Epidemiology
- Anatomic Distribution of Sites of Gastrointestinal Hemorrhage: 90% of quantitatively important gastrointestinal hemorrhage episodes originate from a site above the ligament of Treitz
- xxxx
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Risk Factors
Coagulopathy
Acquired Vitamin K Deficiency (see Vitamin K, [[Vitamin K]])
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Anticoagulation
- Coumadin (see Coumadin, [[Coumadin]])
- Factor IIa (Thrombin) Inhibitors (see Factor IIa Inhibitors, [[Factor IIa Inhibitors]])
- Argatroban (Acova) (see Argatroban, [[Argatroban]])
- Bivalirudin (Angiomax, Angiox) (see Bivalirudin, [[Bivalirudin]])
- Dabigatran (Pradaxa) (see Dabigatran, [[Dabigatran]])
- Desirudin (Iprivask, Revasc) (see Desirudin, [[Desirudin]])
- Lepirudin (Refludan (see Lepirudin, [[Lepirudin]])
- Factor Xa Inhibitors (see Factor Xa Inhibitors, [[Factor Xa Inhibitors]])
- Apixaban (Eliquis) (see Apixaban, [[Apixaban]])
- Betrixaban
- Danaparoid (Orgaran) (see Danaparoid, [[Danaparoid]])
- Edoxaban (Lixiana) (see Edoxaban, [[Edoxaban]])
- Fondaparinux (Arixtra (see Fondaparinux, [[Fondaparinux]])
- Rivaroxaban (Xarelto) (see Rivaroxaban, [[Rivaroxaban]])
- Heparins
- Dalteparin (Fragmin) (see Dalteparin, [[Dalteparin]])
- Enoxaparin (Lovenox) (see Enoxaparin, [[Enoxaparin]])
- Heparin (Unfractionated) (see Heparin, [[Heparin]])
Antiplatelet Agents
- Non-Steroidal Anti-Inflammatory Drugs (NSAID’s) (see Non-Steroidal Anti-Inflammatory Drug, [[Non-Steroidal Anti-Inflammatory Drug]])
- Acetylsalicylic Acid (Aspirin) (see Acetylsalicylic Acid, [[Acetylsalicylic Acid]])
- Other NSAID’s
- Clopidogrel (Plavix) (see Clopidogrel, [[Clopidogrel]])
- Prasugrel (Effient) (see Prasugrel, [[Prasugrel]])
- Ticagrelor (Brilinta) (see Ticagrelor, [[Ticagrelor]])
Coagulopathic Conditions
- Antiphospholipid Antibody Syndrome (see Anti-Phospholipid Antibody Syndrome [[Anti-Phospholipid Antibody Syndrome]])
- Disseminated Intravascular Coagulation (DIC) (see Disseminated Intravascular Coagulation, [[Disseminated Intravascular Coagulation]])
- Factor IX Deficiency (Hemophilia B, Christmas Disease) (see Hemophilia B, [[Hemophilia B]])
- Factor X Deficiency (see Factor X Deficiency, [[Factor X Deficiency]])
- Von Willebrand Disease (see Von Willebrand Disease, [[Von Willebrand Disease]])
IIb/IIIa Inhibitors (see IIb IIIa Inhibitors, [[IIb IIIa Inhibitors]])
- Abciximab (ReoPro) (see Abciximab, [[Abciximab]])
- Eptifibatide (Integrilin) (see Eptifibatide, [[Eptifibatide]])
- Tirofiban (Aggrastat) (see Tirofiban, [[Tirofiban]])
Thrombocytopenia (see Thrombocytopenia, [[Thrombocytopenia]])
- Acute Leukemia Post-Chemotherapy Induction
- Immune Thrombocytopenic Purpura (ITP) (see Immune Thrombocytopenic Purpura, [[Immune Thrombocytopenic Purpura]])
- Thrombotic Thrombocytopenic Purpura (TTP) (see Thrombotic Thrombocytopenic Purpura, [[Thrombotic Thrombocytopenic Purpura]])
Thrombolytics (see Thrombolytics, [[Thrombolytics]])
- Alteplase (see Alteplase, [[Alteplase]])
Drugs
- Bisphosphonates (see Bisphosphonates, [[Bisphosphonates]])
- Physiology: xxx
- Selective Serotonin Reuptake Inhibitors (SSRI’s) (see Selective Serotonin Reuptake Inhibitors, [[Selective Serotonin Reuptake Inhibitors]])
- Physiology: possibly related to their effects on platelet serotonin
Etiology-Upper Gastrointestinal Hemorrhage
- Esophageal Ulcer (see Esophageal Ulcer, [[Esophageal Ulcer]])
- Esophageal Varices (see Esophageal Varices, [[Esophageal Varices]])
- Esophagitis (see Esophagitis, [[Esophagitis]])
- Gastric Cancer (see Gastric Cancer, [[Gastric Cancer]])
- Gastric Ischemia (see Gastric Ischemia, [[Gastric Ischemia]])
- Gastric Ulcer (see Peptic Ulcer Disease, [[Peptic Ulcer Disease]])
- Gastric Varices (see Gastric Varices, [[Gastric Varices]])
- Gastric Volvulus (see Gastric Volvulus, [[Gastric Volvulus]])
- Gastritis (see Gastritis, [[Gastritis]])
- Hemorrhagic Gastritis Due to Isopropanol Intoxication (see Isopropanol, [[Isopropanol]])
- Mallory-Weiss Tear (see Mallory-Weiss Syndrome, [[Mallory-Weiss Syndrome]]): typically occurs after retching or vomiting
- May be associated with ethanol ingestion
