Resident Version
GI BleedingModule
created by Dr. Yvonne Dalton-Etheridge
Obectives
1) Recognize the most common etiologies of GIB
2) Feel comfortable with the initial management of a patient with GIB
3) Choose the appropriate study for further evaluation of GIB
References
1. Bernard B, Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a meta-analysis. Hepatology. 1999; 29: 1655-61.
2. Lee JG, Endoscopy based triage significantly reduces hospitalization rates and costs of treating upper GI bleeding: a randomized controlled trial. Gastrointest Endosc. 1999; 50: 755-61.
3. Manning-Dimmitt et al, Diagnosis of Gastrointestinal Bleeding in Adults, American Family Physician, vol 71, no 7, 2005, 1339-1346.
4. Rockey, Don Gastrointestinal Bleeding, Gatroenterology Clinics of North America 34 (2005) 581-588.
I. Introduction
A. Clinical scenarios
1. bleeding from the upper GI tract
2. bleeding from the lower GI tract
3. occult bleeding (unknown to the patient)
4. patient has obvious bleeding , but site is obscure (whether it is UGIB or LGIB)
B. Epidemiology
1. 300,000 hospitalizations annually in the U.S.
2. UGIB mortality rate 6 -10 %
3. massive LGIB mortality rate 4 -10%
4. Mortality rate increases in the elderly, patients with hepatic and renal dysfunction, CAD and malignancies
C. Fundamental Clinical Principals
1. assess and stabilize hemodynamic status immediately
2. careful history and physical exam
3. predict the etiology and source of bleeding
4. investigate the source of bleeding with endoscopy, etc.
5. stop/treat the source of bleeding
6. prevent recurrence of bleeding
II. UGIB
A. Signs/Symptoms: hematemesis, coffee ground emesis, melena, nausea with epigastric pain and hypotension, hematochezia
B. Etiology
1. PUD 40-79%
2. Gastritis/duodenitis 5-30%
3. Esophageal varicies 6-21%
4. Mallory-Weiss tear 3-15%
5. Esophagitis 2-8%
6. Gastric cancer 2-3%
7. Dieulafoy’s lesion <1% (thick walled arterial vessel surrounded by a shallow ulcer)
8. Gastric arteriovenous malformations <1%
9. Portal gastropathy <1%
10. Other erosions (esophageal, stress ulcers)
C. Initial Management
1. Vitals signs/ABCs to determine patient stability
a. shock (resting hypotension) correlates with 20-25% intravascular blood loss and massive bleed
b. postural (orthostatic tachycardia or hypotension) correlates with 10-20% intravascular blood loss and moderate bleed
c. normal vitals correlates with <10% blood loss and a minor bleed
2. Establish IV access: two or more large bore (18 gauge) PIVs. Start 0.9% NS bolus
3. make pt NPO
4. NGT lavage
a. check placement by Xray or filling 50cc syringe with water and push into NGT while listening to epigastrium
b. fill with NS and then place NGT to suction and see how much NS it takes until clear
5. Labs
a. STAT: CBC, coags, T&S
b. monitor H&H q 4-6 hours
c. Goal is for hgb >8 (>10 in pt with CAD), PLT >50 and INR < 1.5
d. check stool guaic
6. Give blood products (pRBCs, FFP, PLT) if needed
7. stop any anticoagulants (coumadin, heparin, ASA, plavix, NSAIDs)
8. start IV PPI
9. start IV Octreotide if variceal bleed suspected
10. Consult GI for upper endoscopy
11. MICU admission if the following:
a. NGL continues to have bright red blood
b. pt is hypotensive
c. pt develops respiratory distress
d. drop in HCT by >6%
D. Studies
1. EGD
2. Tagged RBC scan
3. Angiography
III. LGIB
A. Signs: hematochezia
B. Etiology
1. Small bowel
a. angiodysplasia
b. jejunoileal diverticula
c. Meckel’s diverticulum
d. Neoplasms/lymphomas
e. enteritis/Crohn’s disease
f. aortoduodenal fistula in patient with synthetic vascular graft
2. Large bowel
a. diverticuli 17-40%
b. arteriovenous malformations 2-30%
c. colitis (ischemia, infectious, IBD, radiation) 9-21%
d. colonic neoplasms/post-polypectomy bleeding 11-14%
e. anorectal causes (hemorrhoids and rectal varicies) 4-10%
f. colonic tuberculosis
C. Initial Management
