Basics
Description
- Bleeding from GI tract:
- Upper GI tract: Proximal to ligament of Treitz
- Lower GI tract: Distal to ligament of Treitz to anus
- Mortality rate:
- 10% overall; from <5% in children up to 25% for adults of age >70
- Upper GI bleed (UGIB) 6-8%; variceal 30-50%
- Lower GI bleed (LGIB) 2-4%
Etiology
Upper GI Bleed (UGIB):
- Ulcerative disease of upper GI tract:
- Peptic ulcer disease (40%):
- Helicobacter pylori infection
- Drug-induced (NSAIDs, aspirin, glucocorticoids, K+ supplements, Fe supplements)
- Gastric or esophageal erosions (25%):
- Reflux esophagitis
- Infectious esophagitis (Candida, HSV, CMV)
- Pill-induced esophagitis
- Esophageal foreign body
- Gastritis and stress ulcerations:
- Toxic agents (NSAIDs, alcohol, bile)
- Mucosal hypoxia (trauma, burns, sepsis)
- Cushing ulcers from severe CNS damage
- Chemotherapy
- Portal HTN:
- Esophageal or gastric varices (10%)
- Portal hypertensive gastropathy
- Arteriovenous malformations:
- Aortoenteric fistula (s/p aortoiliac surgery)
- Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)
- Dieulafoy vascular malformations
- Gastric antral vascular ectasia (GAVE or watermelon stomach)
- Idiopathic angiomas
- Mallory-Weiss tear (5%)
- Gastric and esophageal tumors
- Pancreatic hemorrhage
- Hemobilia
- Strongyloides stercoralis infection
Lower GI Bleed (LGIB):
- Diverticulosis (33%)
- Cancer or polyps (19%)
- Colitis (18%):
- Ischemic, inflammatory, infectious, or radiation
- Vascular:
- Angiodysplasia (8%)
- Radiation telangiectasia
- Aortocolonic fistula
- Inflammatory bowel disease:
- Crohns disease and ulcerative colitis
- Postpolypectomy
- Anorectal (4%):
- Hemorrhoids (internal and external)
- Anal fissures
- Anorectal varices
- Rectal ulcer
- Foreign body
Meckel diverticulum and intussusception are the most common causes of LGIB in children.
Diagnosis
Signs and Symptoms
- Both UGIB and LGIB may present with signs/symptoms of hypovolemia
- UGIB classic presentation:
- Hematemesis or coffee ground emesis
- Melena: Black tarry stool
- LGIB classic presentation:
- Hematochezia: Bright red or maroon stool
Hematochezia classically signals an LGIB, but can also be seen with brisk UGIB.
History
- Hematemesis and melena most common
- Coffee ground emesis
- Black stools
- Bright red blood per rectum
- Abdominal pain
- Weakness or lightheadedness
- Dyspnea
- Confusion or agitation
Physical Exam
- Tachycardia
- Hypotension
- Pale conjunctiva
- Dry mucous membranes
- Bloody, melanotic, or heme-positive stools
- Shock
Essential Workup
- CBC, coagulation studies, electrolytes
- Perform ENT exam. Distinguish between hemoptysis and hematemesis:
- Pulmonary source:
- Bright red and frothy in appearance
- Sputum mixed with blood is likely pulmonary
- pH >7
- GI source:
- Dark red/brown blood, ± gastric contents
- Associated with nausea/vomiting
- pH <7
- Consider nasogastric lavage:
- Might help determine if bleeding is ongoing and facilitate endoscopy
- Controversialstudies have failed to demonstrate outcome benefit. False-negatives, if bleeding beyond pylorus.
- Rectal exam:
- Inspect for hemorrhoids and anal fissures
- Examine stool color
- False-positive Hemoccult result:
- Raw red meat
- Iron supplements
- Fruits: Cantaloupe, grapefruit, figs
- Vegetables: Raw broccoli, cauliflower, radish
- Methylene blue, chlorophyll
- Iodide, bromide
- False-negative Hemoccult result:
- Bile
- Mg-containing antacids
- Ascorbic acid
- Agents causing black stools, but negative Hemoccult:
- Iron
- Charcoal
- Bismuth (i.e., Pepto-Bismol)
- Food dyes
- Beets
Bloody stool in newborns may be caused by the infant swallowing maternal blood.