- Peptic Ulcer Disease (PUD) (see Peptic Ulcer Disease, [[Peptic Ulcer Disease]])
- Portal Hypertensive Gastropathy (PHG) (see Portal Hypertensive Gastropathy, [[Portal Hypertensive Gastropathy]])
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Etiology-Lower Gastrointestinal Hemorrhage
- Anal Fissure
- Colorectal Cancer (see Colorectal Cancer, [[Colorectal Cancer]])
- Colonic Arteriovenous Malformation (AVM): may manifest as small, recurrent bleeds or massive bleed
- Colonic Ischemia (see Colonic Ischemia, [[Colonic Ischemia]])
- Acute Colonic Ischemia (see Colonic Ischemia, [[Colonic Ischemia]])
- Chronic Ischemic Colitis (see Colonic Ischemia, [[Colonic Ischemia]])
- Colonic Polyps
- Espically may occur after polyp biopsy
- Diverticulosis: typically arterial source -> may be brisk
- Hemorrhoids
- Infectious Colitis
- Inflammatory Bowel Disease (IBD)
- Crohn’s Disease (see Crohn’s Disease, [[Crohns Disease]])
- Ulcerative Colitis (UC) (see Ulcerative Colitis, [[Ulcerative Colitis]])
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Etiology
Toxin
- Glyphosate Ingestion (see Glyphosate, [[Glyphosate]])
- xxx
- xxx
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Drugs
- Tolvaptan (Samsca) (see Tolvaptan, [[Tolvaptan]])
Diagnosis
NG Tube
- Useful to exclude UGI source only if bile is returned (bile indicates adequate duodenal sampling)
[Cuellar, Arch Int Med, 1990]
Rectal Exam
- 10% of hematochezia is due to an UGI source
[Jensen, Gastroenterol, 1988]
Tagged RBC Scan
- Requires 0.1 ml/min bleeding to detect: higher sensitivity than angiogram
- However, exact site of bleeding is not always clear, even when detected
IR Mesenteric Angiogram
- Requires 0.5-1 ml/min bleeding rate to detect
- Only 60% sensitive in detecting LGI bleeding site
Clinical Manifestations-Upper Gastrointestinal Hemorrhage
Cardiovascular Manifestations
- Extent of Blood Loss
- 15% loss of blood volume: usually readily tolerated and compensated by contraction of large veins and recruitment of fluid from extravascular site
- 15-40% loss of blood volume: constriction of arterioles, shunting of cardiac output from nonvital areas such as skin and bone, tachycardia, decreased cardiac output, and orthostatic hypotension occur
- The patient is likely to be thirsty and feel faint when standing
- 40-50% depletion of blood volume: shock, impaired flow of blood to vital organs, tissue hypoxemia, lactic acidosis, and ultimately, death
- Hypotension (see Hypotension, [[Hypotension]])
- Syncope (see Syncope, [[Syncope]])
Gastrointestinal Manifestations
- Coffee-Ground Emesis: emesis or gastric aspirate resembling dark brown coffee grounds
- Generally indicates an upper GI source
- Hematemesis: bright red bloody vomitus
- Indicates an upper GI source
- Indicates a large volume of hemorrhage
- Melena: tarry/black stools
- Generally indicates an upper gastrointestinal source (with source proximal to ligament of Treitz)
- However, melena may be seen in some cases (with slow intestinal transit times) with a bleeding source in the small intestine or cecum
- Melena is the most common presenting symptom of major GI bleeding
- It takes at least 50 ml of blood in the stomach to turn stools black
- Approximately 1-2L of blood administered orally will cause bloody or tarry stools for up to 5 days (the first such stool usually appearing within 4 to 20 hours after ingestion) -> therefore, melena indicates recent GI bleeding, but does not provide any informstion about the rapidity or quantity of bleeding
- Black stools may also occur due to iron or bismuth use
- Generally indicates an upper gastrointestinal source (with source proximal to ligament of Treitz)
Clinical Manifestations-Lower Gastrointestinal Hemorrhage
Cardiovascular Manifestations
- Extent of Blood Loss
- 15% loss of blood volume: usually readily tolerated and compensated by contraction of large veins and recruitment of fluid from extravascular site
- 15-40% loss of blood volume: constriction of arterioles, shunting of cardiac output from nonvital areas such as skin and bone, tachycardia, decreased cardiac output, and orthostatic hypotension occur
