies
Gastroesophageal varices, angioectasias
Dieulafoy lesion
gastric antral vascular ectasia
Radiation proctopathy

Drug-induced (aspirin; NSAIDs)

Miscellaneous
Post-polypectomy; MalloryWeiss tear; Meckel diverticulum

Copyright Annals of Internal Medicine, 2012

Ann Int Med. 157 (3): ITC2-1.

Can risk for adverse outcomes be predicted

in patients with acute GI bleeding?
Factors that portend a poorer prognosis
Chronic alcoholism
Active cancer

Risk-stratification tools facilitate triage

Rockall scoring system
GlasgowBlatchford Scale
Incorporate clinical, lab, and/or endoscopic parameters
Predict need for hospitalization or further intervention

Copyright Annals of Internal Medicine, 2012

Ann Int Med. 157 (3): ITC2-1.

Which patients may be evaluated as

outpatients, and which require the
emergency department or hospitalization?
Outpatient management if low-risk for rebleeding:
Rockall score 02
GlasgowBlatchford score 0

Inpatient management & consider admission to ICU:

Brisk, active bleeding
Other parameters for high risk for rebleeding, mortality
Chronic alcoholism
Higher Rockall or GlasgowBlatchford score

Copyright Annals of Internal Medicine, 2012

Ann Int Med. 157 (3): ITC2-1.

What should the initial diagnostic evaluation

for possible acute GI bleeding include?
History
Associated signs and symptoms
Use of NSAIDs, antiplatelet agents, anticoagulants,
SSRIs, -blockers
Prior GI bleeding episodes and comorbid conditions

Physical exam
Routine exam + assess vital signs on postural changes
Examine stool
Check for resting hypotension or tachycardia
Check for increase in pulse (30/min) or severe
lightheadedness when rising from supine position
Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.

 Lab tests
CBC, prothrombin and partial thromboplastin times
Platelet count, blood type and crossmatch, and routine
chemistry panel
Ratio of blood urea nitrogen to creatinine
Increased ratio suggests upper GI source
Nasogastric or orogastric aspiration
May confirm upper GI bleeding
May provide prognostic information on severity
False negative in ~15%
No proof of altered outcomes

Copyright Annals of Internal Medicine, 2012

Ann Int Med. 157 (3): ITC2-1.

When should a gastroenterologist be consulted

in the evaluation of acute GI bleeding?
Consult early
To consider prompt endoscopy and facilitate triage
Initial diagnostic tests of choice: EGD &/or colonoscopy

EGD
For melena and hematemesis
For subset with hematochezia from upper GI source

Early endoscopy (24h admission)

For upper GI bleeding
Ensure volume resuscitation + hemodynamic stabilization

Urgent endoscopy (<12h admission)

For suspected variceal bleeding
Provides valuable information for appropriate triage
Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.

What is the role of prokinetic

medications before upper endoscopy
in patients with acute GI bleeding?
Facilitate clearance of blood and clots from stomach
Erythromycin, metoclopramide
Administered IV 20-120 mins before upper endoscopy
Improve endoscopic visualization
Does not appear to alter important clinical outcomes

Reserve for patients with red blood hematemesis or

blood in nasogastric aspirate

Copyright Annals of Internal Medicine, 2012

Ann Int Med. 157 (3): ITC2-1.

What adjunctive tests help evaluate or treat

patients with acute GI bleeding without an
identified source on EGD or colonoscopy?
Small-bowel barium radiography (historically)
Wireless video capsule endoscopy (VCE)
Higher diagnostic yield (35%76%)
Cant provide hemostatic interventions
Many institutions cant perform urgent VCE inpatient

Angiography
Allows intervention if lesion localized
Requires active bleeding at time of study

CTA or CT/MR enterography

Enables visualization + therapeutics deep in small intestine
Low-risk; no need for high-risk intraoperative enteroscopy
Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.

CLINICAL BOTTOM LINE: Presentation

and Diagnosis
Presents with myriad signs and symptoms
Asymptomatic to overt hematemesis or hematochezia
Due to causes virtually anywhere along the GI tract
Initial evaluation helps narrow differential diagnosis
Including history and physical examination
Routine laboratory tests

Copyright Annals of Internal Medicine, 2012

Ann Int Med. 157 (3): ITC2-1.

What interventions should be started

immediately for acute GI bleeding?
Aggressive volume resuscitation
Large-bore peripheral IV catheters to give fluids and blood
products rapidly
Emesis Intubate if unable to protect airway from aspiration
Isotonic IV fluids to replenish intravascular volume
Blood transfusions may be harmful in hypovolemic anemia

Treat coagulopathy in patients receiving anticoagulants

Dont delay therapeutic endoscopy unless INR >2.5
Except in cirrhosis (INR cant predict bleeding risk)

Target platelets > 50,000/L if no platelet dysfunction

> 100,000/L if suspected dysfunction
Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.

