GI Bleed

1. In a patient with blood in the stools who is hemodynamically stable, use history to differentiate upper vs. lower GI bleed as the investigation differs
2. In a patient with suspected blood in the stool, explore other possible causes (e.g., beet ingestion, iron, Pepto-Bismol) before doing extensive investigation
3. Look for patients at higher risk for GI bleed (e.g. previous bleed, ICU admission, NSAIDs, alcohol) so as to modify treatment to reduce risk of GI bleed (e.g. cytoprotection)
4. In a patient with obvious GI bleeding, identify patients who may require timely treatment even though they are not yet in shock
5. In a stable patient with lower GI bleeding, look for serious cause (e.g., malignancy, inflammatory bowel disease, ulcer, varices) even when there is an apparent obvious cause for the bleeding (e.g., do not attribute a rectal bleed to hemorrhoids or to oral anticoagulation).
6. In a patient with an upper GI bleed;
   1. Include variceal bleeding in your differential,
   2. Use the history and physical exam to assess the likelihood of a variceal bleed as its management differs.

Upper GI Bleed

Presentation

• Commonly present with hematemesis and/or melena
  • Frankly bloody emesis suggests more severe bleeding (coffee-ground likely more limited)
  • Hemodynamic instability or active bleeding should be in monitored setting
• Melenic stool on exam [LR 25]
• Blood or coffee-ground during nasogastric lavage [LR 9.6]
• BUN:Cr >30 [LR 7.5]
• History of melena [LR 5.1-5.9]
• Blood clots in stool [LR 0.05]

DDx UGIB

• Bleed
  • Peptic ulcer
  • Esophagogastric varices
  • AV malformations
  • Tumor
  • Esophageal (Mallory-Weiss) tear
  • Esophagitis/Gastritis
• Not bleed
  • Beet
  • Iron
  • Pepto-Bismol

DDx LGIB

• Diverticulosis - most common
• Angiodysplasia
• Colitis
  • Inflammatory bowel disease
  • Infectious
• Neoplastic
• Anorectal (hemorrhoids, anal fissures, rectal ulcers)

Past Medical History

• Prior episode of upper GI bleeding: 60% likely from same lesion
• Liver disease/alcohol abuse: Varices or portal hypertensive gastropathy
• AAA or aortic graft: Aorto-enteric fistula (rare but deadly)
• Renal disease, aortic stenosis or hereditary hemorrhagic telangiectasia: Angiodysplasia
• H Pylori, smoking, NSAIDs: Peptic ulcer disease
• H Pylori, smoking, alcohol: Malignancy
• Coagulopathies, thrombocytopenias, hepatic dysfunction may require transfusions of FFP or platelets

HPI

• Peptic ulcer: Epigastric or right upper quadrant pain
• Esophageal ulcer: Odynophagia, gastroesophageal reflux, dysphagia
• Mallory-Weiss tear: Emesis, retching, or coughing prior to hematemesis
• Variceal hemorrhage or portal hypertensive gastropathy: Jaundice, weakness, fatigue, anorexia, abdominal distention
• Malignancy: Dysphagia, early satiety, involuntary weight loss, cachexia

Exam

• Hypovolemia: Tachycardia, hypotension
• Consider nasogastric lavage if there is doubt of upper GI bleed
• Ensure no abdominal tenderness, guarding, rebound to rule out acute abdomen (perforation)
• Rectal exam for stool color and guaiac testing

Investigations

• CBC (Hb, platelets), Chem (BUN, creat), Liver enzymes (AST, ALT), Coag (INR), Albumin
• EKG, Troponin if risk of MI (older, hx of CAD, chest pain or dyspnea)

Treatment

• Gown, gloves, face shield mask
• Oxygen, monitor, BP cycle
• NPO
• Two large IVs
• NG + Elective endotracheal intubation if ongoing hematemesis, altered mental status, or risk of aspiration
• Fluid resuscitation
• Type and Screen or Cross-match if risk
  • Blood transfusions to maintain Hb >70g/L (consider >90g/L if massive bleeding or comorbid eg. CAD)
    • Avoid overtransfusing patients in variceal bleeding - can worsen bleeding
  • Consider platelets, plasma if receiving massive RBC transfusions
• In patients with variceal bleeding OR undifferentiated bleeding in cirrhosis,
  • Prophylactic antibiotics (Ceftriaxone 1g IV daily x 7d) as 50% risk of infections when hospitalized for UGIB (UTI, SBP, pneumonia, bacteremia)
• PPI - Reduces rebleeding in high-risk ulcers treated with endoscopic therapy
  • Omeprazole 40mg IV BID or Pantoloc 40mg IV BID
    • Pantoloc 80mg bolus and 8mg/h drip has not been shown to be superior
• Prokinetic - Promotes gastric emptying, shown to reduce second endoscopy
  • Consider Erythromycin 3mg/kg or 250mg IV over 30 mins (30 mins-90mins prior to endoscopy)
• Somatostatin (and analogs) in suspected variceal bleeding, however may have a role in nonvariceal bleeding in settings where endoscopy is unavailable
  • Octreotide 50mcg IV bolus then 50mcg/hour
• Balance risks and benefits of anticoagulant and antiplatelet agents reversal
  • Warfarin → Vitamin K
  • Heparin → Protamine, Fresh frozen plasma
  • Dabigatran → Praxbind (Idarucizumab)
• Balloon tamponade for uncontrollable hemorrhage, intubation necessary prior
• GI consultation for early endoscopy vs. interventional radiologist (angiography)
  • Can risk stratify (AIMS65, or Glasgow-Blatchford Score 0-1 denotes "low-risk" safe for discharge)