Gastrointestinal bleeding

Dr. Székely Hajnal

2nd Department of Internal
Medicine
2015/16-I
 Incidence
1-2% of all hospital admissions
One of the most common dg. of new
ICU admits
5-12% mortality
40% for recurrent bleeders
85% stop spontaneously
massive bleeding - urgent intervention
5-10% need operative intervention after
endoscopic interventions
 Definitions
Upper GI source - (proximal to DJ flexure)
esophagus, stomach, or proximal
duodenum
–Non-variceal bleeding
–Variceal bleeding

Mid-intestinal bleed – distal duodenum to

ileocecal valve

Lower intestinal bleed – colon / rectum

Stool color and origin/pace of bleeding
85% of all GI hemorrhage is upper
– Hematemesis, coffee ground vomit, melena
– UGI origin (can be SB, prox. colon origin if slow pace)
Degradation of hemoglobin to hematin by acid
Bowel bacteria and digestive enzymes contribute
– Hematochezia
– Spectrum: bright red blood, dark red, maroon
– colonic origin (UGI if brisk pace/large volume – 10%)
Guaiac positive stool
– Occult blood in stool - not informative of localization
– slow pace, low volume bleeding
Iron def. anaemia- very slow pace of bleeding
 History and physical examination
Aim : source - cause, severity, precipitating factors.
History Physical exam.
Localizing symptoms Vital signs, orthostatics
History of prior GIB Gen. appearance, mental
NSAID/aspirin/anticoag. status
Liver disease Abdominal tenderness
Vascular disease Skin, oral examination
Aortic valv. disease, Stigmata of liver disease
chronic renal failure Rectal examination
malignancy NG Tube findings (upper
Radiation exposure vs. lower g.i. source)
Family history of GIB Urine output
 Initial Assessment
severity + degree of hypovolemic shock
Class I Class II Class III Class IV
Blood loss 750 750-1500 1500-2000 >2000
(mL)
Blood < 15% 15-30% 30-40% >40%
volume
loss (%)
Heart rate <100 >100 >120 >140
SBP No change Orthostatic Reduced Very low,
change supine
Urine >30 20-30 10-20 <10
output
(mL/hr)
 Upper GI bleeding- UGIB
Crampy abdominal pain, hyperact. bowel sound
Large caliber NGT (?)
useful: severe hematochezia - UGIB vs. LGIB
– Red blood – high risk endoscopic lesion
– Coffee grounds – less severe/inactive bleeding
Neg. aspirate – 15-20% of patients with UGIB.
Can be used for lavage prior to endoscopy

Upper endoscopy indications –dg., progn.,

therapeutic.
Should be completed in 24hrs for HD stable
patients
Risk factors –poor outcome UGIB
Age over 60y
Shock
Malignancy
Variceal bleeding
Onset in hospital
Comorbid illness
Active bleeding
Recurrent bleeding
Severe coagulopathy
High risk: >5; mort:10-41%, rebl:24-40%
interm.:3-5; mort.:3-10%, rebl:11-24%
low:0-2; mort.:0-0.2%, rebl.:4-5%.
Takes priority over determining the
diagnosis/cause
ABC (main focus is ‘C’)
Takes priority over
determining the
diagnosis/cause
 Pre-endoscopic Pharmacotherapy
IV PPI: 80 mg bolus, 8 mg/hr drip for 72 h
– Rationale: suppress acid (pH>6), facilitate clot
formation and stabilization
– Duration: at least until EGD, then based on
findings
– Decreases need for endoscopic therapy
Octreotide - Used in variceal bleeding
Reduces the risk of continued non-varic. UGIB
NOT as primary th.- in patients with peristent
bleeding despite PPI, poor surgical patients
Diagnostic, prognostic, therapeurtic
Goal- treat the bleeding, prevent recurrent bleeding
 UGIB- sources

