A.23 GI Hemorrhage Flashcards
A.23 GI Hemorrhage
Etiology
Upper gastrointestinal bleeding (UGIB): gastrointestinal bleeding from the esophagus, stomach, or duodenum (proximal to the ligament of Treitz)
Lower gastrointestinal bleeding (LGIB): gastrointestinal bleeding from the colon or rectum
Small bowel bleeding: GI bleeding from a source between the ligament of Treitz and the ileocecal valve
Overt GI bleeding: GI bleeding that is visible in the form of hematemesis, melena, or hematochezia (including intermittent scant hematochezia)
Obscure gastrointestinal bleeding: Overt GI bleeding from an undetermined source that persists or recurs after a negative diagnostic evaluation
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Epidemiology
UGIB: ∼ 70–80% of all GI hemorrhages
LGIB: ∼ 20–30% of all GI hemorrhages
Small bowel bleeding: ∼ 5–10 % of all patients presenting with GI bleeding
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Inflammatory or Erosive Causes UGIB
Peptic ulcer disease (20-50% of cases)
Esophagitis
Erosive gastritis and/or duodenitis
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Vascular Causes of UGIB
Varices, e.g., gastric or esophageal varices - A dilated, often tortuous, subcutaneous vein with a diameter ≥ 3 mm.
Gastric antral vascular ectasia - Dilation of small blood vessels in the antrum of the stomach that can lead to gastrointestinal bleeding.
Dieulafoy lesion: abnormally dilated submucosal artery in the GI tract (usually proximal stomach) which can bleed profusely in response to minor trauma
Angioma - A small, dilated, intradermal blood vessel, red to dark blue in color, with a diameter of < 1 mm.
Angiodysplasia - A degenerative disorder of gastrointestinal blood vessels that consists of abnormal, dilated, and tortuous communications between veins and capillaries.
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Tumors that cause UGIB
Esophageal cancer
Gastric cancer
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Traumatic or iatrogenic Causes of UGIB
Mallory-Weiss syndrome - A condition characterized by a longitudinal mucous membrane tear (limited to the mucosa and submucosa) at the gastroesophageal junction that can lead to bleeding.
Hiatal hernias - Hiatal hernias are a risk factor for Mallory-Weiss syndrome and can cause mucosal ischemia through vascular compromise in the herniated portion.
Boerhaave syndrome - A transmural rupture of the distal esophagus as a result of a sudden increase in intraesophageal pressure.
Foreign body ingestion
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Risk Factors for UGIB
Any GI bleeding
NSAID use
Antithrombotic use, e.g., antiplatelet therapy, anticoagulants
History of prior GI bleeding
Older age
Upper GI bleeding
H. pylori infection
Renal failure, especially in the first year of hemodialysis
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Clinical Features UGIB
Hematemesis: vomiting blood, which can vary in color from bright red to brown and may resemble coffee grounds, depending on the cause
The coffee-ground appearance is caused by coagulation and the presence of hematin, a dark pigment that forms when heme is oxidized by gastric acid in the stomach.
Melena: black, tarry stool with a strong offensive odor
Melena is caused by the presence of hematin, a dark pigment formed through the oxidation of heme. In UGIB, heme is oxidized by gastric acid; in LGIB, it is oxidized by intestinal bacteria.
Signs of acute, severe bleeding
Clinical features of shock
Tachycardia
Hypotension
Altered mental status
Syncope
Clinical features of anemia
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Erosive or inflammatory causes of LGIB
Diverticular bleeding (up to 65% of cases)
Colitis
Inflammatory colitis caused by ulcerative colitis or Crohn disease
Infectious colitis, e.g., caused by Shigella or EHEC
Radiation colitis
Proctitis
Ulcers e.g. rectal ulcers, stercoral ulcers
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Vascular Causes of LGIB
Hemorrhoids
Intestinal ischemia (ischemic colitis, late stages of acute mesenteric ischemia)
Arteriovenous malformation - An abnormal, congenital arteriovenous connection. Can result in venous hypertension, tissue ischemia, and/or hemorrhage
Colorectal varices
Angiodysplasia
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Traumatic or iatrogenic causes of LGIB
Lower abdominal trauma
Anorectal trauma (e.g., anorectal avulsion injury, impalement injury)
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Other Causes of LGIB
Anal fissures - A painful, longitudinal tear in the anoderm, typically located distal to the dentate line in the posterior midline. Most commonly caused by increased anal sphincter tone.
Meckel diverticulum - congenital anomaly of the gastrointestinal tract characterized by an outpouching of the ileal wall. Caused by an incomplete obliteration of the vitelline duct.
Children - intussusception
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Clinical features of LGIB
Hematochezia: passage of blood through the anus with or without stool
Most commonly caused by LGIB Maroon, jellylike traces of blood in stool indicate colonic bleeding. Streaks of fresh blood on stool indicate rectal bleeding.
Signs of acute, severe bleeding
Clinical features of shock
Tachycardia
Hypotension
Altered mental status
Syncope
Clinical features of anemia
Features of the underlying cause of GI bleed
Signs of cirrhosis
Abdominal pain, nausea and/or vomiting
Unintentional weight loss
Constipation and/or painful defecation
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Physical Exam focus
Vital signs to assess for massive hemorrhage
Resting SBP ≤ 90 mm Hg and/or HR ≥ 120/min
Orthostatic hypotension [10]
Abdominal examination, including DRE to assess for:
Melena, hematochezia
Hemorrhoids, anal fissures, anal masses
Evaluation for signs of hypovolemia - Clinical signs of significant dehydration (e.g., dry mucus membranes)
Shock and other signs of poor peripheral perfusion may be present.