Diagnosis Tests & Interpretation
Lab
- CBC:
- Anemia (low mean corpuscular volume seen with chronic blood loss)
- Thrombocytopenia
- Electrolytes, BUN, creatinine, glucose
- Coagulation profile
- Lactate
- LFTs, if upper GI bleeding suspected
- Type and screen/cross for active bleeding or unstable vital signs
- BUN/Cr ratio >36 has a high sensitivity but low specificity for UGIB
Hematocrit can remain normal for a period after acute blood loss; a drop may not be immediately seen.
Imaging
- Upright CXR if concern for aspiration or perforation
- Angiography/arterial embolization:
- Effective for identifying large, active bleeding
- Radionucleotide (tagged red blood cell) scan:
- Effective for identifying slow, active bleeding
Diagnostic Procedures/Surgery
- Anoscopy:
- For suspected internal hemorrhoids or fissures
- Esophagogastroduodenoscopy (EGD):
- Diagnostic and possibly therapeutic
- Colonoscopy:
- Diagnostic only
- Best after adequate bowel prep
- Bowel resection:
- Reserved for refractory bleeding
Differential Diagnosis
- Epistaxis
- Oropharyngeal bleeding
- Hemoptysis
- Hematuria
- Vaginal bleeding
- Visceral trauma
Treatment
Pre-Hospital
- Stabilize airway
- Intubate for massive UGIB, if patient unable to protect airway
- Establish access
- Insert large-bore IV (16-18g) and administer crystalloid to keep SBP >90 mm Hg
- Attempt 2nd IV line en route to hospital
Initial Stabilization/Therapy
- Assess airway, breathing, and circulation
- Control airway in unstable patients, with massive bleeding, or unable to protect airway
- Initiate 2 large-bore (16 g) IVs and place on cardiac monitor
- Provide volume:
- Administer 1 L NS bolus (peds: 20 mL/kg) and repeat once, if necessary
- Transfuse RBCs if significant anemia or unstable after crystalloid boluses
- Cross-matched or type-specific blood, if available
- Otherwise, O negative for premenopausal women, O positive for others
- Provide fresh frozen plasma (FFP) along with RBC transfusion in ratio of 1:2-4. For patients requiring massive transfusion, consider adding FFP and platelets in 1:1:1 ratio with RBCs
- For coagulopathy, administer FFP and vitamin K (if INR >1.5) and platelets (if platelets <50,000/uL)
Ed Treatment/Procedures
- Consult gastroenterology for any significant GI bleeding
- Consider surgical consult and/or interventional radiology for massive active bleeding, unstable patient, or evidence of perforation
- Place Foley catheter to monitor urine output
- Consider nasogastric tube (NGT), as above
- Blood transfusion indications:
- Significant anemia:
- Hemoglobin <7 g/dL
- Hemoglobin <10 g/dL when at increased risk of ischemia (e.g., CAD and CVA)
- Evidence of end-organ ischemia
- Ongoing chest pain/ischemic EKG changes
- Unstable vital signs despite crystalloid bolus
Avoid overtransfusion in variceal bleeding; it can precipitate further bleeding
- UGIB treatment
- IV proton pump inhibitor (PPI) (e.g., pantoprazole)
- Octreotide for suspected variceal bleeding
- Consider vasopressin for active variceal bleeding:
- Bleeding cessation benefits may be counterbalanced by increased mortality due to ischemia
- Administer with IV nitroglycerin to reduce tissue ischemia
- High risk for active bleeding with 2 out of 3 risk factors:
- Bright blood from NGT
- Hemoglobin <8 g/dL
- WBC >12,000/uL
- Emergent endoscopy
- Therapeutic options:
- Cauterization of bleeding ulcers/vessels
- Endoscopic sclerotherapy
- Balloon tamponade with Blakemore tube is a last resort for varices
- In cirrhotics with UGIB prophylactic antibiotic use reduce bacterial infections and all cause mortality
- LGIB treatment
- Consider angiography for massive, active bleeding with directed vasopressin infusion
