Upper Gastrointestinal Bleeding
PUD (pain should stop when bleeding starts unless perfed)
Gastritis, Varices, Mallory Weiss, esophagitis
Hyperactive bowel sounds should be present.
Blood is a great cathartic, if no BMs makes UGI bleed less likely.
alka-seltzer contains ASA
iron and pepto-bismal look like melena
Do not use guiac cards for vomitus, HCl will always turn the test positive.
2.5 cc of blood in the gi tract will turn the card positive
Nasogastric aspirates are insensitive but have a reasonable specificity. Yield is low in patients without hematemesis, a sign which obviates the need for nasogastric aspirate (Annals EM April 2004 Volume 43 Number 4)
False-positive occult blood testing Red meat Turnips Horseradish Vitamin C
Hematochezia is sometimes used (incorrectly) as a synonym for lower GI bleeding. The term means literally to defecate blood and is not restricted to bright red blood per rectum. It refers to the passage of blood that still resembles bloodthat is, it is red or maroon and recognizable to the patient as blood. The passage of blood blackened by the digestive process is referred to as melena, from a Greek verb meaning to darken or turn black.
NGT is safe in Varices
Digestive Dis 1973;18(12):1032
Anesth Analg 1988;67:283
Dieulafoys lesion
a GI mucosa defect such that a submucosal artery is in abnormally close contact with the mucosa and causes a pressure erosion, eventually rupturing into the stomach
Recombinant-activated factor VIIas hemostatic therapy in eight cases of severe hemorrhage from esophageal varices. Clinical Gastroenterology & Hepatology. 2(1):78-84, 2004 Jan.
USEFULNESS AND VALIDITY OF DIAGNOSTIC NASOGASTRIC ASPIRATION IN PATIENTS WITHOUT HEMATEMESIS Click here to hear the Reviewer’s comments via MP3. Witting, M.D., et al, Ann Emerg Med 43(4):525, April 2004 METHODS: The authors, from the University of Maryland, performed a methodologically rigorous record review in 220 adults with a final diagnosis of GI bleeding, who were hospitalized with bloody, black or dark stools, but who did not have hematemesis, in order to assess the utility of diagnostic nasogastric aspiration in such patients. The study included only patients for whom confirmatory diagnostic testing (endoscopy in almost all) was completed within three days after admission. RESULTS: A source of bleeding was listed in the hospital discharge diagnoses for 84% of the patients. NG aspiration was aborted without results in 6% of the patients, was questionably to strongly positive in 23% (but strongly positive in only 2%), and was clearly to somewhat negative in the remainder. In the 213 patients for whom a reference standard diagnosis was available, the sensitivity and specificity of diagnostic NG aspiration were 42% and 91%, respectively, the positive and negative predictive values were 92% and 64%, and the positive and negative likelihood ratios were 11 and 0.6, respectively. The final diagnosis was correctly predicted by the results of NG aspiration in 66% of the patients. NG aspiration was positive in only 69% of the patients with a definitive upper GI source of bleeding (20/29). CONCLUSIONS: These results illustrate the limited value of NG aspiration for the evaluation of GI bleeding in patients without hematemesis. A positive test is a good predictor of an upper GI source of bleeding, but a negative test provides virtually no useful diagnostic information. 28 references
Melena
(black, tarry foul-smelling stool) usually signifies the presence of >60ml of blood and it usually implies a GI source proximal to the cecum the black color is due to the effect of bacteria on blood as it passes through the colon – it takes > 8 hours of transit time for melena to develop)
Get initial CBC, 1000 cc NS, repeat CBC 20 minutes later.
BUN elevated in GI bleeds
Place NG tube: + aspirate if >10 cc blood, >30 cc pink fluid PPV >94% but NPV ~22%, coin toss is better (If it is positive then it’s probably upper, if it’s negative then it must still be treated like an upper)
Lavage-ewald tube, LLR in trendelenberg
Transfuse-mix 100 cc c PRBC, shoot for crit >33, need plt only c massive transfusion
Patients with acute variceal hemorrhage have a high incidence of infection, presumably due to bacterial translocation across the damaged variceal wall. As such, empiric antibiotics should be administered to all patients with variceal bleeding. Early administration of broad spectrum antibiotics, namely third generation cephalosporins or fluoroquinolones, has been shown to decrease the incidence of bacteremia and reduce overall mortality (33,36,37).
33) Sharara AI, Rockey DC. Medical progress: gastroesophageal variceal hemorrhage. N Engl J Med 2001;345:669-681. (34) Jenkins SA, Shields R, Davies M, at al.. A multicenter randomized trial comparing octreotide and injection sclerotherapy in the management and outcome of acute variceal hemorrhage. Gut 1997;41:526-33. (35) Gotzsche PC. Somatostatin analogues for acute bleeding esophageal varices. Cochrane Database Syst. Rev. 2002;CD000193. (36) Hou MC, Lin HC, Liu TT, at al.. Antibiotic prophylaxis after endoscopic therapy prevents rebleeding in acute variceal hemorrhage: a randomized trial. Hepatology 2004;39:746-53. (37) Bernard B, Grange JD, Khan EN, at al.. Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a meta-analysis. Hepatology 1999;29:1655-61.
