Gastrointestinal Bleeding

Kent Zettel

A. James Moser

I. Gastrointestinal Bleeding

Overview.

Blood loss into the gastrointestinal (GI) tract from either proximal to the ligament of Treitz (upper GI bleed) or distal (lower GI bleed) is a consequence of many potential causes and has wide array of symptoms, ranging from asymptomatic hemoccult positive stools, recurrent intermittent blood loss, to hemorrhagic shock. For the purpose of this chapter, a general view of gastrointestinal bleeding will focus on the sources of active gastrointestinal bleeding.
Statistics.

Due to the advent of proton-pump inhibitors and H2 inhibitors, the incidence of peptic ulcer bleeding is decreasing, with most of these episodes associated with NSAID use and in the elderly (68% of cases of peptic ulcer are seen in those over the age of 60 years). More recent estimates place the incidence of upper GI bleeding at 89 per 100,000 population annually, with the decrease in incidence found only in those less than 70 years of age. Gastrointestinal bleeding is more common in men, who use NSAIDs and aspirin-related products, and the elderly, who are at an increased risk of death.
Initial patient history and physical evaluation
- Due to the multiple etiologies of GI bleeding, seek information on risk factors and comorbid conditions. Keep an open mind for rare causes of GI bleeding, as atypical bleeding sources may present in the manner of typical etiologies.
- The symptoms of GI hemorrhage range from an asymptomatic positive fecal occult blood test to hypovolemic shock with cardiovascular collapse. The severity of vomiting in upper GIB ranges from frank blood (hematemesis) to coffee ground emesis (hemoglobin degraded by gastric acid). The most common presentation in the hospital setting for lower GIB is hematochezia (gross blood seen either on toilet paper or mixed with stool), although it may also present as melena, anemia, abdominal pain, or hemodynamic instability.
- Key questions include presence of abdominal pain, weight loss, change in bowel habits, vomiting blood, blood per rectum, color of vomit or feces, and clots in their vomitus or feces.
- Evaluate for medications that interfere with the clotting cascade: Aspirin, novel anti-platelet agents such as clopidogrel, dabigatran, NSAID, enoxaparin, heparin, warfarin.
- Past medical history:
  - Ask about bleeding-specific diseases. Prior GIB, portal hypertension due to liver disease or Budd–Chiari, alcohol abuse causing gastritis, Helicobacter pylori infection or treatment for known peptic ulcer disease (PUD), factor VIII deficiency, Von Willebrand disease.
  - Next, seek general diseases that may cause bleeding. Prior operations, GI cancers such as colorectal cancer, gastrointestinal stromal tumors (GISTs), abdominal aortic aneurysm surgery, inflammatory bowel disease (IBD), radiation enteritis, pancreatitis (pseudocysts causing pseudoaneurysm and hemosuccus pancreaticus, splenic vein thrombosis causing sinistral portal hypertensive gastropathy), esophageal varices.
  - Check for significant comorbidities that may impair resuscitation or be exacerbated by resuscitation. Renal failure, congestive heart failure, myocardial infarction, underlying coagulopathy, transfusion reactions.
- Family history. Cancer (colon, pancreatic, gastric).
- Physical examination. Pay particular attention to the following:
  - Vital signs and orthostatic vital sign assessment to detect hypovolemia or shock.
  - Scleral icterus may identify underlying hepatic dysfunction, while pale conjunctivae demonstrate the degree of anemia.
  - Look for jugular venous distension and sternal evaluation for prior sternotomy scar to evaluate for signs of cardiac failure, murmurs from an underlying cardiomyopathy, previous infarction, rhythm, or prior cardiac surgery.
  - Abdominal examination with the focus of
    - Signs of liver disease: Hepatomegaly, jaundice, caput medusa, liver masses (primary or metastatic disease).
    - Splenomegaly: Coagulopathy or portal hypertension.
    - Scars indicating previous operations.
    - Focal tenderness or masses: Perforation, strictures, or cancer.
  - Asterixis suggests encephalopathy and potential end-stage liver disease, while agitation or depressed sensorium, may be from shock.
  - Rectal examination is targeted for a mass, tenderness, hemorrhoids, presence of stool or blood (overt or by guaiac testing), hemorrhoids, or fissures.
- Young and athletic individuals can tolerate more severe stress than their counterparts before demonstrating signs of shock, which may be more abrupt.
Causes of gastrointestinal bleeding
- The most common cause of melena (digested blood per rectum) is an upper GI source (five times more common than a lower GI source).
- Population-specific sources of gastrointestinal bleeding include the following:
  - Young patients. IBD, Meckel’s diverticulum, HIV/CMV infection.
  - Middle-aged patients. IBD, polyps, cancer, hemorrhoids, ulcers, varices, diverticulosis.
  - Older patients. Same as the middle-aged patient but also including AVM and ischemia.
- Use the history to help identify the cause (i.e., history of surgery and anticoagulation with anastomotic bleeding; an alcoholic with esophageal variceal bleeding; excessive NSAID use leading to an ulcer; or recent weight loss, pain, and thin stools that may indicate the presence of a bleeding colon cancer).
- Use the output to judge the location of the bleeding.
  - Hematemesis or coffee ground emesis imply an upper source or one that is proximal to the Ligament of Treitz.
  - Hematochezia and clots per rectum imply a lower source or a very brisk upper source.
  - Melena is black, tarry stool that is usually from an upper source. Fifty cubic centimeters of blood can produce this color and it is foul smelling (unlike the stool from a patient taking bismuth compounds that may have a similar black color).
  - Note that left colon bleeding is usually red; right colon bleeding typically produces melena, unless brisk.
- To determine the cause of a bleed, consider site specific pathology in combination with the four main categories of pathology: Vascular lesions, inflammation, cancer, and specific anatomic lesions.
  - Vascular lesions: Dieulafoy lesions, AVMs, varices.
  - Inflammation: IBD.
  - Cancer: Colon cancer, gastric cancer, polyps.
  - Anatomic lesions: Diverticulosis, Meckel’s diverticulum.
Upper gastrointestinal bleeding sources
- Esophagus. The most common are varices, Mallory–Weiss tear at the gastroesophageal junction (most will stop spontaneously), erosive esophagitis, cancer, Boerhaave’s syndrome.
- Stomach. A highly vascular organ with seven named arteries and perfused via many collaterals.
  - Gastric ulcers. Associated with aspirin, NSAID use or abuse, H. pylori infection, and gastric hypersecretion.
  - Type I is a single ulcer, usually on the lesser cure. Type II (gastric body ulcer in combination to a duodenal ulcer) and type III (prepyloric gastric ulcer) peptic ulcers are associated with increased gastric acid secretion. Type IV ulcers are juxtaesophageal.
  - Other causes. Bleeding from pseudoaneurysm due to pancreatic pseudocyst, lymphoma, cancer, polyp, GIST, Dieulafoy’s lesion, sinistral portal hypertensive gastropathy due to varices caused by splenic vein thrombosis, post-surgical marginal ulceration.
- Duodenum
  - Ulcers here cause 50% of upper GIB; most are in the duodenal bulb and if posterior involve the gastroduodenal artery.
    