- The patient is likely to be thirsty and feel faint when standing
- 40-50% depletion of blood volume: shock, impaired flow of blood to vital organs, tissue hypoxemia, lactic acidosis, and ultimately, death
- Hypotension (see Hypotension, [[Hypotension]])
- Syncope (see Syncope, [[Syncope]])
Gastrointestinal Manifestations
- Hematochezia: bright red blood per rectum
- Generally indicates a lower GI source (although some cases of brisk upper GI bleeding, especially esophageal variceal bleeding, may present with hematochezia)
Treatment
Treatment of Non-Variceal Upper Gastrointestinal Hemorrhage
Supportive Care
- NPO Status
- Intravenous Fluid Resuscitation : as required to mainatin circulatory status
Correction of Coagulopathy
- xxx : in patients receiving anticoagulants, correction of coagulopathy is recommended but should not delay endoscopy. [Consensus Guidelines, Ann Int Med 2010; 152(2): 101-113]
Packed Red Blood Cell Transfusion
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Nasogastric Tube Insertion
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Proton Pump Inhibitors (PPI)
- Intermittent Intravenous Proton Pump Inhibitor Dosing: less expensive than administration by continuous infusion
- Pantoprazole (Protonix) (see Pantoprazole, [[Pantoprazole]]): 40 mg IV BID
- Continuous Intravenus Proton Pump Inhibitor Infusion: recommended by current guidelines [MEDLINE], although it is more expensive and labor-intensive
- Bolus Pantoprazole (Protonix) (see Pantoprazole, [[Pantoprazole]]): 80 mg IV x1
- Maintenance Pantoprazole (Protonix) (see Pantoprazole, [[Pantoprazole]]): 8 mg/hr infusion x 72 hrs
- Systematic Review and Meta-Analysis of Proton Pump Inhibitor Continuous Infusion vs Intermittent Intravenous Proton Pump Inhibitor Dosing (2014) [MEDLINE]
- Study: systematic review and meta-analysis
- Primary Outcome: rebleeding at 7 days (additional predefined outcomes: rebleeding within 3 and 30 days, need for urgent intervention, mortality, red blood cell transfusion, and length of hospital stay)
- Main Findings: intermittent intravenous proton pump inhibitor dosing is comparable to continuous proton pump inhibitor intravenous infusion with endoscopically treated high-risk bleeding ulcers
Esophagogastroduodenoscopy (EGD)
- Early endoscopy (within 24 hours of presentation) is recommended for most patients with acute upper gastrointestinal bleeding. [Consensus Guidelines, Ann Int Med 2010; 152(2): 101-113]
[MEDLINE]
- Selected patients with acute ulcer bleeding who are at low-risk for rebleeding on the basis of clinical and endoscopic criteria may be discharged promptly after endoscopy. [Consensus Guidelines, Ann Int Med 2010; 152(2): 101-113]
- Low-Risk Criteria
- Clean ulcer base or flat pigmented spot
- Hemodynamic stability
- No serious concurrent medical illness
- Easy accessibility to hospital
- Adequate sociofamily support at home
- Low-Risk Criteria
- Most patients who have undergone endoscopic hemostasis for high-risk endoscopic stigmata should be hospitalized for at least 72 hours thereafter. [Consensus Guidelines, Ann Int Med 2010; 152(2): 101-113]
Interventional Radiology Embolization
- Where available, IR-embolization can be considered as an alternative to surgery for patients for whom endoscopic therapy has failed. [Consensus Guidelines, Ann Int Med 2010; 152(2): 101-113]
Reinstitution of Cardiovascular Anti-Platelet Agents
- In patients with previous ulcer bleeding who require cardiovascular prophylaxis, it should be recognized that clopidogrel alone has a higher risk for rebleeding than ASA combined with a PPI. [Consensus Guidelines, Ann Int Med 2010; 152(2): 101-113]
Treatment of Variceal Upper Gastrointestinal Hemorrhage
- See Esophageal Varices, [[Esophageal Varices]]
Treatment of Lower Gastrointestinal Hemorrhage
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References
- International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010 Jan 19;152(2):101-13. doi: 10.7326/0003-4819-152-2-201001190-00009 [MEDLINE]
- Intermittent vs continuous proton pump inhibitor therapy for high-risk bleeding ulcers: a systematic review and meta-analysis. JAMA Intern Med. 2014;174(11):1755 [MEDLINE]