Peptic ulcer disease – DU+GU 50%

Varices – 10-20%
Gastritis – 10-25%
Mallory-weiss – 8-10%
Esophagitis – 3-5%
Malignancy – 3%
Dieulafoy’s lesion – 1-3%
Watermelon stomach – 1-2%
 Peptic ulcer hemorrhage
20% of PUD patients bleed at least once
H. pylori 40-50%, NSAID’s 40-50%
Other (Z-E syndrome)
Stress ulcer
Medical management
Anti-ulcer medication
H. pylori treatment
Stop NSAIDs
Follow up EGD for gastric ulcer in 6 weeks
 Minor Stigmata
Flat pigmented spot Clean base

Low rebleeding risk – no endoscopic

therapy needed
 Adherent Clot

Role of endoscopic
therapy -
controversial
Clot removal usually
attempted after inj.
Underlying lesion
can then be
assessed, treated if
necessary
 Endoscopic th.
High risk stigmata of recent hemorrh.
Inj+thermal coag. endoclip
 Post-endoscopy management
low risk ulcers – prompt feeding, oral PPI th.
ulcers requiring endoscopic th.-PPI iv (72 h.)
Determine H. pylori status
Discharge patients on PPI
duration dictated by
etiology and
need for NSAIDs/aspirin
CV disease on low dose aspirin:
restart as soon as
bleeding has resolved
 Peptic ulcer hemorrhage
Surgical intervention- 10% of patients
– Indications
–Failure of endoscopy
–Significant rebleeding after 1st endoscopy
–Ongoing transfusion requirement
–Need for >6 units over 24 hours
–Earlier for elderly, multiple co-morbidities
E.g. Under-running of ulcer (bleeding DU),
wedge excision of bleeding lesion (e.g. GU),
partial/total gastrectomy (malignancy)
Mallory Weiss tears -5% UGIB
Mucosal /submuc.
lacerations at the GEJ
History of recent
nonbloody vomiting +
excessive retching,
followed by haematemesis after alcohol intake
Endos: – tear at the GEJ
80-90% stops spontaneusly
Rebleeding – endos. electro-coagulation,
Angiographic embol. or surgical oversewing
Endos. hemostasis
Rebleeding-tatoo
Surgery – wedge resection
 Watermelon stomach -GAVE
Rows or stripes of ectatic mucosal blood
vessels
from the pylorus towards the antrum
Cause?
Older women,
end-stage renal disease
liver cirrhosis, scleroderma
Linear / diffuse angiomas
Endos. th.- APC
Surgery-antrectomy
 Upper GI malignancy
1% of severe, 3% of any UGIB
Bening (leiomyoma, stromal tu)
Malignant – primary or sec.
Large, ulcerated masses
Endos. hemostasis –temporal controll
Angiogr.+embilozation – severe UGIB
External beam radiation- palliative
hemostasis in cases of advanced disease
surgery
 Variceal Bleeding

Hep. ven. press. gradient > 12 mmHg

in 1/3 of patients with cirrhosis
1/3 initial bleeding episodes are fatal
1/3 will rebleed within 6 weeks (48-72)
Only 1/3 will survive 1 year or more
Mortality:15-50%-each episod
70-80% in cont. bleeding
1/3 causes of death due to liver cirrhosis
 Variceal Bleeding

Suspect in patients with history of chronic liver

disease/cirrhosis or stigmata on clinical exam.
Liver cirrhosis - portal hypertension - porto-
systemic anastamosis
Sites of porto-systemic anastamosis include:
Oesophagus
Umbilicus
Retroperitoneal
Rectal
+ clotting derrangement - worsens bleeding
Altered liver eznymes, bi., poor synth. function
 Variceal Bleeding -prognosis
closely related to severity of underlying chronic
liver disease (Childs-Pugh grading)

