GI Bleeding

Upper GI Bleeding

• Most common
• Defined as: Intraluminal blood proximal to ligament of Treitz
• Causes 500,000 hospital admissions, mortality 5-10%, 80% stop spontaneously.
  • Continued bleed or re-bleed are at high risk of death.
• High Risk Features:
  • Advanced age, variceal bleeding, comorbid conditions (organ failure or disseminated malignancy), shock, hematemesis
  • Increasing number of erythrocyte transfusions, active bleeding, and a visible vessel or clot in an ulcer base on endoscopy​
• Causes:

• History
  • Focus on history/physical to find origin of bleeding.
  • (See "overview" for basic concepts)
  • Some specific helpful historic Featurs:

  • History	Type Suggested
    Hematemesis	Variceal bleed?
    Coffee Ground Emesis	Gastritis or PUD
    Hx of PUD, NSAID use , EtOH	PUD
    Liver Disease	Variceal Bleed
    Hx of pancreatitis	Pseudoaneurism Bleed
    Chronic GERD	Esophagitis
    Aortic Endovascular Stent	Aorto-enteric fistula
    Biliary manipulation (ERCP/Tips/LiverBx)	Hemobilia
    Radiation Therapy	Radiation-related GI Bleed

• Physical Exam
  • Ruotine + ORTHOSTATIC vital signs. (supine + standing or sitting pulse and BP)
    • Orthostasis: Large volume bleeding even when ruotine vitals are normal.
  • Tachycardia: 15-30% blood loss
  • Hypotension: >30% blood loss
  • Other things to look for:
    • Chronic liver disease  (Scleral icterus, spider angiomata, gynecomastia, ascites, etc..)
• Labs:
  • CBC, INR, BUN, Serum Creat
  • Hb or Hct are NOT accurate measure of blood loss acutely, but help transfusion decisions.
  • Macrocytosis + elevated INR --> clues for liver disease.
  • Microcytosis --> chronic bleed.
  • Elevated BUN to creat ratio --> upper GI source (blood protein absorbed proximally making urea)

• Prognostic Scoring Systems (not used)

  • Blatchford Score: Predict patients with UGIB who can be managed as outpatients if all are present:
    • BUN less than 18 mg/dL (6.4 mmol/L); normal Hb; sBP > 109 mm Hg; HR < 100/min;
    • and absence of melena, syncope, and hepatic and cardiac disease.
  • Rockall Score (pre-endoscopic and complete versions)
• Management:
  • Distinguish Variceal vs. Non-Variceal
  • Initial Management:
    • Protect airway
    • Two large bore IV catheters
    • Resuscitation with IV crystalloids and pRBC infusions.
    • Continuous Hb and Hct monitoring (Hb <70 g/L = absolute indication for RBC transfusions)
    • If INR supratheraputic --> FFP
      • Guidelines: Weigh risk of continued anticoag with benefits.
      • Guidelines: Endoscopy SHOULD NOT be delayed for anticoagulation reversal, unless INR > 3.
    • Other Management Notes:
      • NG tubes NOT ROUTINELY recommended.
      • Promotility Agents (Erythromycin/Metaclopramide) NOT ROUTINELY recommended
        • (did not alter RBC transfusion, surgery, or hosp stay, slightly improved visiblity at endoscopy and decr. need for repeat endoscopy)
  • Non-Variceal Bleed:
    • IV PPI started before endoscopy
    • Endoscopy in 24hrs (once hemodynamically stable) - Non-Variceal Bleeds
  • Variceal Bleeding
    • Antibiotics (Prevent infection complications)
    • Octreotide (Reduces splanchnic blood flow, transiently decr. variceal pressure)
    • Endoscopy in 12hrs (once hemodynamically stable)- Variceal bleeds

