gastrointestinal hemorrhage
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Introduction
Bleeding from the gastrointestinal (GI) tract may be considered upper or lower GI hemorrhage (bleeding proximal or distal to the jejunum).
Etiology
- causes of obscure GI bleed
- proximal to the ligament of Trietz
- small bowel
- angioectasia (angiodysplasia)*
- Peutz-Jeghers syndrome
- Meckel diverticulum
- young adult, acute GI bleed otherwise asymptomatic, normal upper GI endoscopy
- hemangioma
- small intestinal malignancy
- hereditary hemorrhagic telangiectasia
- colon
- risk factors for nosocomial gastrointestinal bleeding
- age > 60 years
- male sex
- acute renal failure
- liver disease
- sepsis
- prophylactic anticoagulation
- combination of anticoagulants & antiplatelet agents[9]
- coagulopathy
- treatment on the medical service
* most common cause of obscure GI bleed[2]
Clinical manifestations
- postural hypotension suggests moderate bleeding (10-20% of circulating volume)
- supine hypotension suggests severe bleeding (> 20% of circulating volume)
- hematemesis suggests upper GI bleed
- melena suggests bleeding proximal to the cecum
- bright red blood per rectum suggests an anorectal or left colon bleed
- maroon-colored stool suggests a right colon or distal cecum bleed
Laboratory
- type & screen (cross-match if transfusion is indicated)
- complete blood count (CBC)
- hemoglobin & hematocrit are poor indicators of acute blood loss
- platelets
- PT/aPTT
- serum chemistries
Diagnostic procedures
- upper GI endoscopy &/or lower GI endoscopy
- capsule endoscopy
- repeat GI endoscopy with biopsies recommended prior to capsule endoscopy[2]
- not so according[16]
- double ballon enteroscopy only for treating identified lesions[16]
- push enteroscopy is third line
- offers opportunity for therapeutic intevention[2]
- electrocardiogram in elderly patients
Radiology
- technetium labeled nuclear scan (scintigraphy) provides the best sensitivity for actively bleeding lesion not detected by upper GI endoscopy &/or lower GI endoscopy or capsule endoscopy[2]
Complications
risk factors for increased morbidity & mortality
- age > 60 years
- more than 1 comorbidity
- severe blood loss (> 5 units)
- hemodynamic instability
- bright red hematemesis with hypotension
- multisystem failure
- variceal bleeding
- peptic ulceration (> 2 cm)
- recurrent hemorrhage (within 72 hours)
- emergency surgery
- weekend hemorrhage[11]
- lack of endoscopy services on the weekend may be linked an increase in mortality in patients with non-variceal upper gastrointestinal hemorrhage[11]
Management
- assessment & restoration of hemodynamic stability
- two large bore intravenous (IV) catheters (14-18 gauge), central venous catheter adds no additional benefit
- normal saline or lactated ringers to restore volume
- urine output is best measure of adequate fluid replacement
- hetastarch 5% (Hespan) until blood products available
- transfusion therapy
- packed red blood cells (RBC) to maintain hematocrit> 25% or > 30% in patients with cardiopulmonary disease
- correct coagulopathy with fresh frozen plasma (FFP)
- thrombocytopenia (platelets < 40,000/mm3) should be corrected with platelet transfusions or with therapy directed at the cause of the thrombocytopenia
- platelet transfusion not indicated for GI bleed associated with antiplatelet therapy[10]
- increased mortality, no reduction of risk for rebleed
- platelet transfusion not indicated for GI bleed associated with antiplatelet therapy[10]
- massive transfusion (> 6 units)
- blood warming
- monitor for hypocalcemia from citrate in blood products
- nasogastric tube placement
- aspiration of gastric contents to confirm upper GI bleed
- gastric lavage with normal saline
- coffee ground-like material, strong + occult blood
- false negatives with: intermittent bleeding, duodenal bleed without reflux to stomach
- use of iced saline or norepinephrine of no value
- gastric lavage increases likelihood of early endoscopy but not better patient outcomes[3]
- digital rectal examination or anoscopy: masses, hemorrhoids, gross or occult blood, melena
- specific measures to control bleeding
- specific measures for comorbidities
- restarting anti-platelet therapy &/or anticoagulation within 7 days is reasonable (benefits seem to outweigh risks) [14[
- also see algorithm for management of GI bleed
More general terms
More specific terms
- lower gastrointestinal hemorrhage
- small bowel gastrointestinal hemorrhage
- upper gastrointestinal hemorrhage
References
- ↑ Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 346-348
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2006, 2012, 2015, 2018.