Mortality 32% Child A, 46% Child B, 79% Child C

 leed

Vasoconstrictor th.
Antibiotics
Resuscitation
ICU level care
Endoscopy
ALternative / rescue th.
Beta blockade
 asoconstrictor therapy
Goal: Reduce splanchnic blood flow
Terlipressin – only agent that improves
control of bleeding and survival
Vasopressin
Somatostatin
Octreotide (somatostatin analogue)
Efficacy is controversial;
Standard dose: 50 mcg bolus, then 50 mcg/hr
drip for 3-5 days

Beta-blockers- prevent rebleeding

Management – variceal bleeding
 ntibiotics

Bacterial infection - in up to 66% of

variceal bleed
Negative impact on hemostasis
(endogenous heparinoids)
Prophylactic AB reduces the incidence
of bacterial infection, early rebleeding

– Ceftriaxone 1 g IV QD x 5-7 days

– Alt: Norfloxacin 400 mg po BID
 esuscitation

Promptly but with caution

Goal = maintain HD stability, Hgb ~7-8,
CVP 4-8 mmHg
Avoid excessively rapid overexpansion
of volume; may increase portal
pressure, greater bleeding
 ndoscopy
as soon as possible
after resuscitation
(within 12 hours)
Endotracheal intubation
frequently needed
Band ligation is
preferred method
Acute hemostasis:
80-85%
Fewer complications
↓rebleeding, mortality
Endoscopic injection sclerotherapy
1-3 ml scler. agent
Effective
More complic.,
rebleed.,
more sessions,
higher mortality rate
 ternative/Rescue therapies
Very effective immediate,
Sengstaken-Blakemore Tube temporary control
(85-98%)
Up to 60% - rebleed. after
ballon deflation
High complication rate
(30%)– aspiration,
migration, necrosis +
perforation of esophagus
bridge to TIPS within 24 h.
Airway protection
strongly recommended
 eta blockade

↓risk for recurrent variceal hemorrhage

nonselective beta blocker (splanchnic
vasoconstriction, decrease cardiac output)
titrate up to maximum tolerated dose
(HR 50-60 / min.)
– Start as inpatient, once acute bleeding has
resolved and patient shows hemodynamic
stability
 Lower GI Bleeding - LGIB
arising from the colorectum /anus
20% of GIB, 15% of massive GIB
first consider possibility of UGIB (10-15%)
Intermittent
Less severe
Up to 42% -
multiple sites
Mean age:63-77y.
80% stops spont.
Mort::2-4%.
 Differential Diagnosis – LGIB
Diverticulosis Most common
diagnosis

Angiectasias
Hemorrhoids
Colitis (IBD, Infectious, Ischemic)
Neoplasm
Post-polypectomy bleed (up to 2 weeks)
Dieulafoy’s lesion
LGIB - etiology
Diverticulosis – 40-55%
– Right sided lesions > left
– 10% rebleed in 1st year and 25% at 4 years
– 90% stop spontaneously
Angiodysplasia – 3-20%
– Most common cause of SB bleeding in >50 y/o
– >50% are in right colon
Neoplasia
– Typically bleed slowly
Inflammatory conditions
– 15% of UC patients, 1% of chron’s patients
– Radiation, infectious, AIDS rarely
Vascular
Hemorrhoids
– >50% have hemorrhoids, but only 2% of bleeding attributed to them
Others meckel’s, polyps, solitary rectal ulcer, Dieulafoy’s lesion of the colon,
portal colopathy, NSAIDs, intussusception, or bleeding following colonoscopic
biopsy or polypectomy.
 LGIB - etiology
Colon Rectum Anus

Diverticular Disease Polyps Haemorrhoids

Polyps Malignancy Fissure

Malignancy Proctitis Malignancy

Colitis

Angiodysplasia
 LGIB - diagnostics
Evaluation
Same for UGIB bleed; If unstable – first EGD
After stable – Rectal exam., anoscopy for
hemorrhoids
Colonoscopy
Within 12 hours- in stable patients without massive
bleeding
Selective visceral angiography
Need >0.5 ml/min bleeding
40-75% sensitive if bleeding at time of exam
Tagged RBC scan
Can detect bleeding at 0.1 ml/min
85% sensitive if bleeding at time of exam
Not accurate in defining left vs right colon
 LGIB – Risk Stratification
Predictors of severe* LGIB:
 HR>100
 SBP<115 0 factors: ~6% risk
 Syncope
 nontender abdominal 1-3 factors: ~40%
examination
 bleeding during first 4 hours >3 factors: ~80%
of evaluation
 aspirin use
 >2 active comorbid conditions

