(1)
Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
Keywords
Gastrointestinal bleedingPeptic ulcer diseaseEsophageal varicesCoagulopathyDiverticulosisAngiodysplasiaEndoscopyUpper GI bleeding (UGIB)Non-steroidal anti-inflammatory drugs (NSAIDS)Initial Assessment
The urgency with which GI bleeding is managed is dictated by the rate of bleeding
the patient with trace heme-positive stools and without severe anemia can be managed as an outpatient
visible blood requires hospitalization and inpatient evaluation
persistent bleeding or re-bleed with hemodynamic instability necessitates ICU admission
massive bleeding is defined as loss of 30 % or more of estimated blood volume or bleeding requiring blood transfusion of 6 or more units/24 h.
Hemodynamic assessment (see Table 35.1)
Table 35.1
Correlation between physical signs and severity of UGIB
Physical sign
Mild
Moderate
Severe
Blood Loss
<1 L
1–2 L
≥2 L
Blood pressure
Normal
N-borderline low
Hypotensive
Orthostasis
No
Possible
Likely
Tachycardia
None-mild
Moderate
Severe
Skin
Warm, perfused
Diaphoretic
Cool, clammy
Urine output
Normal
Diminished
Poor
Sensorium
Alert/anxious
Anxious
Confused/drowsy
blood pressure, pulse, postural changes and assessment of peripheral perfusion.
The presence of co-morbid disease must be determined, especially CAD and cardiac failure
Estimating blood loss. This can be estimated by measuring the return from a NG tube.
An approximate estimate of blood loss can also be made by the hemodynamic response to a 2-L crystalloid fluid challenge:
If BP returns to normal and stabilizes, blood loss of 15–30 % has occurred
If BP rises but falls again, blood volume loses of 30–40 % has occurred
If BP continues to fall, blood volume loss of >40 % has probably occurred
History and examination: Attempt to localize most likely source of bleeding
Use of NSAID, alcohol, antiplatelet drugs and anticoagulants
History of GERD, chronic epigastric pain, renal failure, weight loss, vomiting before bleeding, etc.
Previous history of bleeding
The presence for melena indicates upper GI bleeding
Hematemesis indicates upper GI bleeding
When small amounts of bright red blood are passed per rectum; the lower GI tract can be assumed to be the source
In patients with large-volume maroon stools, NG tube aspiration should be performed to exclude upper GI hemorrhage. It should be noted that in about 15 % of patients with upper gastrointestinal bleeding NG aspirate will fail to obtain blood or “coffee ground” material.
Nasogastric aspiration with saline lavage is beneficial to detect the presence of intragastric blood, to determine the type of gross bleeding, to clear the gastric field for endoscopic visualization, and to prevent aspiration of gastric contents. NG tube placement is essential to monitor ongoing bleeding and to decompress the stomach.
Concerns that placement of a nasogastric tube may induce bleeding in patients with coagulopathies are outweighed by the benefits of the information obtained.
Laboratory tests:
serum chemistries (incl. BUN and creatinine), CBC, coagulation profile PT, PTT, INR), liver function tests
Cardiac enzymes (troponins) and ECG
Patients should be risk stratified on admission based on the patient’s age (over 65 years), hemodynamics, hemoglobin, renal function and comorbidities into a high and low risk group. The Blatchford risk score can be used for this purpose (see Table 35.2) [1]. A score ≥6 indicates an increased risk for an intervention to control bleeding. Such patients should be admitted to the ICU.
Initial Resuscitation
Establish 2 large bore IV lines or a large bore central line.
Insert NG tube and aspiration (by hand).
Volume expansion with crystalloids (LR preferred, see Chap. 9).
Monitor BP, pulse and urine output.
Cross match blood. Blood products are the most efficient volume expanders and should be infused as soon as possible in patients with significant bleeds. Transfusion requirements are determined by multiple factors, including patient age, presence of comorbidities, cardiovascular status, baseline hematocrit, and tempo of the bleeding, along with the current hematocrit level. RBCs are transfused in patients who have significant blood loss, continuing active bleeding, and those who manifest cardiac, renal, or cerebral ischemia. The rate of blood transfusion is determined by the severity of the hypovolemia, by the tempo of the bleeding, and by the presence of comorbidities. Patients should be resuscitated to a target hemoglobin of 7 g/dL; targeting a higher hemoglobin is associated with an increased risk of rebleeding, infections and death (see Chap. 38). Villanueva et al. randomized patients with an UGIB to a transfusion trigger of 7 g/dL or 9 g/dL [2]. In this study, the restrictive transfusion strategy was associated with a lower risk of rebleeding (10 % vs. 16 %, P = 0.01) and adverse events (40 % vs. 48 %, P = 0.02) with a greater probability of survival in the subgroup of patients with cirrhosis and Child–Pugh class A or B disease (hazard ratio, 0.30; 95 % CI, 0.11–0.85).
It is important to note that it takes up to 72 h for the hematocrit to reach its nadir after a single episode of bleeding (assuming no other intervention). Therefore a normal hemoglobin (on admission or soon thereafter) does not exclude significant bleeding. Blood transfusion should not be withheld from actively bleeding patients, based on their hemoglobin/hematocrit. Conversely a falling hematocrit does not imply continued bleeding; but rather may represent equilibration of fluid between the intravascular and extra-cellular extravascular compartment.