- Consider bowel resection for massive bleeding refractory to medical management
Medication
- Pantoprazole: 80 mg (peds: Dosing not approved) IV bolus followed by an infusion of 8 mg/h for 72 hr
- Octreotide: 50 μg (peds: 1-2 μg/kg) bolus, then 50 μg/h (peds: 1-2 μg/kg/h) IV
- Somatostatin: 250 μg (peds: Not established) IV bolus and 250-500 μg/h for 2-5 days (not available in US)
- Vasopressin: 0.4-1 IU/min (peds: 0.002-0.005 IU/kg/min) IV
- Nitroglycerin: 10-50 μg/min (peds: Not established) IV
- Vitamin K: 10 mg (peds: 1-5 mg) PO/SC/IV q24h
Follow-Up
Disposition
Admission Criteria
- Active bleeding
- Age >65 or comorbid conditions
- Coagulopathy
- Decreased hematocrit
- Unstable vital signs at any time
Discharge Criteria
- Resolution of UGIB with negative nasogastric lavage and EGD
- Minor or resolved LGIB
- Stable hematocrit >30 or hemoglobin >10 g/dL
- Otherwise healthy patient
Issues for Referral
Consider referral to gastroenterologist for outpatient colonoscopy and/or EGD
Follow-Up Recommendations
- Patients discharged from the ED should have close follow-up within 24-36 hr
- Give strict discharge instructions to return if further bleeding or other concerning symptoms (lightheadedness, dyspnea, chest pain, etc.) occur
- Patients with UGIB should be discharged on a PPI, and advised to avoid caffeine, alcohol, tobacco, NSAIDs, and aspirin
Pearls and Pitfalls
- 10-15% of UGIB present with hematochezia
- Consider GIB in patients presenting with signs of hypovolemia or hypovolemic shock
- Common pitfall: Failure to adequately resuscitate with crystalloid and blood products
PUD is the predominant cause of GIB in elderly and has a higher associated mortality.
Additional Reading
- Das AM, Sood N, Hodgin K, et al. Development of a triage protocol for patients presenting with gastrointestinal hemorrhage: A prospective cohort study. Crit Care. 2008;12:R57.
- Gralnek IM, Barkun AN, Bardou M. Management of acute bleeding from a peptic ulcer. N Engl J Med. 2008;359(9):928-937.
- Johansson PI, Stensballe J. Hemostatic resuscitation for massive bleeding: The paradigm of plasma and platelets-a review of the current literature. Transfusion. 2010;50(3):701-710.
- Pallin DJ, Saltzman JR. Is nasogastric tube lavage in patients with acute upper GI bleeding indicated or antiquated? Gastrointest Endosc. 2011;74(5):981-984.
- Wolfson AB, Hendey GW, Ling LJ, et al., eds. Harwood-Nuss' Clinical Practice of Emergency Medicine. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009.
Codes
ICD9
- 533.40 Chronic or unspecified peptic ulcer of unspecified site with hemorrhage, without mention of obstruction
- 535.51 Unspecified gastritis and gastroduodenitis, with hemorrhage
- 578.9 Hemorrhage of gastrointestinal tract, unspecified
- 562.12 Diverticulosis of colon with hemorrhage
- 537.83 Angiodysplasia of stomach and duodenum with hemorrhage
- 578.0 Hematemesis
- 578.1 Blood in stool
ICD10
- K27.4 Chronic or unsp peptic ulcer, site unsp, with hemorrhage
- K29.71 Gastritis, unspecified, with bleeding
- K92.2 Gastrointestinal hemorrhage, unspecified
- K57.31 Dvrtclos of lg int w/o perforation or abscess w bleeding
- K31.811 Angiodysplasia of stomach and duodenum with bleeding
- K92.0 Hematemesis
- K92.1 Melena
SNOMED
- 74474003 Gastrointestinal hemorrhage (disorder)
- 64121000 peptic ulcer with hemorrhage (disorder)
- 2367005 Acute hemorrhagic gastritis (disorder)
- 197092000 Bleeding diverticulosis (disorder)
- 235224000 Hemorrhagic enteritis (disorder)
- 37372002 Upper gastrointestinal hemorrhage (disorder)
- 43935004 Vascular ectasia of gastric antrum (disorder)
- 8765009 Hematemesis (disorder)
- 87763006 lower gastrointestinal hemorrhage (disorder)