*Defined as continued bleeding within first 24 hours (transfusion of 2+ Units, decline

in HCT of 20+%) and/or recurrent bleeding after 24 hours of stability
 Urgent Colonoscopy
Within 6-12 h.
rapid “purge” prep., colonoscopy performed
within 1 hour after clearance
bowel prep. + sedation - may affect the
unstable patient
Def. bleeding source identified more frequently
endoscopic th. - in 10-40% of patients
Evidence - colonoscopy should be performed
within 12-24 hours in stable patients
unclear if affects major clinical outcomes
 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 th. capability

Coordinate with IR so that positive scan is

followed closely by angiography
Angiography
Detects bl. rates of
0.5-1 ml/min
Th. capability – embolization
with microcoils, polyvinyl
alcohol, gelfoam
Complications: bowel
infarction, renal failure,
hematomas, thromboses,
dissection

Recommended for patients with brisk bleeding who cannot

be stabilized or prepped for colonoscopy
(or had colonoscopy with failure to localize/treat bleeding
site)
 Multi-Detector CT (CT angio)

Readily available
Can detect bl. 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
 Role of Surgery
Reserved for patients with life-threatening
bleed who failed other options
General indications: hypotension/shock
despite resuscitation, >6 U PRBCs
transfused
Preoperative localization of bleeding source
important
 LGIB - treatment
Emergency resuscitation - as described
Pharmacological
– Stop NSAIDS/anti-platelets/anti-coagulants if safe

Endoscopic
– OGD (15% have upper GI source!)
– Colonoscopy – dg. + th. (injection, diathermy, clipping)

Angiographic
– Selective embolization for poor surgical candidates
– Can lead to ischemic sites requiring later resection

Surgery
– Ongoing hemorrhage, >6 units or ongoing transfusion
requirement
 LGIB - treatment
Radiological
CT angiogram – diagnostic only (non-invasive)
Determines site and cause of bleeding

Mesenteric Angiogram – diagnostic and therepeutic

(but invasive)
Determines site of bleeding and allows embolisation of
bleeding vessel
Can result in colonic ischaemia

Nuclear Scintigraphy – technetium labelled red blood

cells: diagnostic only
Determines site of bleeding only (not cause)
 LGIB - treatment
Surgical – Last resort in management as very
difficult to determine bleeding point at
laparotomy
Segmental colectomy – where site of bleeding is
known
Subtotal colectomy – site of bleeding unclear
Beware of small bowel bleeding – always
embarassing when bleeding continues after
large bowel removed!
Algorithm: 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 stable?
positive
Algorithm: Evaluation of Patient with
Hematochezia

Active Lower GIB

Hemodynamically
stable?
No Yes

Angiography
Consider “urgent
(+/- Tagged RBC
colonoscopy” vs.
scan) /
traditional
Surgery if life-
approach
threatening
 Small intestinal bleeding-sources
Angioectasia 20–55%
Tumor 10–20%
Crohn’s disease 2–10%
NSAID enteropathy 5%
Coeliak dis. 2–5%
Meckel diverticulum 2–5%
Dieulafoy lesion 1–2%
Ectopic varices 1–2%
Portal hypert. enteropathy 1–2%
Irradiation enteritis <1%

Aliment Pharmacol Ther 2011; 34:416–423K. Liu* & A. J. Kaffes, Mussetto A et al. Dig Liv Dis. 45 (2013) 124– 128.
Small bowel endoscopy