GIB

Major Causes of upper GIB:

• • Esophageal varices, Mallory-Weiss tear, peptic ulcer, esophagitis, erosive gastritis, AVM, Dieulafoy's lesion, neoplasm, Aortoenteric fistula (h/o AAA repair).

Major Causes of lower GIB

• • Diverticulosis (common, usually right sided in severe H'ge), vascular ectasia (AVM), neoplasm, IBD, ischemic colitis, hemorrhoids, infectious colitis, post-polpectomy, NSAID ulcers, radiation colitis, rectal varices, sterocral ulcer (ulcer from hard stool), volvulus, anticoagulation, aortoenteric fistula, chemotherapy, irradiation injury, strangulated infarcted bowel, anal fissure, Meckel's diverticulum (with ectopic gastric mucosa). Consider upper GI source.

H&P:

• • What was the onset of bleeding and reason for admission?

  • Is the bleeding hematemesis +/- melena, or hematochezia?

  • How much blood has been lost?

  • Check BP, pulse, RR, O2 sat, temp. Check for orthostatic BP.

  • Quickly look at the Pt and review chart.

  • How does the Pt. look?

  • Mentation

  • HR, JVD, skin temp, color, and capillary refill.

  • Abdomen, rectal exam.

Lab/Dxtic:

CBC, CMP, PTT, PT/INR, ECG, AXR, type and screen, type and cross.

Management:

• • Consider whether special blood products are required based on comorbidities (e.g., irradiated washed RBCs).

  • Insert 2 large bore IV (16 - 18 gauge), type and cross PRBCs. It may take up to 8 hours for CBC to equilibrate, so initial Hct may be falsely elevated. In absence of renal disease, high BUN suggests GIB. Check coags and platelets to exclude bleeding d/o. Is the Pt. receiving anticoagulants? If so, consider reversal with vitamin K or FFP.

  • Transfuse until hemodynamic stability is reached and the hematocrit reaches >25% or more. Patients with cardiac or pulmonary disease may need transfusion to a Hct of >30% or more.

  • Replenish the IV volume by giving IVF (NS), especially while awaiting blood products. Keep Pt. NPO.

  • For UGI: insert NGT to check for bleeding. Suppress acid with PPI (omeprazole) 40 mg PO bid or give 80 mg IV.

  • GIB - Protonix IV 80 mg IV bolus, followed by 8 mg/h IV x 12 h

  • GI consult for EGD. If bleeding stops and Pt. stable, elective EGD can be done within the next 24 hours.

  • Varices should be treated as upper GIB, but also consider octreotide, 50 mcg bolus, then 50 mcg/hr and correct coagulation deficits.

  • Consider banding, sclerosant, epinephrine, and/or electrocautery for UGIB.

  • Refractory UGIB: esophageal balloon tamponade (Minnesota or Sengstaken-Blakemore tubes) for varices as a bridge for TIPS or shunt.

  • For mild to moderate LGIB: NG lavage, urgent colonic purge (4-6 hrs); then C-scopy.

  • Massive LGIB: Upper GIB must be excluded. Technetium-labeled RBC scan and/or mesenteric angiography. If more than 6 units of blood are transfused, consider surgical intervention.

  • Minimum bleeding rate: RBC scan, 1 PRBC unit q2-4 hours, or 0.1 - 0.5 ml/min. Radionuclide (RBC) scan is more sensitive than angiography. For arteriography, bleeding rate must be greater >0.5 - 1 ml/min.

  • NPO, NGT, 2 large bore IVs keep HCT goal of 25 - 30%

  • In presence of active LGIB and platelets <50,000/uL, or if there is impaired function (uremia, aspirin, plavix), transfuse platelets or desmopressin. With active LGIB and INR >1.5, transfuse FFP.

  • D/C ASA, plavix, NSAIDs.

  • C-scopy typically performed within 12 hours after presentation and stabilization. Do after urgent colonic purge (4 - 6 hrs)

  • Mesenteric angiography/embolization: the intervention of choice in brisk LGIB.

  • Surgery is indicated if LGIB involves >4-6 units of blood x 24h or >10 units total. If site is localized, consider hemicolectomy; otherwise perform total abdominal colectomy.

  • Surgery for Aortoenteric fistula, visible naked vessel in PUD by endoscopy.

  • If the LGIB site cannot be localized by C-scopy and site unknown, segmental resection of bowel. In massive LGIB without localization, exploratory laprotomy with or without small intestine enteroscopy and total abdominal colectomy with primary anastamosis of ileum to rectum as last resort (10%)

UGIB:

• • Bleeding into the lumen of the proximal GIT, usually proximal to the ligament of Treitz.

  • Self limited in 80% of cases

  • EGD is performed after stabilization and resuscitation, <12 hrs from admission.

  • H. pylori testing of all pts with PUD.

  • As little as 50 mL of blood in GIT can cause melena.

  • Risk factors: alcohol, cig, liver dz, burn/trauma, asa/NSAIDs, vomiting, sepsis, steroids, pervious UGIB, PUD, esophageal varices, portal HTN, splenic vein thrombosis, abdominal aortic aneurysm, aortoenteric fistula, burn injury, trauma.

  • DDx: PUD, acute gastritis, gastric ulcer, esophageal varices, M-W tear, gastric cancer, esophagitis, hemobilia, gastric volvulus, Boerhaave's synd, aorto-enteric fistula, paraseophageal hiatal hernia, NGT irritation, Dieulafoy's ulcer, angiodysplasia.

  • Surgical indications for UGIB: refractory or recurrent bleeding and site unknown, >3 units PRBCs to stabilize or >6 units PRBCs overall.

  • Risk factors for death following UGIB: age >60 yo, shock, >5 units PRBC transfusion, concomitant health problems.

  • Clinical Rockall score and complete Rockall score.

  • Clinical Rockall score:

    • Age < 60 yr: O

    • 60 - 79 yr: 1

    • >80: 2

    • Shock

      • HR >100: 1

      • SBP <100: 2

      • Comorbidities:

        • CAD, CHF, other major illness: 2

        • Renal failure, hepatic failure, metastatic cancer: 3

    • Complete Rockall score:

      • Clinical Rockall score: +

      • Endoscopic Dx

        • No finding, MW tear: 0

        • PUD, erosive esophagitis: 1

        • Ca of the upper GI: 2

        • Endoscopic stigmata of recent bleeding

          • Clean based ulcer, flat pigmented spot: 0

          • Blood in upper GIT, active bleeding, visible vessel, clot: 2

LGIB:

Bleeding distal to the ligament of Treitz; vast majority occurs in the colon.

Hematochezia (BRBPR) w/wo abdominal pain, melena, anorexia, fatigue, syncope, shortness of breath, shock, abdominal tenderness, hypovolemic shock, orthostatic changes, positive hemoccult

Bleeding in ESRD give

DDAVP 0.3 mcg/kg IV or SC, or 30 mcg/kg intransal. Effect lasts 6-8 h, and repeated dosing leads to tachyphylaxis. Responsiveness is restored if the drug is withheld for 3-4 days. DDAVP does not have the vasoconstrictor actions or ADH effects of vasopressin.

Give one dose - 2nd dose 8-12 hr later, but repeated dosing >24 leads to tachyphylaxis.

Conjugated estrogens, 0.5 mg/kg IV qd x 5 consecutive days. Onset of action takes a day, but effects last 2 wks. Good to given in pts with recurrent GIB