- ↑ 3.0 3.1 Huang ES et al. Impact of nasogastric lavage on outcomes in acute GI bleeding. Gastrointest Endosc 2011 Nov; 74:971. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21737077
Pallin DJ and Saltzman JR. Is nasogastric lavage in patients with acute upper GI bleeding indicated or antiquated? Gastrointest Endosc 2011 Nov; 74:981. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22032314 - ↑ Herzig SJ et al Risk Factirs for Nosocomial Gastrointestinal Bleeding and Use of Acid-Suppressive Medication in Non-Critically Ill Patients. J Gen Intern Med. Jan 2013 http://link.springer.com/content/pdf/10.1007%2Fs11606-012-2296-x
- ↑ ASGE Standards of Practice Committee, Fisher L, Lee Krinsky M, Anderson MA et al The role of endoscopy in the management of obscure GI bleeding. Gastrointest Endosc. 2010 Sep;72(3):471-9. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20801285 corresponding NGC guideline withdrawn Dec 2015
- ↑ de Leusse A, Vahedi K, Edery J et al Capsule endoscopy or push enteroscopy for first-line exploration of obscure gastrointestinal bleeding? Gastroenterology. 2007 Mar;132(3):855-62 PMID: https://www.ncbi.nlm.nih.gov/pubmed/17324401
- ↑ Raju GS, Gerson L, Das A et al American Gastroenterological Association (AGA) Institute technical review on obscure gastrointestinal bleeding. Gastroenterology. 2007 Nov;133(5):1697-717. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17983812
- ↑ Shinozaki S, Yamamoto H, Yano T et al Long-term outcome of patients with obscure gastrointestinal bleeding investigated by double-balloon endoscopy. Clin Gastroenterol Hepatol. 2010 Feb;8(2):151-8 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19879968
- ↑ 9.0 9.1 Abraham NS et al. Risk of lower and upper gastrointestinal bleeding, transfusions, and hospitalizations with complex antithrombotic therapy in elderly patients. Circulation 2013 Sep 11 PMID: https://www.ncbi.nlm.nih.gov/pubmed/24025594
- ↑ 10.0 10.1 Zakko L, Rustagi T, Douglas M, Laine L. No benefit from platelet transfusion for gastrointestinal bleeding in patients taking antiplatelet agents. Clin Gastroenterol Hepatol 2016 Jul 24; PMID: https://www.ncbi.nlm.nih.gov/pubmed/27464591
- ↑ 11.0 11.1 11.2 Bachert A Weekends May Be Worse for GI Bleeding Death. Disadvantage with non-variceal hemorrhage, lack of weekend rounder. https://www.medpagetoday.com/MeetingCoverage/ACG/68637
Gupta A et al Weekend effect in patients with upper gastrointestinal hemorrhage: a systematic review and meta-analysis World Congress of Gastroenterology at ACG 2017; Oral Abstract 29. - ↑ Abraham NS. Management of Antiplatelet Agents and Anticoagulants in Patients with Gastrointestinal Bleeding. Gastrointest Endosc Clin N Am. 2015 Jul;25(3):449-62. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26142031
- ↑ Singh M, Koyfman A, Martinez JP. Abdominal Vascular Catastrophes. Emerg Med Clin North Am. 2016 May;34(2):327-39. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/27133247
- ↑ Sostres C, Marcen B, Laredo V et al Risk of rebleeding, vascular events and death after gastrointestinal bleeding in anticoagulant and/or antiplatelet users. Aliment Pharmacol Ther. 2019 Sep 4. doi:http://dx.doi.org/ 10.1111/apt.15441. [Epub ahead of print] PMID: https://www.ncbi.nlm.nih.gov/pubmed/31486121
- ↑ Brito HP, Ribeiro IB, Moura DTH de et al. Video capsule endoscopy vs double-balloon enteroscopy in the diagnosis of small bowel bleeding: a systematic review and meta-analysis . World J Gastrointest Endosc. 2018;10(12):400-421 PMID: https://www.ncbi.nlm.nih.gov/pubmed/30631404 PMCID: PMC6323498 Free PMC article https://www.wjgnet.com/1948-5190/full/v10/i12/400.htm
- ↑ 16.0 16.1 16.2 NEJM Knowledge+ Gastroenterology
- ↑ Abraham NS, Barkun AN, Sauer BG, et al. American College of Gastroenterology-Canadian Association of Gastroenterology clinical practice guideline: management of anticoagulants and antiplatelets during acute gastrointestinal bleeding and the periendoscopic period. Am J Gastroenterol. 2022;117:542-558. PMID: https://www.ncbi.nlm.nih.gov/pubmed/35297395
- ↑ Sengupta N et al. The role of imaging for gastrointestinal bleeding: Consensus recommendations from the American College of Gastroenterology and Society of Abdominal Radiology. Am J Gastroenterol 2024 Mar; 119:438. Not yet indexed in PubMed https://journals.lww.com/ajg/fulltext/2024/03000/the_role_of_imaging_for_gastrointestinal_bleeding_.15.aspx
Sengupta N, Kastenberg DM, Bruining DH et al The Role of Imaging for GI Bleeding: ACG and SAR Consensus Recommendations. Radiology. 2024 Mar;310(3):e232298. PMID: https://www.ncbi.nlm.nih.gov/pubmed/38441091 Review.