If the goal is to improve endoscopic visualization, two randomized trials have demonstrated success using intravenous erythromycin (18,19). Erythromycin is a motilin receptor agonist that has been shown to enhance antroduodenal coordination and promote gastric emptying (20) . Although the total number of patients in these studies is relatively small, both studies demonstrated improved quality of endoscopy using a single dose of erythromycin at 3 mg/kg given 20 to 120 minutes prior to the procedure. Iced saline lavage, once thought to control active hemorrhage, is ineffective and no longer recommended ( 12).
(18) Coffin B, Pocard M, Panis Y, at al.. Erythromycin improves the quality of EGD in patients with acute upper GI bleeding: a randomized controlled study. Gastrointest Endosc 2002;56:174-9.
(19) Frossard JL, Spahr L, Queneau PE, at al.. Erythromycin intravenous bolus infusion in acute upper gastrointestinal bleeding: a randomized, controlled, double-blind trial. Gastroenterology 2002;123:17-23.
Octreotide:
50 mcg bolus then 50 mcg/hr
May be effective in up to 80% of bleeds (Sharara AI, et.al. Gastroesophageal Variceal Hemorrhage NEJM 2001; 345: 669-81)
do not over fluid load the variceal bleeders, when they drop their pressure slightly, they stop bleeding
You do not need special monitoring for this drug, American Society Of Gastroenterology
may rebolus then increase to 100 per hour if continued bleeding, may be benefit for non-varcieal bleeding
There is evidence to support the use of octreotide in variceal and non-variceal upper GI bleeding (UGB). As a somatostatin analogue, octreotide binds with endothelial cell somatostatin receptors, inducing strong, rapid and prolonged vaso-constriction [1]. Octreotide reduces portal and variceal pressures as well as splanchnic and portal-systemic collateral blood flows [2]. It also prevents postprandial splanchnic hyperemia in patients with portal hypertension [3] and lowers gastric mucosal blood flow in normal and portal hypertensive stomachs [4]. Octreotide inhibits both acid and pepsin secretion. As a result, it prevents the dissolution of freshly formed clots at the site of bleeding [5].
Crit Care. 2006; 10(4): 218. Pro/con debate: Octreotide has an important role in the treatment of gastrointestinal bleeding of unknown origin?
Protonix:
80 mg over 10 minutes then 8 mg/hr
omeprazole 80mg followed by continuous infusion of 8 mg/hr for 72 hours
No benefit in any way, shape or form to the use of H2 blockers in GI Bleed
PPIs help platelets stick, they can not do that in an acidic environment
Omeprazole before Endoscopy in Patients with Gastrointestinal Bleeding–Conclusions Infusion of high-dose omeprazole before endoscopy accelerated the resolution of signs of bleeding in ulcers and reduced the need for endoscopic therapy (Nejm 2007;356(16):1631-1640)
Some definite ICU admission criteria
- hemodynamic instability
- severe bleeding – hematemesis or hematochezia
- active bleeding + two or more co-morbidities
- patient requires intubation to protect the airway or provide mechanical ventilation
- patient has severe underlying coronary artery disease
- endoscopy shows ulcer with stigmata of recent hemorrhage
- requirement for multiple blood transfusions
- any bleeding from esophageal varices
Risk of re-bleeding, need for surgery and mortality rate based on the endoscopic appearance of an ulcer
Ulcer appearance
Rebleeding risk Need for surgery Mortality rate Clean base 5% 0.5% 2% Flat spot 10% 6% 3% Adherent clot 22% 10% 7% Visible vessel 43% 34% 11% Active bleeding 55% 35% 11%
(Jeff Mann Guidemap)
vessels that cause the bleeds are about 1mm, if they are 2mm then patient is goin’ to the er or is going to die. both the epi and the heat are just causing trauma to tissues surrounding vessel to cause tamponade, the epi itself and the heat don’t really matter.
give antibiotics for variceal bleeding, definitely give before endoscopy
ICU Stress Ulceration
Sucralfate and H2 blockers have been the standard for prophylaxis. H2 blockers may be slightly more effective, but are associated with a higher rate of pneumonia. PPIs are taking over, though data on sequelae is still accumulating.
surgery for upper gastrointestinal bleeding
Place a large bore NG tube and flush the stomach with 50 cc of water and aspirate
Intraoperative retrograde gastroscopy: Place a purse strings suture on the anterior surface of the stomach wall. make a small cut suction out the clots place in the scope in tightening the purse string in order to inflate the stomach
Risk Score Identifies Patients with Upper Gastrointestinal Bleeding
Acute bleeding from the upper gastrointestinal track is a common emergency. Patients may experience a spectrum of events from mild and clinically self-limited bleeding to fatal exsanguination. Several scoring systems have been developed to assist in the urgent assessment of patients presenting with acute upper gastrointestinal bleeding, but these have not been widely adopted in clinical practice. Many scores are based on the risk of death or rebleeding and do not accommodate the impact of modern changes in treatment. Blatchford and colleagues developed and tested a simple scoring system to identify patients at highest risk of requiring hospital admission and aggressive treatment to control gastrointestinal bleeding.
