Term
|
Definition
arising from the
esophagus, stomach, or proximal
duodenum |
|
|
Term
|
Definition
arising from distal
duodenum to ileocecal valve |
|
|
Term
|
Definition
|
|
Term
|
Definition
• Occult blood in stool
• Does not provide any localizing information
• Indicates slow pace, usually low volume bleeding |
|
|
Term
|
Definition
• Very dark, tarry, pungent stool
• Usually suggestive of UGI origin (but can be small intestinal,
proximal colon origin if slow pace) |
|
|
Term
|
Definition
• Spectrum: bright red blood, dark red, maroon
• Usually suggestive of colonic origin (but can be UGI origin if
brisk pace/large volume) |
|
|
Term
How sick is this patient?
(risk stratification)
• Determines |
|
Definition
disposition
• Guides resuscitation
• Guides decision re: need for/timing of
endoscopy |
|
|
Term
| Differential Diagnosis—Upper GIB |
|
Definition
• Peptic ulcer disease (most common)
• Gastroesophageal varices (most common)
• Erosive esophagitis/gastritis/duodenitis (most common)
• Mallory Weiss tear
• Vascular ectasia
• Neoplasm
• Dieulafoy’s lesion
• Aortoenteric fistula
• Hemobilia, hemosuccus pancreaticus |
|
|
Term
| Differential Diagnosis—Lower GIB |
|
Definition
• Diverticulosis (most common)
• Angioectasias
• Hemorrhoids
• Colitis (IBD, infectious, ischemic)
• Neoplasm
• Post-polypectomy bleed (up to 2 weeks
after procedure)
• Dieulafoy’s lesion |
|
|
Term
|
Definition
• Localizing symptoms
• History of prior GIB
• NSAID/aspirin use
• Liver disease/cirrhosis
• Vascular disease
• Aortic valvular disease, chronic
renal failure
• AAA repair
• Radiation exposure
• Family history of GIB |
|
|
Term
|
Definition
• Vital signs, orthostatics
• Abdominal tenderness
• Skin, oral examination
• Stigmata of liver disease
• Rectal examination
- Objective description of
stool/blood
- Assess for mass,
hemorrhoids
- No need for guaiac test |
|
|
Term
|
Definition
Always get objective description of
stool
Avoid non-informative terms such as
“grossly guaiac positive”
If you need a card to tell you whether there’s
blood in the stool, it’s not an acute GIB |
|
|
Term
| Predictors of UGI source: |
|
Definition
• Age <50
• Melenic stool
• BUN/creatinine ratio
- If ratio ≥ 30, think upper GIB |
|
|
Term
|
Definition
- Most useful situation: patients with severe
hematochezia, and unsure if UGIB vs. LGIB
• Positive aspirate (blood/coffee grounds) indicates UGIB
- Can provide prognostic info:
• Red blood per NGT—predictive of high risk endoscopic
lesion
• Coffee grounds—less severe/inactive bleeding
- Negative aspirate—not as helpful
• 15–20% of patients with UGIB have negative NG aspirate |
|
|
Term
even if NG
aspirate negative |
|
Definition
Upper GI bleed must still be
considered in patients with severe
hematochezia |
|
|
Term
| GI bleeding classifications |
|
Definition
|
|
Term
|
Definition
IV access: large bore peripheral IVs best
• Use crystalloids first
- Anticipate need for blood transfusion
• Threshold should be based on underlying condition,
hemodynamic status, markers of tissue hypoxia
• Should be administered if Hgb ≤ 7 g/dL
• 1 U PRBC should raise Hgb by 1 (HCT by 3%)
• Remember that initial Hct can be misleading (Hct
remains the same with loss of whole blood, until reequilibration occurs)
-Correct coagulopathy |
|
|
Term
| restrictive vs liberal transfusions |
|
Definition
| restrictive has better outcomes |
|
|
Term
|
Definition
Weigh risks and benefits of
reversing anticoagulation
Assess degree of
coagulopathy
Vitamin K—slow acting,
long-lived
FFP- fast acting, short lived, give 1 U FFP for every 4 U PRBCs |
|
|
Term
Causes of Mortality
in Patients with Peptic Ulcer Bleeding |
|
Definition
• Patients rarely
bleed to death
• Prospective cohort
study >10,000 cases
of peptic ulcer bleed
• Mortality rate 6.2%
• 80% of deaths not
related to bleeding |
|
|
Term
Causes of Mortality
in Patients with Peptic Ulcer Bleeding |
|
Definition
• Terminal malignancy (34%)
• Multi-organ failure (24%)
• Pulmonary disease (24%)
• Cardiac disease (14%) |
|
|
Term
to reduce
mortality from UGIB |
|
Definition
Early resuscitation and supportive
measures are critical |
|
|
Term
|
Definition
• Identify patients at high risk for adverse
outcomes
• Helps determine disposition (ICU vs. floor
vs. outpatient)
• May help guide appropriate timing of
endoscopy |
|
|
Term
|