Lower GI Bleeding

• Distal to the ligament of Treitz - typically colon and anorectum.
• Presents as bright red blood per rectum (BRBPR) or red/maroon colored stools (hematochezia).
• Usually acute in onset without pain.
• Clinical Features:
  • Anemia, (rarely hemodynamically unstable).
  • If hypotensive, consider brisk bleed, or brisk upper GI bleed.
• Risk:
  • Increases in age, usually 7th-8th decade of life.
• Causes:
  • 
• Figure and data adapted/reprinted from Savides TJ, Jensen DM. Gastrointestinal bleeding. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. Volume 1. 9th ed. Philadelphia: Saunders Elsevier, 2010:285-322. AND Reprinted/adapted from Clinical Gastroenterology and Hepatology. 6(9). Strate LL, Ayanian JZ, Kotler G, Syngal S. Risk factors for mortality in lower intestinal bleeding. 1004-1010. PMID: 18558513

• Cause of bleed	Notes
  Diverticulosis (Most Common)	Actually pseudodiverticula (outpouching between muscle fibers). Increased intraluminal pressure causes outpouching of colonic mucosa+submucosa through muscular wall  (at points of weakness in colon wall) Occur at sites of entry of "vasa recta" (small arteries). Can bleed at the base of diverticular neck. Most common in L colon, but R-sided are more likely to bleed. 5-10% of pts with diverticulosis experience bleeding at some point.
  Internal Hemorrhoids (2nd Most Common)	- Bright red blood on outside of the stool, toilet paper, or toilet bowl. - Occasionally very large volumes and clots.
  Post-colonoscopy (w/ polypetctomy) bleeding - 13% of lower GI bleeds!	- Can happen immediatley after procedure or days later from colonic ulceration due to electrocautery.
  Angioectasias Aka Angiodysplasia	- NOT arteriovenous malformations - frequency increases with age - Can be easily missed on colonoscopy

Obscure GI Bleeding

• Defined as: Recurrent bleeding without defined source following standard upper endoscopy and colonoscopy.
  • "Overt Bleeding" -->  If blood/melena present:
  • "Occult Bleeding" --> Clinically suspected without overt blood lost (anemia of FOBT)
• 5% of GI bleeds.
• Causes of Obscure/Overt Bleeding:
  • Angioectasias
  • Cameron erosions (if large hiatal hernia)
  • NSAID-induced ulcers
  • Malignancy
• Causes of Obscure/Occult Bleeding:
  • Angioectasias
  • Dieulafoy Lesions
  • Colonic Diverticula
  • Meckel Diverticula

Causes of Obscure Gastrointestinal Bleeding

• Source: MKSAP16

• Evalutation:
  • Should undergo repeat upper or lower scope (depending on suspected site)
    • 30-50% of lesions detected on repeat endoscopy.
    • If site of bleeding not known... then do secondary tests (below):
  • Capsule Endoscopy is the first-line test for repeated negative endoscopy

• Technique	Notes
  Angiography   (For Active Bleeding)	- Only in ACTIVE OVERT bleeding (requires a bleeding rate >1mL/min) - Esp works if hemodynamically unstable. - Allows for embolization immediately - 40% sensitivity, operator dependent. - Complications: AKI, organ necrosis, vascular dissection/aneurism.
  Technetium-Labeled Nuclear Scan   (For Active Bleeding)	- Best sensitivity for ACTIVE bleeding (requiers bleed 01-0.5mL/min)   (more sensitive than angiography, often first test performed) - Uses Tc99m-labeled RBCs - Non-specific (often do not show specific site or intervention) Two types of scans   1. Tc99m pertechnetate RBC   2. Tc99m surfur colloid   - RBC scanning positive in 45% of pts with active bleed, 78% accurate for localizing bleed.
  Wireless Capsule Endoscopy (NEW!)   (Active Bleed Not Required)	- NEW: Excellent visualization of small bowel. - Effective even if absence of active bleeding (50-75% find bleed) - Complication: Capsules can get stuck at small bowel tumors or stenosis. - Generally replaced push enteroscopy as test of choice in occult bleeding
  Push Enteroscopy   (For therapy/diagnosis)	- Performed with dedicated enteroscope or pediatric colonoscope.      - See distal jejunum/duodenum....      - Allows visualization up to 80cm beyond ligament of Treitz - Now less often (use wireless capsule endoscopy) - Allows for intervention (i.e. coagulation of angiodysplasias) Compilcations: RARE, perforation, mucosal evulsion, bleeding.
  Spiral Enteroscopy (NEW!)	- NEW technique for deep bowel scoping - Spiral-shaped overtube that fits over a standard colono/enteroscope.    Using "corkscrew" motion allow deep visualization into jejunum and ilium. - Can deliver intervention (also useful for ERCP post Roux-en-Y) - No comparison data with capsule/push endoscopy. Complications: perforation (increased torque on bowel)
  Single and Double-Balloon Enteroscopy	- Simliar to spinal endoscopy to see small bowel. - Latex balloons on overtube to deliver enteroscope into small bowel by    inflating/deflating balloons - Can be given orally and rectally for diagnosis and therapy. Complications: perforation and bleeding via bowel avulsion. Contraindications: radiation enteritis, severe ulceration, recent bowel surgery
  Small-Bowel Radiography (Rarely Done)	- Small bowel barium studies and enteroclysis (small bowel barium enema)    not first line - Can see luminal masses, diverticula, but cannot asses other (angioectasias etc.)
  Intraoperative Endoscopy	- Last Resort for life threatening bleeding - Laparotomy or laparoscopy + colonoscopy. - Rarely done, yield is low (25%)