How should acute upper GI bleeding due

to peptic ulcer disease be managed?
Endoscopy allows biopsy / assess cause
100% specific (rare false-+ result); >90% sensitive
Forrest classification: describes ulcers, predicts risk
Clean ulcer base or flat pigmented spot in ulcer base:
low rebleeding riskpharmacologic Rx only
Adherent clots, nonbleeding visible vessels, or active
bleeding: high-risk continued or recurrent bleeding
endoscopic interventions + pharmacologic Rx
High-risk lesions having endoscopic therapy: 3 days in-hospital IV PPI required, then oncedaily oral PPI; H2 blockers not as effective
Low-risk lesions, hemodynamically stable, no serious comorbidities: consider early D/C on
daily PPI

Consider pre-endoscopic PPIs (but dont delay endoscopy

or replace resuscitation)
Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.

How should acute esophageal variceal

bleeding be treated?
Result of significant portal hypertension
Bleeding occurs under high pressure and often brisk
Monitor closely for adverse effects of volume replacement
Target hemoglobin: 78 g/dL

Antibiotic prophylaxis reduces infectious complications

Medical Rx (infusion octreotide, somatostatin analogue)
Endoscopic therapy (for known or suspected varices)
Refractory to medical and endoscopic therapy?
Balloon tamponade: temporizing measure
TIPS placement: within 72 hours (recommended)
Surgery: portosystemic shunting, esophageal transection,
liver transplant
Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.

How should acute lower GI bleeding from

colonic diverticulosis be treated?
Initially: Fluid resuscitation, blood transfusion, testing

Colonoscopy: to localize (difficult if brisk hemorrhage)

Within 12-24 h of presentation with rapid colonic prep
Allows exclusion of other causes (cancer)
Can be therapeutic if visible vessel or adherent clot noted

Nuclear imaging
Angiography
Surgical resection: if bleeding doesnt resolve (20%)
Segmental colectomy: if bleeding can be localized
Subtotal colectomy: if bleeding cant be localized source
Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.

What is the role of angiography?

Local administration of vasopressin
Controls bleeding in up to 80% of patients
Rebleeding often occurs when infusion stopped
Temporizing measure, allows for more controlled procedure
Use with caution if CAD or PVD present

Embolization of the source

Injection of sealant materials or mechanical devices
Alternative if vasopressin has failed or too risky
More definitive means to control bleeding
Contraindication: poor collateral blood supply

More effective in absence of coagulopathy

Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.

How should therapy for acute GI bleeding

be monitored?
Tachycardia
Early warning recurrent bleeding, followed by hypotension

Hemoglobin levels
Check at least every several hours initially
Possible ongoing blood loss if levels dont increase by
1 g/unit of transfused packed RBCs

Additional blood transfusions and diagnostic testing

Consider if evidence of ongoing blood loss

Platelet count and coagulation

Measure serially to assess need for repeated transfusions
If multiple transfusions of RBCs: monitor for hypocalcemia
Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.

When should a surgeon be consulted for

the management of acute GI bleeding?
Early in evaluation and management
For severe or hemodynamically significant bleeding
Consult shouldnt delay initial interventions

Surgery indicated when

Life-threatening bleeding continues
Hemodynamic compromise despite resuscitation
Bleeding cant be stopped by endoscopy / angiography
Localization of site of bleeding critical for surgical planning
Surgery type also depends on presence of comorbidities
Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.

What instructions do patients require

following acute GI bleeding?
Signs and symptoms of recurrent bleeding
Benefit and duration of targeted therapies
Bleeding from
H. pylori: complete therapy; test for eradication d/c PPI if
eradicated unless NSAID or antiplatelet Rx needed
NSAID: discontinue NSAID if feasible
Low-dose aspirin Rx: resume after bleeding stops for
secondary prevention of established CV disease
Aspirin or clopidogrel for primary prevention of CV events:
weigh risks & benefits on individual basis
Dual antiplatelet Rx: PPI prophylaxis as long as antiplatelet Rx
indicated

Bleeding not associated with H. pylori, NSAID, or antiplatelet

agents: continue daily PPI indefinitely no good data

Copyright Annals of Internal Medicine, 2012

Ann Int Med. 157 (3): ITC2-1.

CLINICAL BOTTOM LINE: Treatment

Depends on cause and severity of bleeding
Initial evaluation and management in all cases should include:
History and physical examination
Stabilization interventions
Placement of IV access & IV fluid resuscitation
Emergent endoscopy (within 6 h) rarely indicated
Urgent endoscopy if variceal bleeding suspected
PPI for suspected PUD (but dont delay endoscopy)
Transfusion: target hemoglobin of 7-8 g/dL
Base outpatient follow-up on:
Establish etiology of bleeding
Estimated risk of re-bleeding

Copyright Annals of Internal Medicine, 2012

Ann Int Med. 157 (3): ITC2-1.