Definition
• Predicts need for
endoscopic therapy
• Based on readily
available clinical and
lab data
• Can use UpToDate
calculator
[image]
• Most useful for safely discriminating low risk
UGIB patients who will likely not require
endoscopic hemostasis
• “Fast track Blatchford”—patient at low risk if:
BUN < 18 mg/dL
Hgb > 13 (men), 12 (women)
SBP >100
HR < 100 |
|
|
Term
| Pre-endoscopic Pharmacotherapy |
|
Definition
• For non-variceal UGIB
- IV PPI: 80 mg bolus, 8 mg/hr drip
- Rationale: suppress acid, facilitate
clot formation, and stabilization
- Duration: at least until EGD, then
based on findings
• Reduces the proportion of patients
with high risk endoscopic stigmata
(“downstages” lesion)
• Decreases need for endoscopic
therapy
• Has not been shown to reduce rebleeding,
surgery, or mortality rates
Endoscopic treatment required:
Omeprazole—19% (23% of PUD)
Placebo—28% (37% of PUD) |
|
|
Term
| Endoscopy—Non-variceal UGIB |
|
Definition
• Early endoscopy (within 24 hours) is
recommended for most patients with acute
UGIB
• Achieves prompt diagnosis, provides risk
stratification, and hemostasis therapy in
high-risk patients |
|
|
Term
When is
Endoscopic Therapy Required? |
|
Definition
• ~80% bleeds spontaneously resolve
• Endoscopic stigmata of recent hemorrhage
Active bleeding 55–90%
Non-bleeding visible vessel 40–50%
Adherent clot Variable, depending on
underlying lesion: 0–35%
Flat pigmented spot 7–10%
Clean base < 5% |
|
|
Term
|
Definition
• Role of endoscopic
therapy of ulcers with
adherent clot is
controversial
• Clot removal usually
attempted
• Underlying lesion can
then be assessed,
treated if necessary |
|
|
Term
|
Definition
-Flat pigmented spot
-Clean base
Low re-bleeding risk—
no endoscopic therapy needed |
|
|
Term
| Endoscopic Hemostasis Therapy |
|
Definition
• Epinephrine injection
• Thermal
electrocoagulation
• Mechanical (hemoclips)
• Combination therapy
superior to
monotherapy |
|
|
Term
Non-variceal UGIB—
Post-endoscopy Management |
|
Definition
• Patients with low-risk ulcers can be fed
promptly, put on oral PPI therapy.
• Patients with ulcers requiring endoscopic
therapy should receive PPI gtt x 72
hours.
- Significantly reduces 30-day re-bleeding rate
vs. placebo (6.7% vs. 22.5%)
- Note: there may not be major advantage with
high dose over non-high dose PPI therapy
• Determine H. pylori status in all ulcer patients
• Discharge patients on PPI (once to twice daily), duration
dictated by underlying etiology and need for
NSAIDs/aspirin
• In patients with cardiovascular disease on low dose
aspirin: restart as soon as bleeding has resolved
- RCT demonstrates increased risk of re-bleeding (10% vs. 5%)
but decreased 30-day mortality (1.3% vs. 13%)
-Not dying is more important
than not re-bleeding |
|
|
Term
|
Definition
• Occurs in 1/3 of
patients with cirrhosis
• 1/3 initial bleeding
episodes are fatal
• Among survivors, 1/3
will re-bleed within 6
weeks
• Only 1/3 will survive
- 1 year or more |
|
|
Term
|
Definition
• Vasoconstrictor therapy
• Antibiotics
• Resuscitation
• ICU-level care
• Endoscopy
• ALternative/rescue therapy
• Beta blockers |
|
|
Term
|
Definition
• Goal: reduce splanchnic blood flow
• Vasopressin plus nitroglycerine—too many
adverse effects
• Octreotide (somatostatin analogue)
- Decreases splanchnic blood flow (variably)
- Efficacy is controversial; no proven mortality
benefit
- Standard dose: 50 mcg bolus, then 50 mcg/hr
drip for 3–5 days |
|
|
Term
|
Definition
• Bacterial infection occurs in up to 66% of
patients with cirrhosis and variceal bleed
• Negative impact on hemostasis
(endogenous heparinoids)
• Prophylactic antibiotics reduce
incidence of bacterial infection,
significantly reduces early re-bleeding
- Ceftriaxone 1 g IV QD x 5–7 days
- Alt: Norfloxacin 400 mg po BID |
|
|
Term
|
Definition
• Promptly but with caution
• Goal is to maintain hemodynamic
stability
- Maintain Hgb ~7-8, CVP 4–8 mmHg
• Avoid excessively rapid
overexpansion of volume; may
increase portal pressure, greater
bleeding |
|
|
Term
|
Definition
• Should be performed
as soon as possible
after resuscitation
(within 12 hours)
• Endotracheal
intubation frequently
needed
• Band ligation is
preferred method |
|
|
Term
| ALternative/Rescue Therapies |
|
Definition
• TIPS—transjugular
intrahepatic portosystemic
shunt
• Early placement of shunt