In patients with active bleeding fresh frozen plasma should be given if the INR > 1.6. However, as there is limited data that correcting the INR improves outcome endoscopy should NOT be delayed pending attempts at correcting the INR [3].
Platelet transfusion is indicated if the platelet count is <50,000/mm3. In general FFP and platelets should be given after 4–6 units of RBC’s (see Chap. 38). While a ratio of 1:1:2 (1 unit FFP, one unit platelets for each unit 2 units of blood) has shown a benefit in trauma patients, there is a lack of data for the use of these blood products in non-traumatic patients requiring massive transfusion.
Airway protection. The risk of aspiration is especially high in patients with massive bleeding or those who have an altered mental status. Endotracheal intubation is recommended in these patients. In addition, endotracheal intubation facilitates endoscopy. It may be advisable to place a NG tube prior to intubation in an attempt to empty the stomach and reduce the risk of aspiration during endotracheal intubation.
In patients with severe upper GI bleeding and clinical evidence or a history of advanced liver disease or a history of previous variceal bleeding an octreotide infusion should be commenced prior to endoscopy (see treatment of variceal hemorrhage below).
In patients with presumed UGIB proton pump inhibitor (PPI) therapy is recommended before EGD. The rationale for PPI therapy is that the most common causes of UGIB, including ulcers, gastritis, duodenitis and hemorrhagic reflux esophagitis, are medically treated with acid-suppressive therapy. PPI therapy is also useful, however, for hemostasis of lesions that are not caused by acid and are not usually treated by PPI therapy, probably because neutralization of intraluminal gastric acid promotes hemostasis by stabilizing blood clots. Experimental data have shown that gastric acid impairs clot formation, promotes platelet disaggregation, and favors fibrinolysis.
Intravenous erythromycin (70–100 mg), through its effect as a motilin receptor agonist, has been shown to promote gastric motility and substantially improve visualization of the gastric mucosa on initial endoscopy. A meta-analysis by Barkun et al. demonstrated that a prokinetic agent significantly reduced the need for repeat EGD (OR 0.55; 95 % CI, 0.32–0.94) [4]. Prokinetic agents may therefore be useful in patients who are suspected to have substantial amounts of blood or clot in their upper GI tract or those who have recently eaten [3].
All patients who have acute GIB require gastroenterology consultation.
Surgical consultation is recommended for patients who have ongoing active bleeding, massive bleeding, recurrent bleeding, bleeding associated with significant abdominal pain, acute lower gastrointestinal bleeding, and abdominal findings suggestive of an acute abdomen.
Triage of Patients. Who to Admit to the ICU?
At the time of triage the following criteria can stratify patients into a high risk group (high risk of re-bleeding, requiring surgery, and dying).
a systolic blood pressure of <100 mmHg on admission
severe comorbid disease
evidence of active, ongoing GI hemorrhage at the time of triage
INR > 1.6
The rate of rebleeding is approximately 3 % in the low risk group as compared to 25 % in the high risk group. Patients in the low risk group do not require admission to an ICU and can be adequately managed on a general medical floor. The Blatchford Risk Severity Score can also used to risk stratify patients (see Table 35.2). A score ≥6 indicates an increased risk for an intervention to control bleeding. Such patients should be admitted to the ICU.
Table 35.2
Blatchford risk severity score
Admission risk marker | Score |
|---|---|
BUN (mg/dL) | |
<17.1 | 0 |
>17 < 22.5 | 2 |
>22.5 < 28 | 3 |
>28 < 70 | 4 |
>70 | 6 |
Hemoglobin (g/dL)—men | |
≥13 | 0 |
≥12 < 13 | 1 |
≥10 < 12 | 3 |
<10 | 6 |
Hemoglobin (g/dL)—women | |
≥12 | 0 |
≥10 < 12 | 1 |
<10 | 6 |
Systolic blood pressure | |
>109 | 0 |
100–109 | 1 |
90–99 | 2 |
<90 | 3 |
Other markers | |
Pulse >100 | 1 |
Presentation with melena | 1 |
Presentation with syncope | 2 |
Hepatic disease | 2 |
Cardiac failure | 2 |
Upper GI Bleeding
Upper gastrointestinal bleeding (UGIB) is a common, potentially life threatening condition responsible for more than 300,000 hospital admissions and about 30,000 deaths per annum in America. Accurate patient evaluation and appropriate early management before esophagogastroduodenoscopy (EGD) is critical to decrease the morbidity and mortality [5].
UGIB is defined as bleeding proximal to the ligament of Treitz, to differentiate it from lower gastrointestinal bleeding involving the colon, and middle gastrointestinal bleeding involving the small intestine distal to the ligament of Treitz. It has a mortality of 7–10 % [5]. The mortality has decreased only minimally during the last 30 years, despite the introduction of endoscopic therapy that reduces the rate of rebleeding. This observation has been attributed to the increasing percentage of UGIB occurring in the elderly, who have a much worse prognosis than other patients because of their frequent use of antiplatelet medications or anticoagulants, and their frequent comorbid conditions. Peptic ulcer disease causes more than 60 % of cases of UGIB whereas esophageal varices cause approximately 6 % [6].
