Gastrointestinal Bleeding
Adult-Gerontology Acute Care Practice Guidelines
Definition
A.Gastrointestinal bleeding (GIB) is a symptom of a disease process or condition in the gastrointestinal (GI) tract.
B.Bleeding that occurs in any part of the GI tract.
C.Upper GI tract includes esophagus and stomach.
D.Lower GI tract includes structures distal to the ligament of Treitz including small and large intestines, rectum, and anus.
Incidence
A.Upper gastrointestinal bleeding (UGIB).
1.Most common with approximately 100 cases per 100,000 population.
2.Mortality rates 6% to 10%.
3.Associated with comorbid illness.
a.Peptic ulcer disease is most common cause of UGIB in up to 40% of cases.
b.Mallory–Weiss tears account for 15% of UGIB cases.
c.Caused by forceful vomiting, retching, coughing, or straining.
d.Gastritis.
e.Caused by acute stress, acute renal failure, and sepsis.
B.Lower gastrointestinal bleeding (LGIB).
1.Annual incidence 20 to 27 cases per 100,000 population.
2.May be significantly underreported.
3.Four main types of LGIB.
a.Anatomic (diverticulosis, hemorrhoids)—most common type, accounting for approximately 60% of cases.
b.Vascular (ischemia, radiation-induced).
c.Neoplasms account for approximately 12.7% of cases.
d.Inflammatory (infectious versus noninfectious such as Crohn’s disease).
4.Segmented into significance of bleeding.
a.Occult bleeding.
b.Moderate bleeding.
c.Massive bleeding.
Pathogenesis
A.UGIB.
1.Variceal hemorrhage—increases in blood pressure in portal vein system, usually from cirrhosis, can create enlarged veins (varices) which are prone to bleeding.
2.Nonvariceal hemorrhage—process occurs from either arterial hemorrhage, typically from ulcers, deep mucosal tears, or from low pressure venous hemorrhage from telangiectasias or arteriovenous malformations.
B.LGIB.
1.The most common cause of LGIB is diverticulosis. Bleeding can occur in the absence of diverticulitis. Bleeding occurs when segmental weakness of the lumen of the bowel predisposes the artery to rupture. Bleeding can be massive and life-threatening.
2.Other forms of LGIB occur from ulceration or erosion of the mucosa, inflammatory changes that predispose the GI tract to mucosal friability, fissures, and fistulas that develop from infectious processes, radiation exposure, and vascular malformations.
Predisposing Factors
A.Occurs more frequently in men.
B.Older age.
C.Nonsteroidal anti-inflammatory drug (NSAID) use.
D.Admission to ICU for sepsis, trauma, or ventilatory support.
Subjective Data
A.Common complaints/symptoms.
1.UGIB: Presence of bleeding from vomiting, black tarry stools, dyspepsia.
2.LGIB: Presence of bright red blood in stool, may present with or without abdominal pain.
B.Common/typical scenario.
1.UGIB: Patients typically complain of presence of vomiting blood or passing black malodorous stool. They may present with weakness, dizziness, and possibly syncope.
2.LGIB: Depends on the amount of bleeding.
a.Minor bleeding—may complain of some rectal bleeding, diarrhea, and abdominal pain.
b.Moderate and massive bleeding—may present with signs and symptoms of shock including dehydration, hypotension, tachycardia, and fever.
C.Family and social history.
1.Ask about family history of colon cancer.
2.Smoking or alcohol use.
3.NSAID use.
D.Review of systems.
1.Constitutional: Dizziness or episodes of lightheadedness, may appear exhausted.
2.GI: Ask about color and consistency of stools, any pain during defecation, any associated nausea or vomiting, red streaking on toilet paper, abdominal pain severity and location, presence of heartburn, or unintentional weight loss.
Physical Examination
A.Head, ear, eyes, nose, and throat (HEENT): Assess oropharynx and nasopharynx for sources of bleeding.
B.GI: May have benign abdominal examination; check for hematemesis and melena, or rectal exam for bleeding.
C.Cardiovascular: Hemodynamic instability in massive hemorrhage; assess for signs and symptoms of shock, or orthostatic hypotension.
Diagnostic Tests
A.Lab studies.
1.Complete blood count (CBC), basic metabolic panel (BMP), coagulation studies.
2.In suspected UGIB, check calcium level for increased levels, which can be associated with excessive acid secretion.
3.Test for Helicobacter pylori in UGIB.
B.Imaging studies.
1.UGIB.
a.Endoscopy to find source of bleeding.
b.Chest radiography to exclude other causes of symptoms.
c.CT may be used to find unusual causes of bleeding.
d.Ultrasound can be useful to evaluate liver disease that may be associated with bleeding.
e.Angiography offered when bleeding persists and a clear source has not been found or if an arterial UGIB does not respond to endoscopic management.
2.LGIB.
a.Colonoscopy: Initial approach starts with colonoscopy unless the patient is unstable and
offers ability to treat during diagnostic stage.
b.Esophagogastroduodenoscopy (EGD): Can rule out UGIB.
c.CT: Useful when endoscopy is limited.
d.Computed tomography angiography (CTA): Has high positive predictive value for LGIB and often used as a first-line diagnostic study.
e.Angiography: Useful in active bleeding where colonoscopy cannot be done or fails to identify a source. Also can be used emergently in massive ongoing LGIB.
Differential Diagnosis
A.Determine location in UGIB.
1.Esophagus.
a.Barrett esophagus.
b.Esophageal cancer.
c.Esophageal varices.
d.Esophagitis.
2.Stomach.
a.Gastric cancer.
b.Gastric outlet obstruction.
c.Gastric ulcers.
d.Peptic ulcer disease.
