GI Bleeding

GI Bleeding – Matthew Meyers

Background

  • Intraluminal blood loss anywhere from the nasopharynx/oral cavity to the anus
  • Don’t forget epistaxis or oropharyngeal bleeding as possible source of melena
  • IV PPI prior to endoscopy may need for endoscopic therapy but does not impact transfusion requirement, rebleeding risk, need for surgical intervention, or mortality
  • Classification: relative location to the Ligament of Treitz (LoT)
  • Upper = proximal to LoT
    • PUD, gastritis (alcohol, stress, NSAIDs, ASA), esophagitis, variceal bleed, Mallory-Weiss tear, AVM, Dieulafoy’s lesion, aorto-enteric fistula, gastric antral vascular ectasias, malignancy
  • Lower = distal to LoT
    • Diverticular bleed, ischemic/infectious/IBD/radiation colitis, malignancy, angiodysplasia, anorectal (hemorrhoids, anal fissure), Meckel’s diverticulum, post-polypectomy bleed

 

Presentation

  • Hematemesis (very specific for upper GI bleed), hematochezia (usually lower although brisk upper possible), melena (usually upper), coffee-ground emesis, epigastric/abdominal pain, acute or chronic, hx of GI bleed and prior endoscopies, NSAID use, alcohol use, anticoagulant use, hx of cirrhosis
  • Exam: VITALS – assess stability to determine resuscitation needs, MICU vs. floor; orthostatic vs, rectal exam every time (smear stool on white tissue paper to look for melena), look for signs of cirrhosis (jaundice, palmar erythema, ascites, spider angiomata)

 

Evaluation

  • CBC, PT/INR, CMP, Lactic Acid, Blood Gas
  • EGD: usually best
  • Difficulty localizing GIB: pill-capsule, balloon enteroscopy Meckel’s scan, tagged RBC scan
  • Massive lower GI bleeds will require arteriography

 

Management

  • Secure airway (intubation) if comatose, extremely combative, or massive hematemesis
  • At least 2 large bore IV’s (> 18 gauge) – ask nurses directly to ensure these are placed
  • Maintain active type and screen
  • Bolus IVF to maintain MAP >65H/H monitoring q6-q12 hours; transfusions as indicated
  • IV PPI (pantoprazole) 40 mg BID if thought to be upper/possible ulcer
  • If possibility of variceal bleed: Octreotide IV 50 mcg x1 then 50 mcg/hr drip x 3-5 days
  • NPO if unstable vs. clear liquids (no reds or purples) until morning for EGD
  • Never give prep to a patient for colonoscopy (GoLytely) without discussing with GI fellow
  • Consult gastroenterology to facilitate endoscopy
  • If endoscopy is unable to stop bleeding IR is next who can embolize
  • If embolization fails EGS for source removal

 

Additional Information:

  • Any upper GI bleed in a cirrhotic: will require SBP prophylaxis (see Hepatology)
  • If a source of bleeding cannot be found on both upper and lower endoscopy and still bleeding, ask about push enteroscopy, capsule endoscopy, and/or balloon enteroscopy