• Treatment:
  • Depends on source and site of pathology.
  • Surgery for:
    • luminal tumors
    • Focal lesions (Meckel's Diverticulum)
  • Endoscopic Treatment (electrocautery and/or argon plasma coagulation)
    • Angioectasias (localized)
    • Dieulafoy Lesions
    • GAVE lesions
  • Angiography + embolization
    • For brisk bleeds that cannot be done endoscopically
  • NOTE:
    • Angioectasias associated with Aortic Stenosis (Heyde Syndrome) --> replace valve.
    • Von Willebrand Disease: Desmopressin or replacement of factor.
    • Diffuse Ectasias not amenable to therapy: Estrogens, Octreotide or thalidomide had some success.

Managment of Anticoagulation

• In patients with CAD and on ASA:
  • Restart ASA 3-5 days after bleed.
  • ASA shown to reduce all-cause mortality (cardiovascular, cerebrovascular and GI complications) 10-fold over 30 days while increasing bleeding rates only 2-fold. 
  • Long-term daily PPI should be used for H.pylori-negative patients who are on NSAIDs, anticoagulants, glucocorticoids, or antiplatlet agents.
• Source: International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding (2010) Anals of Int. Med.

Guideline Summaries

• International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding (2010)
  • Blood transfusions to a patient with Hb < 70 g/L
  • In patients receiving anticoagulants --> correct coagulopathy, but should not delay endoscopy!
  • Do not use pro-motility agents (used prev. to increase diagnostic yield)
  • Early endoscopy < 24hrs recommended for most pts with acute upper GI bleed.
  • Endoscopy:
    • Endoscopic hemostatic therapy not indicated if low-risk stigmata (clean base, non-protuberant dot)
    • If find a clot in ulcer base --> attempt to irrigate to dislodge and treat underlying ulcer.
    • If find clot --> role of therapy controversial (endoscopic tx vs. PPI)
    • If high risk stigmata --> endoscopic therapy
    • Epinephrine injection is suboptimal, must combine with other methods.
    • NO routine second-look endoscopy.  Only re-scope if rebleeds.
    • Surgery if endoscopy fails (percutaneous embolization also preferred if available)
• Prevent Re-Bleeding
  • IV PPI (bolus + infusion) should be used (decreases re-bleeding and mortality) if high-risk stigmata found and got successful endoscopy therapy.
  • If bleeding ulcers --> test FOR H.pylori +/- treat  + confirm eradication. 
  • Negative H.pylori tests done acutely should be repeated
• Other:
  • If low risk --> can feed patients within 24hrs.
• Hospitalization
  • Low risk endoscopy --> Discharge (use scoring systems)
  • High risk endoscopy --> Hospitalize for at least 72hrs.
• Discharge
  • If bleeding ulcer + require NSAIDs
    • Combination of PPI + COX-2 inhibitor recommended.
  • If require ASA
    • Restart in 3-5 days (if low risk) with ASA + PPI.