Practical Approach to Acute

Gastrointestinal Bleeding

Komba
 Learning Objectives
• Upper Gastrointestinal Bleeding (UGIB)
– Nonvariceal (PUD) and variceal
– Initial evaluation, Resuscitation, risk assessment, pre-
endoscopy management
– Role of endoscopy
– Post-endoscopy management
• Lower Gastrointestinal Bleeding (LGIB)
– Risk assessment
– Role and timing of colonoscopy
– Non-endoscopic diagnostic and treatment options
 Definitions
• Upper GI bleed – arising
from the esophagus,
stomach, or proximal
duodenum
• Mid-intestinal bleed –
arising from distal
duodenum to ileocecal
valve
• Lower intestinal bleed –
arising from colon/rectum
Stool color and origin/pace of bleeding

• Guaiac positive stool

– Occult blood in stool
– Does not provide any localizing information
– Indicates slow pace, usually low volume bleeding
• Melena
– Very dark, tarry, pungent stool
– Usually suggestive of UGI origin (but can be small
intestinal, proximal colon origin if slow pace)
• Hematochezia
– Spectrum: bright red blood, dark red, maroon
– Usually suggestive of colonic origin (but can be UGI origin
if brisk pace/large volume)
 Differential Diagnosis – Upper GIB
• Gastroesophageal varices
• Peptic ulcer disease Most
common
• Erosive esophagitis/gastritis/duodenitis
• Mallory Weiss tear
• Vascular ectasia
• Neoplasm
• Dieulafoy’s lesion
Rare, but cannot
• Aortoenteric fistula afford to miss
• Hemobilia, hemosuccus pancreaticus
 Differential Diagnosis – Lower GIB
Most common
• Diverticulosis diagnosis
• Angioectasias
• Hemorrhoids
• Colitis (IBD, Infectious, Ischemic)
• Neoplasm
• Post-polypectomy bleed (up to 2 weeks after
procedure)
• Dieulafoy’s lesion
 History and Physical

History Physical Examination

• Localizing symptoms • Vital signs, orthostatics
• History of prior GIB • Abdominal tenderness
• NSAID/aspirin use • Skin, oral examination
• Liver disease/cirrhosis • Stigmata of liver disease
• Vascular disease • Rectal examination
• Aortic valvular disease, – Objective description of
stool/blood
chronic renal failure
– Assess for mass, hemorrhoids
• AAA repair
– No need for guaiac test
• Radiation exposure
• Family history of GIB
 History and Physical

History Physical Examination

• Localizing symptoms • Vital signs, orthostatics
• History of prior GIB • Abdominal tenderness
• NSAID/aspirin use • Skin, oral examination
• Liver disease/cirrhosis • Stigmata of liver disease
• Vascular disease • Rectal examination
• Aortic valvular disease, – Objective description of
stool/blood
chronic renal failure
– Assess for mass, hemorrhoids
• AAA repair
– No need for guaiac test
• Radiation exposure
• Family history of GIB
 Take Home Point # 1

Always get objective description of

stool

Avoid noninformative terms such as

“grossly guaiac positive”
 Utility of NG Tube
• Most useful situation: patients with severe
hematochezia, and unsure if UGIB vs. LGIB
– Positive aspirate (blood/coffee grounds) indicates
UGIB
• Can provide prognostic info:
– Red blood per NGT – predictive of high risk
endoscopic lesion
– Coffee grounds – less severe/inactive bleeding
• Negative aspirate – not as helpful; 15-20% of
patients with UGIB have negative NG aspirate
Ann Emerg Med 2004;43:525
Arch Intern Med 1990;150:1381
Gastrointest Endosc 2004;59:172
 Take Home Point #3

Upper GI bleed must still be

considered in patients with severe
hematochezia, even if NG aspirate
negative
 Initial Assessment
• Always remember to assess A,B,C’s
• Assess degree of hypovolemic shock
 Resuscitation
• IV access: large bore peripheral IVs best (alt:
cordis catheter)
• Use crystalloids first
• Anticipate need for blood transfusion
• Threshold should be based on underlying condition,
hemodynamic status, markers of tissue hypoxia
• Should be administered if Hgb ≤ 7 g/dL
• 1 U PRBC should raise Hgb by 1 (HCT by 3%)
• Remember that initial Hct can be misleading (Hct remains
the same with loss of whole blood, until re-equilibration
occurs)
• Correct coagulopathy
 Resuscitation
• IV access: large bore peripheral IVs best (alt:
cordis catheter)
• Use crystalloidsbleed
first Time
• Anticipate need for blood transfusion
IVFs
40%
• Threshold should be based
40% on underlying 20%
condition,
hemodynamic status, markers of tissue hypoxia
• Should be administered if Hgb ≤ 7 g/dL
• 1 U PRBC should raise Hgb by 1 (HCT by 3%)
• Remember that initial Hct can be misleading (Hct remains
the same with loss of whole blood, until re-equilibration
occurs)
• Correct coagulopathy
 Transfusion Strategy

