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Gastrointestinal Bleeding, Emergency Medicine

Basics

Description

- Gastritis and stress ulcerations: - Toxic agents (NSAIDs, alcohol, bile) - Mucosal hypoxia (trauma, burns, sepsis) - Cushing ulcers from severe CNS damage - Chemotherapy

- 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

- Colonoscopy: - Diagnostic only - Best after adequate bowel prep

- 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

- 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

- Emergent endoscopy - Therapeutic options: - Cauterization of bleeding ulcers/vessels - Endoscopic sclerotherapy

  • Bleeding from GI tract:Upper GI tract: Proximal to ligament of TreitzLower GI tract: Distal to ligament of Treitz to anus
  • Mortality rate:10% overall; from <5% in children up to 25% for adults of age >70Upper 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 infectionDrug-induced (NSAIDs, aspirin, glucocorticoids, K+ supplements, Fe supplements)Gastric or esophageal erosions (25%):Reflux esophagitisInfectious esophagitis (Candida, HSV, CMV)Pill-induced esophagitisEsophageal foreign bodyGastritis and stress ulcerations:Toxic agents (NSAIDs, alcohol, bile)Mucosal hypoxia (trauma, burns, sepsis)Cushing ulcers from severe CNS damageChemotherapy
  • 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 malformationsGastric 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 telangiectasiaAortocolonic fistula
  • Inflammatory bowel disease:Crohns disease and ulcerative colitis
  • Postpolypectomy
  • Anorectal (4%):Hemorrhoids (internal and external)Anal fissuresAnorectal varicesRectal ulcerForeign 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 emesisMelena: 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 appearanceSputum mixed with blood is likely pulmonarypH >7GI source:Dark red/brown blood, ± gastric contentsAssociated with nausea/vomitingpH <7
  • Consider nasogastric lavage:Might help determine if bleeding is ongoing and facilitate endoscopyControversialstudies have failed to demonstrate outcome benefit. False-negatives, if bleeding beyond pylorus.
  • Rectal exam:Inspect for hemorrhoids and anal fissuresExamine stool colorFalse-positive Hemoccult result:Raw red meatIron supplementsFruits: Cantaloupe, grapefruit, figsVegetables: Raw broccoli, cauliflower, radishMethylene blue, chlorophyllIodide, bromideFalse-negative Hemoccult result:BileMg-containing antacidsAscorbic acidAgents causing black stools, but negative Hemoccult:IronCharcoalBismuth (i.e., Pepto-Bismol)Food dyesBeets

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 onlyBest 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 airwayIntubate for massive UGIB, if patient unable to protect airway
  • Establish accessInsert large-bore IV (16-18g) and administer crystalloid to keep SBP >90 mm HgAttempt 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 necessaryTransfuse RBCs if significant anemia or unstable after crystalloid bolusesCross-matched or type-specific blood, if availableOtherwise, O negative for premenopausal women, O positive for othersProvide 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 RBCsFor 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/dLHemoglobin <10 g/dL when at increased risk of ischemia (e.g., CAD and CVA)Evidence of end-organ ischemiaOngoing chest pain/ischemic EKG changesUnstable vital signs despite crystalloid bolus

Avoid overtransfusion in variceal bleeding; it can precipitate further bleeding

  • UGIB treatmentIV proton pump inhibitor (PPI) (e.g., pantoprazole)Octreotide for suspected variceal bleedingConsider vasopressin for active variceal bleeding:Bleeding cessation benefits may be counterbalanced by increased mortality due to ischemiaAdminister with IV nitroglycerin to reduce tissue ischemiaHigh risk for active bleeding with 2 out of 3 risk factors:Bright blood from NGTHemoglobin <8 g/dLWBC >12,000/uLEmergent endoscopyTherapeutic options:Cauterization of bleeding ulcers/vesselsEndoscopic sclerotherapyBalloon tamponade with Blakemore tube is a last resort for varicesIn cirrhotics with UGIB prophylactic antibiotic use reduce bacterial infections and all cause mortality
  • LGIB treatmentConsider angiography for massive, active bleeding with directed vasopressin infusionConsider 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)