B.Consider process in LGIB.
1.Anatomic: Diverticulosis.
2.Vascular.
a.Arteriovenous malformations.
b.Angiodysplasia.
c.Vasculitides.
3.Neoplasm.
a.Colon cancer.
b.Polyps.
4.Inflammation.
a.Inflammatory bowel disease.
b.Colitis.
c.Radiation induced.
d.Ulceration.
e.Abscess.
f.Fistulas.
g.Fissures.
Evaluation and Management Plan
A.General plan.
1.UGIB.
a.Stabilize and fluid resuscitate patient by correcting states of shock and bleeding abnormalities.
b.Insert nasogastric tube for lavage to determine if GIB is upper or lower. LGIB will result in bile aspirate but no bleeding.
c.Risk assessment using predictive models.
i.Rockall score.
ii.Blatchford score.
iii.AIMS65.
d.Perform EGD to identify and treat source of bleeding.
i.Contraindicated in uncooperative or unstable patients.
ii.Consider surgical intervention if:
1)Two attempts at endoscopic control are unsuccessful.
2)Failure of medical therapy or persistent bleeding.
3)Bleeding from perforation, obstruction, or malignancy.
4)Prolonged bleeding.
e.Start proton pump inhibitors.
f.Assess for complications of treatment with EGD.
i.EGD can cause:
1)Aspiration pneumonia.
2)Perforation.
3)Arrhythmias.
ii.Surgery.
1)Poor wound healing.
2)Rebleeding.
3)Ileus.
4)Sepsis.
2.LGIB.
a.Stabilize and resuscitate patients with active bleeding and signs of hemodynamic instability.
b.Insert nasogastric tube to rule out UGIB source.
c.Risk assessment.
d.Localize bleeding site.
i.If stable colonoscopy should be performed for diagnosis and treatment.
ii.Endoscopic hemostasis therapy can control active bleeding.
iii.Angiography for embolization of source and to temporize bleeding with vasopressin infusion if needed.
iv.Emergent surgery may be required if:
1)Medical and endoscopic therapy is unsuccessful.
2)Persistent hemodynamic instability with active bleeding.
3)Persistent, recurrent bleeding.
4)Transfusion of more than four units of packed red blood cells in a 24-hour period with active or recurrent bleeding.
e.Supportive measures.
i.Fluid resuscitation.
ii.Blood transfusions for hemoglobin less than 7 g/dL.
iii.Management of coagulopathies or antiplatelet agents: Consider transfusing with fresh frozen plasma and platelets if prolonged prothrombin time with international normalized ratio greater than 1.5 or low platelet count less than 50,000/L.
f.Assess for complications of treatment of LGIB.
i.Reactions to multiple blood transfusion.
ii.Bleeding from surgery.
iii.Sepsis.
iv.Poor wound healing from surgery.
v.Anastomotic strictures, incisional hernias after surgery.
B.Patient/family teaching points.
1.UGIB.
a.Lower the risk of UGIB by avoiding NSAIDs as much as possible.
b.Anticoagulants and antiplatelet agents must be ordered in consultation with GI provider. The risk and benefits must be weighed in deciding which medications are necessary.
c.Advise patient to take medications as prescribed for the entire duration.
d.Follow-up with the necessary tests as determined by provider.
e.If H. pylori positive, will need eradication therapy and confirmation of eradication in 4 to 6 weeks with a stool sample.
f.Long-term acid suppression therapy is needed.
2.LGIB.
a.If symptoms recur may need further workup. LGIB can be difficult to isolate in some cases.
b.Avoid NSAIDs and aspirin use.
c.Diet and lifestyle may prevent progression of certain causes of LGIB.
C.Pharmacotherapy.
1.UGIB.
a.Proton pump inhibitors (PPIs): Reduce acid secretion.
i.Inpatient start intravenous (IV) high dose therapy.
1)Bolus followed by twice daily injections.
2)Continuous infusions of PPIs have failed to show a difference in clinically relevant endpoints.
b.Prokinetics to promote gastric emptying; especially useful to improve gastric visualization prior to endoscopy.
i.Erythromycin.
ii.Metoclopramide.
c.Vasoactive medications treat variceal bleeding, may be used as adjunctive therapy in select cases of nonvariceal UGIB.
i.Octreotide: IV bolus followed by a continuous infusion.
d.Prophylactic antibiotics are used in patients with cirrhosis due to the high rate of bacterial infections associated with hospitalized events of UGIB.
2.LGIB.
a.There are no medications specifically to treat LGIB. Medications used are supportive and depend heavily on identifying and treating the source of bleeding.
D.Discharge instructions.
1.UGIB.
a.Depending on the cause of UGIB, certain medications will be prescribed.
b.Follow-up with gastroenterologist within 2 weeks.
c.Endoscopy typically repeated with ulcers to document healing.
d.If symptoms recur, patient should call the office immediately.
e.Diet and lifestyle changes.
2.LGIB.
a.Will need to follow-up within 2 weeks.
b.Start psyllium seed.
c.Encourage fluids.
d.Diet and lifestyle changes.
e.May need repeat colonoscopy if recurrence of symptoms.
Follow-Up
A.Follow-up with gastroenterologist within 2 weeks of leaving the hospital.
Consultation/Referral
A.GIB is a sign of an underlying condition. Refer to gastroenterologist for full workup.
B.General surgery should be consulted as needed and emergently if there is massive bleeding.
C.Patients who are hemodynamically unstable will require monitoring in the ICU.
Special/Geriatric Considerations
A.Older patients may present with minimal symptoms typically in LGIB.
Bibliography
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