Data were obtained from more than 1,740 admissions to hospitals in Scotland for acute upper gastrointestinal bleeding. The logistic regression model constructed from these data focused on the need for blood transfusion, operative or endoscopic intervention to control bleeding, or death, rebleeding or a substantial fall in hemoglobin to identify and rank the associated risk factors (see accompanying table). Hemoglobin and blood urea nitrogen levels, blood pressure, pulse and readily accessible clinical factors emerged as the most predictive. These factors were used to construct the scoring system. In a second study, the scoring system was used prospectively on 197 consecutive adult patients presenting to three hospitals during a three-month period because of upper gastrointestinal hemorrhage.
Admission Risk Markers for GI Hemorrhage and Associated Score Component Values Risk marker Score component value Risk marker Score component value Blood urea nitrogen–mg per dL (mmol per L) Systolic blood pressure–mm Hg >=18.2 and <22.4 (>=6.5 and <8.0 ) 2 2 100 to 109 1 >=22.4 and <28.0 (>=8.0 and <10.0) 3 3 90 to 99 2 >=28.0 and <70.0 (>=10.0 and <25.0) 4 4 <90 3 >=70.0 (>=25) 6 6 Other markers Hemoglobin in men–g per dL (g per L) Pulse >=100 per minute 1 >=12.0 and <13.0 (>=120 and <130) 1 1 Presentation with melena 1 >=10.0 and <12.0 (>=100 and <120) 3 3 Presentation with syncope 2 <10.0 (<100) 6 6 Hepatic disease 2 Hemoglobin in women–g per dL (g per L) Cardiac failure 2 >=10.0 and <12.0 (>=100 and <120) 1 1 <10.0 (<100) 6 6
GI = gastrointestinal
Adapted with permission from Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper gastrointestinal haemorrhage. Lancet 2000;356:1319.
Blatchford Score of 0 effectively rules out the need for urgent intervention (Ann Emerg Med 2013;62:627)
Emycin increases gastric emptying
Patients admitted within 12 hours after hematemesis were randomly assigned to receive erythromycin 250 mg or placebo 20 minutes before endoscopy. Endoscopy revealed a clear stomach in 82% of 51 patients in the erythromycin group and in 33% of 54 patients in the placebo group ( P<.001). This difference remained significant even in patients with cirrhosis.
Compared with placebo, erythromycin shortened the endoscopic duration (13.7 vs. 16.4 minutes; P=.036) and reduced the need for second-look endoscopy (6 vs. 17 cases; P=.018). Length of hospital stay and blood units transfused were similar in the two groups, and no complications were noted.
“Erythromycin infusion before endoscopy in patients with recent hematemesis makes endoscopy shorter and easier, thereby reducing the need for a repeat procedure,” the authors write. “Systemic intravenous erythromycin use might reduce the need for and the risks associated with gastric lavage.”
Gastroenterology. 2002;123:17-23
TIPS much better than endoscopy for variceal bleeding (Randomized Trial of Emergency Endoscopic Sclerotherapy Versus Emergency Portacaval Shunt for Acutely Bleeding Esophageal Varices in Cirrhosis. J Am Coll Surg. 2009 Jul;209(1):25-40. Epub 2009 May 1. (Original) PMID: 19651060)
Transfusions
Transfusion threshold should be 7 rather than 9 in non-exsanguinating bleeds (NEJM 2013;368(1):11)
Lower Gastroinstestinal Bleeding
Diverticulosis(most bleeds are r sided), Angiodysplasia (dont show up on imaging), Malignancy, rectal disease
In young adults-UC/infxns
Children-intussusception
(Apt test to differentiate swallowed blood from gi bleed)
False Neg on guiaic-red fruits, meth blue
Commonly used guiacbased tests (which detect heme pseudoperoxidase activity instool
give 4-8 liters of peg then can go lower endo within 4 hours.
no bleeding, or slow bleed-colonoscopy
moderate bleeding still going on-rbc scan if neg colon, if pos to angio. angio for treatment, if angio is neg then colon
others would ignore the nuclear route and go straight to angio
get excited after 2nd or third unit of blood; get to the OR after 5th or 6th
neoplasm
ibd
diverticulosis
ischemic colitis
avm/angiodysplasia
hemorrhoids
post-op
meckel’s
infectious
radiation proctitis
get patient history/consider rectoscope
fresh blood per rectum in a stable patient is not ugi bleed
Upper GI Bleed Risk Stratification
Glasgow-Blatchford score is better than AIMS65 (Acad Emerg Med 2015;22:23)