    A rare cause of duodenal ulcers is from hypergastrinemia from Zollinger–Ellison syndrome, which is associated with multiple duodenal ulcers, distal duodenal or proximal jejunal ulcers and ulcers recalcitrant to medical therapy.
  - Other causes include cancer, diverticulum, hemobilia, aortoenteric fistula (after an abdominal aortic aneurysm repair).
Lower sources of GIB.
- Most (80%) will stop spontaneously, but 25% will recur. Most present in the elderly (>65 years) with medical comorbidities, making the patient less able to tolerate the consequences of major bleeding. Bleeding from a lower source is more likely to present as bright red blood per rectum. Brisk GI bleeding from an upper gastrointestinal source can also present with bloody stool and is often associated with hemodynamic compromise. About 10% of lower GIBs will have no identifiable source, and up to 40% of lower GIBs have more than one potential source.
- Small bowel
  - Meckel’s diverticulum (omphalomesenteric remnant). These are located within 2 ft of the ileocecal valve in the ileum and may contain acid-secreting gastric mucosa. The gastric mucosa is the target of technetium-99m during a “Meckel’s scan.”
  - Other causes include intussusception, sprue, IBD, AVMs associated with radiation enteritis, cancer, entero-enteral fistula, melanoma, lymphoma, infection, ischemia, small bowel diverticula, Zollinger–Ellison syndrome causing jejunal ulcers, aortoenteric fistulae.
- Large bowel
  - Diverticulosis. 30% to 50% of diverticular bleeding is massive; 25% of bleeds will recur after the initial spontaneous resolution.
  - AVM cause 20% to 30% of massive lower GIB cases. These are detected later in life (age 60 years or older) when ectatic and dilated vessels become thin-walled. The right colon is more often affected and they are usually multiple.
  - IBD. The majority of ulcerative colitis patients and one-third of Crohn’s patients will present with a GIB.
  - Cancer. Hemorrhage can arise from colonic polyps or cancers.
- Rectum/perianal disease including fistulae, fissures, hemorrhoids (with or without associated liver disease), and rectal prolapse. Many patients have a previous history, and an external examination with anoscopy may be helpful.