• Randomized trial:
– 921 subjects with severe acute UGIB
– Restrictive (tx when Hgb<7; target 7-9) vs. Liberal
(tx when Hgb<9; target 9-11)
– Primary outcome: all cause mortality rate within
45 days

NEJM 2013;368;11-21
 Restrictive Strategy Superior
Restrictive Liberal P value
Mortality rate 5% 9% 0.02
Rate of further 10% 16% 0.01
bleeding
Overall 40% 48% 0.02
complication rate

Benefit seen primarily in

Child A/B cirrhotics

NEJM 2013;368;11-21
 Resuscitation
• IV access: large bore peripheral IVs best (alt:
cordis catheter) Weigh risks and benefits of
• Use crystalloids first reversing anticoagulation

• Anticipate need for blood transfusion

Assess degree of coagulopathy
• Threshold should be based on underlying condition,
hemodynamic status, markers ofVitamin K – slow acting, long-
tissue hypoxia
lived
• Should be administered if Hgb ≤ 7 g/dL
• 1 U PRBC should raise Hgb by 1 (HCT
FFP –byfast3%)
acting, short lived
• Remember that initial Hct can be misleading
- Give 1 U(Hct remains
FFP for every 4 U
the same with loss of whole blood, until re-equilibration
PRBCs
occurs)
• Correct coagulopathy
 Take Home Point #4

Early resuscitation and supportive

measures are critical to reduce
mortality from UGIB
 Risk Stratification

• Identify patients at high risk for adverse

outcomes
• Helps determine disposition (ICU vs. floor vs.
outpatient)
• May help guide appropriate timing of
endoscopy
 Rockall Scoring System
• Validated predictor of mortality in patients with
UGIB
• 2 components: clinical + endoscopic
Variable 0 1 2 3

Age <60 60-79 ≥ 80

Shock No Tachy- Hypotension-

SBP ≥ 100 SBP ≥ 100 SBP <100
P<100 P>100
Comorbidity No major Cardiac Renal failure,
failure, CAD, liver failure,
other major malignancy

Gut 1996;38:316
Clinical Rockall Score – Mortality Rates
 AIMS65

• Simple risk score that predicts in-hospital

mortality, LOS, cost in patients with acute
UGIB (applied within 12 hrs of adm)

Gastrointest Endosc 2011;74:1215

AIMS65

Gastrointest Endosc 2011;74:1215

 Blatchford Score
• Predicts need
for endoscopic
therapy
• Based on
readily available
clinical and lab
data
• Can use
UpToDate
calculator
Lancet 2000;356:1318
Pre-endoscopic Pharmacotherapy

• For Non-Variceal UGIB

– IV PPI: 80 mg bolus, 8 mg/hr drip
– Rationale: suppress acid, facilitate clot formation
and stabilization
– Duration: at least until EGD, then based on
findings
 Endoscopy - Nonvariceal UGIB
• Early endoscopy (within 24 hours) is
recommended for most patients with acute
UGIB
• Achieves prompt diagnosis, provides risk
stratification and hemostasis therapy in high-
risk patients

J Clin Gastroenterol 1996;22:267

Gastrointest Endosc 1999;49:145
Ann Intern Med 2010;152:101
Major Stigmata – Active Spurting

Kelsey, PB (Dec 04 2003). Duodenum - Ulcer, Arterial Spurting, Treated with Injection
and Clip. The DAVE Project. Retrieved Aug, 1, 2010, from
http://daveproject.org/viewfilms.cfm?film_id=39
Major Stigmata - NBVV
 Adherent Clot
• Role of endoscopic
therapy of ulcers with
adherent clot is
controversial
• Clot removal usually
attempted
• Underlying lesion can
then be assessed,
treated if necessary
 Minor Stigmata