Orthostasis
Oliguria (e.g., as a sign of prerenal AKI)
↓ CVP and ↓ JVP
Evaluation for signs of portal hypertension - signs of increased blood flow via portosystemic anastomoses (caput medusae, anorectal, esophageal, and gastric varices), splenomegaly, and ascites
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Labs
CBC
Normal or ↓ Hb and Hct
Platelets to assess for thrombocytopenia
BMP: ↑ BUN/Cr ratio suggests UGIB.
Lactate: Initial levels > 2.5 mmol/dL are associated with adverse outcomes.
Albumin
Coagulation panel
Pretransfusion testing: type and screen, crossmatching
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fecal occult blood test
Detects small quantities of blood in stool.
Cannot differentiate between upper gastrointestinal bleeding (UGIB) and lower gastrointestinal bleeding (LGIB).
A positive result should be followed up with endoscopy for further evaluation.
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Endoscopy
Colonoscopy: Used to visualize the mucosa of the colon.
Upper Endoscopy: Allows visualization of the inner layer of the upper gastrointestinal tract (UGIT) extending to the duodenal papilla.
Timing: Should be conducted within 24 hours of admission.
Biopsies: Can be performed for additional diagnostic purposes.
Treatment: Therapy can be initiated immediately (e.g., with epinephrine injection therapy or clipping).
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Nasogastric Tube Lavage
- Purpose: To rule out upper gastrointestinal bleeding (UGIB), with negative results in approximately 15% of patients with UGIB.
- Additional Benefits: Aids in identifying the site of bleeding and may allow for the initiation of therapy.
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Forrest Classification
Forrest classification categorizes lesions observed during endoscopy to assess the risk of rebleeding without requiring repeated interventions:
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Stage I: Active hemorrhage (high risk; 80-100%).
IA: Spurting arterial hemorrhage.
IB: Oozing hemorrhage.
Stage II: Inactive hemorrhage (moderate risk; 20-50%).
IIA: Lesion with a visible vessel.
IIB: Lesion with an adherent clot.
Stage III: Lesion with no active bleeding (lowest risk).
III: Lesion with a clean ulcer.
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Initial TX
- Elective Intubation: Consider for patients with altered mental status or respiratory issues, along with severe ongoing bleeding.
- Hemodynamic Resuscitation:
- Administer IV fluids to stabilize blood pressure and heart rate.
- Transfuse packed red blood cells if hemoglobin is below 7 g/dL.
- IV Proton Pump Inhibitors (PPIs): Administer to reduce the risk of rebleeding.
- Management of Anticoagulants:
- If INR is between 1.5 and 2.5, endoscopic hemostasis may be possible.
- If INR exceeds 2.5, consider reversal agents before endoscopy.
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Interventions to Stop the Bleeding
- Endoscopy:
- Identify and treat the bleeding site using:
- Injection Therapy: For actively bleeding ulcers or blood vessels.
- Surgical Procedures: Such as sclerotherapy, band ligation, cauterization, or clip placement.
- Polypectomy: For bleeding polyps (e.g., in the colon).
- Angiography:
- Use vasoconstriction of a bleeding vessel through intravascular vasopressin infusion or embolization. - Laparotomy:
- Consider this for cases where bleeding cannot be controlled via endoscopic methods (rare).
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Keys
Hypotension + melena = treat as UGIB until proven otherwise
Painless hematochezia in elderly = think diverticulosis or angiodysplasia
Alcoholic with hematemesis + splenomegaly = suspect varices
Post-endoscopy or anticoagulated patient = high-risk bleeding
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How do you differentiate upper from lower GI bleeding clinically?
Hematemesis or melena → suggests upper
Bright red blood per rectum (hematochezia) → usually lower, but can be upper if brisk
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What are the initial steps in managing a patient with GI bleed?
ABCs:
Secure airway Two large-bore IVs Fluids ± blood Monitor vitals, urine output Group & crossmatch Arrange endoscopy or colonoscopy
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When should endoscopy be performed in upper GI bleeding?
Within 24 hours (urgent within 12 hours if unstable or high-risk features)
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What medications are used in variceal bleeding?
Octreotide IV
IV antibiotics (e.g., ceftriaxone) PPIs usually given empirically at first (until varices are confirmed) Endoscopic band ligation or sclerotherapy
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What scoring systems are used in GI bleeding?
Glasgow-Blatchford Score (GBS)
→ Predicts need for intervention in UGIB
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Patient with massive hematochezia. Do they have a lower GI bleed?
Not necessarily — brisk upper GI bleeding can present as hematochezia. If unstable, start with EGD.
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What lab abnormality might falsely suggest increased protein breakdown in upper GI bleeding?
↑ BUN without ↑ creatinine
→ Due to digestion of blood proteins
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Can iron-deficiency anemia be due to a GI bleed without visible blood loss?
Yes — that’s called an occult GI bleed.
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What’s the first imaging you do if colonoscopy is not possible in unstable lower GI bleed?
CT angiography — can localize active bleeding for possible embolization
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When would you suspect an obscure GI bleed, and how would you investigate it?”
Suspect after normal upper and lower endoscopy → Next step: Capsule endoscopy or enteroscopy