II. Initial Resuscitation and Development of a Treatment Plan

Initial resuscitation.
- Check the ABCs, start two large-bore (16 gauge preferred) IVs, and resuscitate initially with 1 to 2 L of crystalloid.
  - Recognize that if vital signs are initially profoundly abnormal or fail to respond to first fluid infusions, the patient is likely to need transfusion. Failure to respond to resuscitation also raises the likelihood that operative intervention will be required.
  - Determine the degree of shock and integrate into the decision making process (i.e., class III shock in an 80-year-old woman will need a far more aggressive plan than a 20-year-old with blood visible upon wiping).
  - Large bore central venous catheters may be indicated for unstable patients or when peripheral access is limited.

Develop a treatment plan

Risk-stratify the patient: Determine degree of anemia which can be tolerated and the best setting in which to resuscitate the patient. Several scoring systems have been developed to identify high-risk patients who will benefit from urgent intervention. Scoring systems for upper GIB include the Blatchford score (Table 47-1) and the Rockall score (Table 47-2).

The Blatchford score (Table 47-1) stratifies the risk that a patient will require intervention for GI bleeding. Patients with Blatchford score of zero may be discharged without endoscopic therapy and treated in outpatient setting.

The Rockall score (Tables 47-2 and 47-3) evaluates the risk of mortality of a patient with GI bleeding. Although this is a good predictor of mortality, it does not adequately assess the risk of need for intervention.

Table 47-1 The Glasgow-Blatchford Score Assess the Likelihood That a Patient with an UGIB will Require Intervention. A Score of 0 Identifies Low Risk Patients Who Can be Managed in an Outpatient Setting

Risk factor	Score
BUN
≥6.5–<8.0	2
≥8.0–<10.0	3
≥10.0–<25	4
≥25	6
Hemoglobin (men, women) (g/dL)
≥12.0–<13, men; ≥10.0–<12.0, women	1
≥10.0–<12.0, men	3
<10.0, men; <10.0, women	6
Systolic blood pressure (mm Hg)
100–109	1
90–99	2
<90	3
Other
Pulse ≥100 beats/min	1
Presentation with melena	1
Presentation with syncope	2
Hepatic disease	2
Cardiac failure	2

Table 47-2 The Rockall Score is a Screening Evaluation to Assess the Risk of Mortality of a Patient with an UGIB. The Full Score Requires Endoscopy. The Maximum Score Prior to Endoscopy is 7, and After Endoscopic Findings, the Maximum Score is 11. The Pre-endoscopy Rockall Score is a Poor Predictor of Need for Endoscopic Therapy in Upper GIB. The Glasgow-Blatchford is a Better Predictor of the Need for Endoscopic Therapy.

Risk factor	Score
Age (y)
<60	0
60–79	1
≥80	2
Shock
No shock, SBP >100 mm Hg, HR <100 beats/min	0
Tachycardia (HR ≥100 beats/min)	1
Hypotension (SBP <100 mm Hg)	2
Comorbidities
None	0
Cardiac failure, ischemic heart disease, any major comorbidity	2
Renal failure, liver failure, disseminated malignancy	3
Diagnosis
Mallory–Weiss	0
All other diagnoses	1
Malignancy of upper GI tract	2
Stigmata of recent hemorrhage
None	0
Blood in upper GI tract, adherent clot, or spurting vessel	2