Flat pigmented spot Clean base

Low rebleeding risk – no endoscopic therapy

needed
 Endoscopic Hemostasis Therapy
• Epinephrine injection
• Thermal electrocoagulation
• Mechanical (hemoclips)

• Combination therapy
superior to monotherapy

Kelsey, PB (Nov 08 2005). Stomach - Gastric Ulcer, Visible Vessel. The DAVE Project.
Retrieved Aug, 1, 2010, from http://daveproject.org/viewfilms.cfm?film_id=306

Baron, TH (May 01 2007). Duodenum - Bleeding Ulcer Treated with Thermal Therapy,
Perforation Closed with Hemoclips. The DAVE Project. Retrieved Aug, 1, 2010, from
http://daveproject.org/viewfilms.cfm?film_id=620
 Nonvariceal UGIB –
Post-endoscopy management
• Patients with low risk ulcers can be fed
promptly, put on oral PPI therapy.
• Patients with ulcers requiring endoscopic
therapy should receive PPI gtt x 72 hours
– Significantly reduces 30 day rebleeding rate vs
placebo (6.7% vs. 22.5%)
– Note: there may not be major advantage with
high dose over non-high dose PPI therapy

N Engl J Med 2000;343:310

Arch Intern Med 2010;170:751
 Nonvariceal UGIB –
Post-endoscopy management
• Determine H. pylori status in all ulcer patients
• Discharge patients on PPI (once to twice daily),
duration dictated by underlying etiology and
need for NSAIDs/aspirin
• In patients with cardiovascular disease on low
dose aspirin: restart as soon as bleeding has
resolved
– RCT demonstrates increased risk of rebleeding (10% v
5%) but decreased 30 day mortality (1.3% v 13%)
Ann Intern Med 2010;152:1
 Nonvariceal UGIB –
Post-endoscopy management
• Determine H. pylori status in all ulcer patients
• Discharge patients on PPI (once to twice daily),
duration dictated by underlying etiology and
need forNot
Not dying
dying is
is more
NSAIDs/aspirinmore important
important
than
than
• In patients with not
not rebleeding
rebleeding
cardiovascular disease on low
dose aspirin: restart as soon as bleeding has
resolved
– RCT demonstrates increased risk of rebleeding (10% v
5%) but decreased 30 day mortality (1.3% v 13%)
Ann Intern Med 2010;152:1
 Variceal Bleeding

• Occurs in 1/3 of patients with cirrhosis

• 1/3 initial bleeding episodes are fatal
• Among survivors, 1/3 will rebleed within 6
weeks
• Only 1/3 will survive
1 year or more
• Goal: Reduce splanchnic blood flow
• Terlipressin – only agent shown to improve control of
bleeding and survival in RCTs and meta-analysis
– Not available in US
• Vasopressin + nitroglycerine – too many adverse
effects
• Somatostatin – not available in US
• Octreotide (somatostatin analogue)
• Decreases splanchnic blood flow (variably)
• Efficacy is controversial; no proven mortality benefit
• Standard dose: 50 mcg bolus, then 50 mcg/hr drip for 3-5 days
Gastroenterology 2001;120:946
Cochrane Database Syst Rev 2008;16:CD000193
N Engl J Med 1995;333:555
Am J Gastroenterol 2009;104:617
• Bacterial infection occurs in up to 66% of
patients with cirrhosis and variceal bleed
• Negative impact on hemostasis (endogenous
heparinoids)
• Prophylactic antibiotics reduces incidence of
bacterial infection, significantly reduces early
rebleeding
– Ceftriaxone 1 g IV QD x 5-7 days
– Alt: Norfloxacin 400 mg po BID
Hepatology 2004;39:746
J Korean Med Sci 2006;21:883
Hepatogastroenterology 2004;51:541
• Promptly but with caution
• Goal = maintain hemodynamic stability, Hgb
~7-8, CVP 4-8 mmHg
• Avoid excessively rapid overexpansion of
volume; may increase portal pressure, greater
bleeding
• Should be performed as
soon as possible after
resuscitation (within 12
hours)
• Endotracheal intubation
frequently needed
• Band ligation is
preferred method
Layer, L. & Jaganmohan, S. & Raju, GS & DuPont, AW (Oct 28 2009). Esophagus -
Band Ligation of Actively Bleeding Gastroesophageal Varices. The DAVE Project.
Retrieved Aug, 2, 2010, from http://daveproject.org/viewfilms.cfm?film_id=715
• Reduces risk for recurrent variceal
hemorrhage
• Use nonselective beta blocker (e.g. Nadolol –
splanchnic vasoconstriction, decrease cardiac
output) and titrate up to maximum tolerated
dose, HR 50-60
– Start as inpatient, once acute bleeding has
resolved and patient shows hemodynamic
stability
•Lower GI Bleed
 Lower GI Bleed