1. hard to determine if you are dealing with brisk UGIB vs. LGIB
2. same as above for UGIB, including NG lavage
3. NG lavage is negative, most likely LGIB
a. colonoscopy prep (2 gallons golytely)
b. call GI consult if bleeding is brisk or pt is unstable
c. consider tagged RBC scan if brisk bleeding and pt is stable to go to nuclear medicine
d. consider surgical intervention if bleeding doesn’t stop
D. Studies
1. Colonoscopy
a. identifies bleeding etiology in 70% patients
b. advantages include visualization, ability to biopsy, ability to treat with heat probe, epinephrine injection, laser therapy, band ligation and hemoclipping
2. Angiography
a. can be used if massive bleeding doesn’t allow for visualization by colonoscopy
b. sensitivity 41%
c. mesenteric arteriography can be helpful in AVM bleeding
3. Tagged RBC scan
a. pt has to be actively bleeding at 0.1 – 0.4 cc/min
b. not as accurate as angiography in determining exact site of bleeding
IV. Small Bowel Bleeding- need to evaluate when EGD/colonoscopy nondiagnostic
A. Push enteroscopy
1. Extension of upper endoscopy
2. Allows for visualization 15 to 160 cm distal to ligament of Treitz
B. Barium UGI series/SBFT sensitivity <5%
C. Enteroclysis (endoscopic placement of contrast material directly in small bowel)
D. Nuclear Scans
1. Tagged RBC scan
2. Meckel’s scan
a. Identifies gastric mucosa in small bowel
b. Best used in evaluation younger patients
E. Arteriorgraphy
F. Capsule endoscopy
1. Diagnostic yield 66-69%
2. Well tolerated
3. Contraindicated in patients with bowel strictures
G. Laparotomy with intraoperative enteroscopy (obviously a last resort)
V.
table 4History and Clinical Findings Associated with Specific GI Sources of Rectal Bleeding
Cause / History and clinical findings
Upper GI tract
Peptic ulcer disease / Use of aspirin, NSAIDs, or tobacco
Esophageal varices / Alcohol abuse; jaundice; signs of portal hypertension, including: ascites, palmar erythema, spider angiomata, hepatomegaly, splenomegaly, and rectal varices
Mallory-Weiss tear / Bleeding preceded by vomiting, retching, or seizures
Gastric cancer / Left supraclavicular adenopathy; palpable mass; abdominal pain; weight loss; cachexia
Lower GI tract
Diverticular disease / Age > 60 years; painless bleeding; possible recent constipation
Arteriovenous malformations / Age > 60 years; painless bleeding; chronic renal failure
Colonic neoplasms / Age > 50 years; abdominal pain; weight loss; muscle wasting; protein calorie malnutrition; right-sided colon cancer may be associated with palpable right-sided abdominal mass; hepatomegaly; liver nodules; history of adenomatous polyps or longstanding ulcerative colitis; prior exposure to ionized radiation; family history of familial polyposis coli or cancer family syndrome
Inflammatory bowel disease / Ulcerative colitis: starts in younger patients (20 to 40 years of age); usually involves the rectum; associated with diarrhea mixed with blood and mucus
Crohn's disease: starts in younger patients (20 to 40 years of age); perianal, peritoneal, and/or abdominal wall fistulas may be associated
Radiation colitis / History of radiation treatment to abdomen and/or pelvis
Hemorrhoids / Perianal mass may be painful (external hemorrhoid) or painless (internal hemorrhoid); commonly starts in younger patients; associated with constipation, pregnancy, or postpartum period
Anal fissures / More common in patients with history of constipation; associated with severe sharp pain occurring with straining on defecation; pain resolves within an hour after defecation; commonly starts at
20 to 40 years of age
Colon tuberculosis / History of pulmonary tuberculosis or past exposure to tuberculosis
Aortoduodenal fistula / History of abdominal aortic aneurysm surgically repaired with synthetic vascular graft placement
GI =gastrointestinal; NSAIDs = nonsteroidal anti-inflammatory drugs.
