GI Bleeding

Alex DeWeerd

Background

Intraluminal blood loss anywhere from the nasopharynx/oral cavity to the anus
- Don’t forget epistaxis or oropharyngeal bleeding as possible source of melena
IV PPI prior to endoscopy may ↓ need for endoscopic therapy but does not impact transfusion requirement, rebleeding risk, need for surgical intervention, or mortality
Classification: relative location to the Ligament of Treitz (LoT)
- Upper = proximal to LoT
  - PUD, gastritis (alcohol, stress, NSAIDs, ASA), esophagitis, variceal bleed, Mallory-Weiss tear, AVM, Dieulafoy’s lesion, aorto-enteric fistula, gastric antral vascular ectasias, malignancy
- Lower = distal to LoT
  - Diverticular bleed, ischemic/infectious/IBD/radiation colitis, malignancy, angiodysplasia, anorectal (hemorrhoids, anal fissure), Meckel’s diverticulum, post-polypectomy bleed

Historical factors to consider when trying to identify source of bleeding

Cirrhosis or chronic alcohol use: varices or portal hypertensive gastropathy
Hx of AAA or aortic graft: aorto-enteric fistula
Hx of renal disease, aortic stenosis, HHT: angiodysplasia
Hx of H. pylori, NSAID use, tobacco use: PUD
Hx of tobacco use, H. pylori, weight loss, early satiety, dysphagia, change in bowel habits: malignancy
Painless hematochezia: diverticular bleed
Abdominal pain: colitis
Look out for false positives: bismuth, charcoal, licorice, and iron

Presentation

Hematemesis (very specific for upper GI bleed), hematochezia (usually lower although brisk upper possible), melena (usually upper), coffee-ground emesis, epigastric/abdominal pain, acute or chronic, hx of GI bleed and prior endoscopies.
Exam: VITALS – assess hemodynamic stability to determine resuscitation needs, MICU vs. floor; orthostatic vs, rectal exam every time (smear stool on white tissue paper to look for melena), look for signs of cirrhosis (jaundice, palmar erythema, ascites, spider angiomata)
- Vital signs that may help estimate severity of bleed:
  - Blood loss <15% - resting tachycardia
  - Blood loss 15-40% - orthostatic hypotension
  - Blood loss >40% - supine hypotension

Evaluation

CBC, PT/INR, CMP, Lactic Acid, Blood Gas
BUN/Crt ratio > 30:1 more predictive of upper GI bleed, <20:1 more predictive of lower GI bleed
EGD: usually best
Difficulty localizing GIB: pill-capsule, balloon enteroscopy Meckel’s scan, tagged RBC scan
Massive lower GI bleeds will require arteriography

Management

Secure airway (intubation) if comatose, extremely combative, or massive hematemesis
At least 2 large bore IV’s (> 18 gauge) – ask nurses directly to ensure these are placed
Maintain active type and screen
Bolus IVF to maintain MAP >65H/H monitoring q6-q12 hours; transfusions as indicated
Active bleeding: Start IV PPI (pantoprazole) 40 mg BID if thought to be upper/possible ulcer. If no active bleeding, can start IV PPI 40mg qd
If cirrhotic, Ceftriaxone 1g daily for empiric SBP prophylaxis
If possibility of variceal bleed: Octreotide IV 50 mcg x1 then 50 mcg/hr drip x 3-5 days
NPO if unstable vs. clear liquids (no reds or purples) until morning for EGD
Balloon tamponade can be temporizing measure for uncontrolled hemorrhage 2/2 EV (needs to be intubated if device is placed)
For massive lower GI bleed: If hemodynamically unstable, consult IR and get a CTA abd/pelvis while doing fluid and blood product resuscitation. If hemodynamically stable, start with upper endoscopy to rule out UGIB. If source not identified on EGD, get CT angiography (if actively bleeding) or colonoscopy (if severe bleeding has stopped). If source not identified, investigate for small bowel bleed.
Never give prep to a patient for colonoscopy (GoLytely) without discussing with GI fellow
Consult gastroenterology to facilitate endoscopy. Consider consulting hematology if emergent anticoagulant reversal agent is needed.
- If endoscopy is unable to stop bleeding -> IR is next who can embolize
- If embolization fails -> EGS for source removal