• Bleeding arising from the colorectum

• In patients with severe hematochezia, first
consider possibility of UGIB
– 10-15% of patients with presumed LGIB are found
to have upper GIB
 Lower GI Bleed

• Differential Diagnosis
-- Diverticulosis
Diverticulosis (#(# 11 cause)
cause) Large volume, painless
-- Angioectasias
Angioectasias
-- Hemorrhoids
Hemorrhoids
-- Colitis
Colitis (IBD,
(IBD, Infectious, Ischemic) Smallerdiarrhea
Infectious, Ischemic) volume, pain,

-- Neoplasm
Neoplasm
-- Post-polypectomy
Post-polypectomy
-- Dieulafoy’s
Dieulafoy’s lesion
lesion
 LGIB – Risk Factors for Mortality
• Age
• Intestinal ischemia
• Comorbid illnesses

• Secondary bleeding (developed during admission

for a separate problem)
• Coagulopathy
• Hypovolemia
• Transfusion requirement
• Male gender
Clinical Gastro Hepatol 2008;6:1004
 Role of Colonoscopy
• Like UGIB, ~80% of LGIBs will resolve
spontaneously; of these, ~30% will rebleed
• Lack of standardized approach
– Traditional approach:
• elective colonoscopy after resolution of bleeding, bowel
prep – low therapeutic benefit
• Angiography for massive bleeding, hemodynamically
unstable patient
– Urgent colonoscopy approach
• Similar to UGIB – identify stigmata of hemorrhage, perform
therapy
 Radiographic Studies

Tagged RBC scan

• Noninvasive, highly
sensitive (0.05-0.1 ml/min)
• Ability to localize bleeding
source correctly only ~66%
• More accurate when
positive within 2 hours (95-
100%)
• Lacks therapeutic capability
Coordinate
Coordinate with
with IR
IR so
so that
that positive
positive scan
scan is
is
followed
followed closely
closely by
by angiography
angiography
 Radiographic Studies

Angiography
• Detects bleeding rates of
0.5-1 ml/min
Recommendedcapability –test
Recommended
• Therapeutic test for
for patients
patients with
with brisk
brisk
embolization
bleeding with who cannot be stabilized or
bleeding who cannot be stabilized or
microcoils, polyvinyl
alcohol, gelfoamprepped
prepped for for colonoscopy
colonoscopy
(or
(or have had
had colonoscopy
havebowel
• Complications: colonoscopy withwith failure
failure to
to
localize/treat
localize/treat
infarction, renal failure, bleeding
bleeding site)
site)
hematomas, thromboses,
dissection
 Radiographic Studies

Multi-Detector CT (CT angio)

• Readily available, can be performed in
ER within 10 minutes
• Can detect bleeding rate of 0.5 ml/min
• Can localize site of bleeding (must be
active) and provide info on etiology
• Useful in the actively bleeding but
hemodynamically stable patient

Gastrointest Endosc 2010;72:402

 Role of Surgery

• Reserved for patients with life-threatening

bleed who have failed other options
• General indications: hypotension/shock
despite resuscitation, >6 U PRBCs transfused
• Preoperative localization of bleeding source
important
 Algorithmic Evaluation of Patient
with Hematochezia
Hematochezia

Assess activity
of bleed
active inactive

Prep for
NG lavage
Colonoscopy

Positive Negative
No risk for UGIB
Risk for
UGIB
EGD
negative Hemodynamically
Treat lesion positive stable?
Algorithmic Evaluation of Patient
with Hematochezia
Active Lower GIB

Hemodynamically
stable?
No Yes

Angiography
(+/- Tagged RBC
Consider “urgent
scan)
colonoscopy” vs.
Or
traditional approach
Surgery if life-
threatening
 Take Home Points

• Always get objective description of stool color

(best way – examine it yourself)

• Don’t order guaiac tests on inpatients

• Severe hematochezia can be from UGIB, even

if NG lavage is negative
 Take Home Points

• All bleeding eventually stops (and majority of

nonvariceal bleeds will stop spontaneously,
with the patient alive)

• Early resuscitation and supportive care are key

to reducing morbidity and mortality from GIB