Gastrointestinal bleeding resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Twinkle Singh, M.B.B.S. [2]

Overview

Gastrointestinal bleeding refers to any bleeding that occurs in gastrointestinal tract from the pharynx to the rectum.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

• Esophageal varices
• Gastric ulcer
• Gastric varices
• Aorto-enteric fistula
• Hemosuccus pancreaticus
• Superior mesenteric artery syndrome

Common Causes

• Upper gastrointestinal bleeding
  • Duodenal ulcer
  • Esophageal ulcer
  • Esophageal varices
  • Gastric ulcer
  • Gastritis
  • Mallory-Weiss tear
• Lower gastrointestinal bleeding
  • Angiodysplasia
  • Anal fissure
  • Colonic polyps
  • Diverticulitis
  • Diverticulosis
  • Hemorrhoids
  • Infectious colitis
  • Infectious diarrhea
  • Inflammatory bowel disease
  • Ischemic colitis

Management

Initial Work Up for GI bleed

Shown below is an algorithm summarizing the approach to [[Initial work up of GI bleed]].

Patient with GI bleed

Assess airway, intubate if required Assess circulation, 2IV bore lines 500ml NS nil per oral start PPI infusion (80mg bolus followed by 8mg/h infusion)

Send CBC, PT/PTT blood type and cross match

UGIB management see below

LGIB management see below

Approach to Upper GI Bleed

Shown below is an algorithm summarizing the approach to [[Upper GI bleed]]

History of coffee-ground emesis, dark stools, abdominal pain, past history of Peptic ulcer disease, NSAID use, liver failure

Consider Upper GI bleed

Initial work up of GI bleed, see above

UGIB

Pre-endoscopy medications: IV infusion of erythromycin (250 mg for 30 minutes), IV PPI therapy. If varices are suspected, give octreotide (50 mcg followed by 50 mcg/hr infusion, in patients with cirrhosis give prophylactic antibiotics (IV ciprofloxacin)

Early EGD

Lesion not localised

Lesion localised

Consider mid/ lower GI bleed

peptic ulcer disease

Varices

Esophagitis/Gastritis

Mallory-Weiss tear

Active bleeding/ Non bleeding visible vessel

Adherent clot

Flat spot/ clean base

bleeding actively

If no active bleed

Endoscopic therapy + IV PPI therapy

+/- Endoscopic therapy + IV PPI therapy

No endoscopic therapy, no IV PPI therapy

Ligation/ sclerotherapy

PPI therapy

Endoscopic therapy (cauterization/ epinephrin injection)

Observation/ supportive management

Approach to Lower GI Bleed

Shown below is an algorithm summarizing the approach to [[Lower GI bleed]]

History of frank blood per rectum, blood mixed with stool

Consider LGIB

Initial work up, see above

Rule out anorectal outlet bleed

Rule out UGIB

Persistent active bleed

Intermittent bleed

Unstable patient (colonoscopy not possible)

Stable patient

Colonoscopy

Colonoscopy

Brisk active bleeding

Slow active bleeding

Lesion not identified

Lesion identified

Angiography

Tagged RBC scan

Negative

Small bowel series, capsule endoscopy

Colonoscopic therapy

Failes

Positive

Surgery

Angiography

Surgery

Do's

• Assess haemodynamic status immediately and begin resuscitative measures if required.
• Blood transfusion required to maintain Hb>7mg/dl.
• Early endoscopy is strongly recommended, however patients with blood urea nitrogen<18.2 mg/dl, Hb>13.0 mg/dl in men, Hb> 12.0 mg/dl in women, systolic blood pressure> 110 mmHg, pulse< 100beats per minute, absence of melena, syncope, cardiac failure and liver disease can be discharged without endoscopy.
• In patients with UGIB endoscopy should be considered with in 24 hours of presentation, however in patients with tachycardia, hypotension, bloody emesis should be done with in 12 hrs after presentation.
• Endoscopic therapy considered in patients with adherent clot which is resistant to vigorous irrigation.
• For actively bleeding patents, thermal therapy or epinephrin therapy plus a second modality endoscopic therapy are recommended over clips and sclerosant therapy alone. (Conditional recommendation)
• After endoscopic therapy, patients with actively bleeding ulcer, non bleeding visible vessel and adherent clot should be given IV PPI therapy (80 mg bolus infusion followed by 8 mg/h infusion) for 72 hours.

Dont's

• Nasogastric lavage is not required in patients with UGIB. (Conditional recommendation)
• Epinephrin therapy should not be used alone.

References

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