From Manning-Dimmitt et al, Diagnosis of Gastrointestinal Bleeding in Adults, American Family Physician, vol 71, no 7, 2005, 1339-1346.
Review Questions
1. 50 yo female is brought to the ED after a syncopal event at home. She is noted to take ibuprofen for “arthritis” in her knees. Her friend also mentions to you that she has been concerned about her continued alcohol intake and depression after her husband’s unexpected death 2 years ago. Her supine pulse is 100 and systolic blood pressure is 96. With assistance you sit your patient up and for several minutes her pulse is noted to be at 125 and her SBP is 80. The patient has complaints of dizziness and vomits bright red blood on the RN who is assisting you. The next appropriate step in medical management is:
a) Endoscopy
b) Call the MICU for admission
c) Octreotide
d) 2 units pRBCs
e) Normal saline “wide open”
2. A 35 yo male with no chronic medical problems comes to the ED because of one episode of melena 30 hours prior. He denies any other symptoms such as hematemesis, weakness or dizziness. He has been taking ibuprofen for knee pain which has developed since he has running recently. The patient’s pulse is 80 and his blood pressure is 120/70. The patient is not orthostatic. Endoscopy reveals a 0.8 cm clean based gastric ulcer. The best medical management scenario is which of the following:
a) Initiate feeding, d/c NSAIDs, startPPI, check for H. Pylori, discharge patient to home
b) Initiate feeding, d/c NSAIDs, startPPI, check for H. Pylori, admit patient to general medicine ward for further observation
c) Keep NPO, d/c NSAIDs, startPPI, check for H. Pylori, admit patient to general medicine ward for further observation
d) Initiate feeding, d/c NSAIDs, startPPI, admit patient to general medicine ward for further observation
e) Initiate feeding, d/c NSAIDs, startPPI, discharge patient to home
3) A 75 yo male with h/o DM and CAD is seen in the ED after 4 episodes of BRBPR in the last 10 hours. His supine pulse is 100 and systolic blood pressure is 96. With assistance you sit your patient up and for several minutes his pulse is noted to be at 125 and her SBP is 80. The patient denies nausea, vomiting, abdominal pain and NGL is clear. After volume resuscitation and obtaining laboratory results, the diagnostic test of choice should be:
a) Tagged RBC scan
b) Barium enema
c) Flexible sigmoidoscopy
d) Colonoscopy
e) Upper endoscopy
4) A 62 yo alcoholic man is brought to the ED after several episodes of hematemesis and melena, the last of which was five hours ago. The patient appears jaundiced and has ascites. Recent outpatient abdominal ultrasound showed splenomegaly and nodular liver. The patient is not febrile, wbc’s are normal and abdominal exam is benign other than showing evidence of ascites. The patient is volume resuscitated, and the patient is awaiting endoscopy and MICU transfer. Which of the following therapies should be started in this patient:
a) Octreotide alone
b) Octreotide and antibiotics
c) vasopressin
d) Transjugular intrahepatic portosystemic shunt
Post Module Evaluation
Please place completed evaluation in an interdepartmental mail envelope and address to Dr. Wendy Gerstein, Department of Medicine, VAMC (111).
1) Topic of module:______
2) On a scale of 1-5, how effective was this module for learning this topic? ______
(1= not effective at all, 5 = extremely effective)
3) Were there any obvious errors, confusing data, or omissions? Please list/comment below:
______
4) Was the attending involved in the teaching of this module? Yes/no (please circle).
5) Please provide any further comments/feedback about this module, or the inpatient curriculum in general:
6) Please circle one:
Attending Resident (R2/R3) Intern Medical student