(within 24–72hrs) associated
with improved survival among
high-risk patients
• Preferred treatment for gastric
variceal bleeding (rule out
splenic vein thrombosis first) |
|
|
Term
ALternative/Rescue Therapies
Sengstaken-Blakemore Tube |
|
Definition
• Very effective for
immediate, temporary
control
• High complication rate—
aspiration, migration,
necrosis plus perforation of
esophagus
• Use as bridge to TIPS
within 24 hours
• Airway protection strongly
recommended |
|
|
Term
ALternative/Rescue Therapies
Self-Expanding Metal Stent |
|
Definition
• Specially designed
covered metal stent
• Tamponades distal
esophageal varices
• Removable; does not
require airway
protection
• Very limited data |
|
|
Term
|
Definition
• Reduces risk for recurrent variceal
hemorrhage
• Use nonselective beta blocker (e.g.,
Nadolol—splanchnic vasoconstriction,
decrease cardiac output) and titrate up to
maximum tolerated dose, HR 50–60
- Start as inpatient, once acute bleeding has
resolved and patient shows hemodynamic
stability |
|
|
Term
|
Definition
• Bleeding arising from the colon-rectum
• In patients with severe hematochezia, first
consider possibility of UGIB
- 10–15% of patients with presumed LGIB are
found to have upper GIB |
|
|
Term
Lower GI Bleed
Differential Diagnosis |
|
Definition
• Diverticulosis (number 1 cause) (large volume, painless)
• Angioectasias
• Hemorrhoids
• Colitis (IBD, infectious, ischemic) (smaller volume, pain, diarrhea)
• Neoplasm
• Post-polypectomy
• Dieulafoy’s lesion |
|
|
Term
| Predictors of severe* LGIB: |
|
Definition
• HR>100
• SBP<115
• Syncope
• Non-tender abdominal examination
• Bleeding during first 4 hours of evaluation
• Aspirin use
• >2 active comorbid conditions
0 factors: ~6% risk
1–3 factors: ~40%
>3 factors: ~80% |
|
|
Term
| LGIB—Risk Factors for Mortality |
|
Definition
• Age
• Intestinal ischemia
• Comorbid illnesses
• Secondary bleeding (developed during
admission for a separate problem)
• Coagulopathy
• Hypovolemia
• Transfusion requirement
• Male gender |
|
|
Term
|
Definition
- Like UGIB, ~80% of LGIBs will resolve
spontaneously; of these, ~30% will re-bleed
- Lack of standardized approach
• Traditional approach
• Elective colonoscopy after resolution of bleeding, bowel prep
—low therapeutic benefit • Angiography for massive bleeding, hemodynamically
unstable patient
• Urgent colonoscopy approach • Similar to UGIB—identify stigmata of hemorrhage, perform
therapy |
|
|
Term
|
Definition
• Within 6–12 hours of presentation
• Requires rapid “purge” prep with 5–6 L
Golytely administered 1L every 30–45
minutes
• Colonoscopy performed within 1 hour after
clearance of stool, blood, and clots
• Need for bowel prep and risks of
procedural sedation may be prohibitive in
unstable patient |
|
|
Term
Radiographic Studies
Angiography |
|
Definition
• Detects bleeding rates of
0.5–1 ml/min
• Therapeutic capability—
embolization with
microcoils, polyvinyl
alcohol, gelfoam
• Complications: bowel
infarction, renal failure,
hematomas, thromboses,
dissection
Recommended test for patients with brisk
bleeding who cannot be stabilized or
prepped for colonoscopy
(or have had colonoscopy with failure to
localize/treat bleeding site) |
|
|
Term
Radiographic Studies
Multi-Detector CT (CT angio) |
|
Definition
• Readily available, can be performed
in ER within 10 minutes
• Can detect bleeding rate of 0.5
ml/min
• Can localize site of bleeding (must be
active) and provide info on etiology
• Useful in the actively bleeding but
hemodynamically stable patient |
|
|
Term
|
Definition
• Reserved for patients with life-threatening
bleed who have failed other options
• General indications
-Hypotension/shock despite resuscitation
- >6 U PRBCs transfused
• Preoperative localization of bleeding
source important |
|
|
Term
Algorithmic Evaluation of
Patient With Hematochezia |
|
Definition
|
|
Term
| Take Home Points for all of GIB |
|
Definition
• Always get objective description of stool color
(best way—examine it yourself)
• Don’t order guaiac tests on inpatients
• Severe hematochezia can be from UGIB, even if
NG lavage is negative
• All bleeding eventually stops (and majority of
non-variceal bleeds will stop spontaneously, with
the patient alive)
• Early resuscitation and supportive care are key
to reducing morbidity and mortality from GIB |
|
|
