Upper and Lower Gastrointestinal Bleeding



Upper and Lower Gastrointestinal Bleeding


Ryan F. Porter

Gary R. Zuckerman

Chandra Prakash Gyawali



Acute gastrointestinal (GI) bleeding is a common emergency that often necessitates admission to the intensive care unit (ICU). There are compelling differences in incidence, clinical presentation, severity, and mortality between lower and upper GI hemorrhage. The annual incidence rate of lower intestinal bleeding is estimated at 20.5 to 33 cases per 100,000 adult populations [1,2], while that of upper GI bleeding is estimated between 60 and 125 cases per 100,000 [3,4]. The incidence of upper GI bleeding has declined in those younger than age 70 years to as low as 47 per 100,000 over the past decade [2,5]. Helicobacter pylori eradication efforts and widespread use of proton pump inhibitor (PPI) therapy may account for this decline. The incidence in older populations, however, remains stable possibly from more frequent use of aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) [4,6]. The majority of upper GI bleeds are nonvariceal (80% to 90%), of which 28% to 59% are attributable to peptic ulcer bleeding [3,4]. Patients with lower GI bleeding are half as likely to present with hemodynamic compromise or require blood transfusion, and have significantly higher hemoglobin concentrations at presentation compared to upper GI bleeding [7]. The mortality rate from upper GI bleeding has remained stable at 5% to 12%, while mortality rates for lower intestinal bleeding remain below 5% [4,7]. Newer surgical, endoscopic, and medical therapies, as well as improved ICU care, will hopefully improve survival rates for both upper and lower GI bleeding in the coming years.


Initial Evaluation and Resuscitation

Resuscitating the actively bleeding patient takes priority over localizing the bleeding source. The immediate goals are to replete intravascular volume and prevent irreversible shock. However, even in situations of exsanguinating hemorrhage, limited attempts to localize bleeding while resuscitation continues may be required to help direct a surgical or angiographic approach.

An initial brief history and physical examination that includes serial measurement of vital signs and evaluation of the volume and character of bleeding helps determine the urgency and degree of resuscitation necessary. Tachycardia (pulse > 100 beat per minute), hypotension (systolic blood pressure < 100 mm Hg), or orthostatic hypotension (an increase in the pulse of ≥ 20 beats per minute or a drop in systolic blood pressure of ≥ 20 mm Hg on standing) indicates significant intravascular volume depletion [4]. Insight into volume status can also be gained from evaluation of mucous membranes and neck veins, and measurement of urine output [4]. Bleeding patients will need large bore intravenous-access catheters (e.g., peripheral catheters 16 or 18 guage or central venous access), supplemental oxygen, correction of coagulopathies and prompt packed red blood cell transfusion for tachycardia, hypotension or hemoglobin less than 10 g/dL [4]. Clinical parameters and evidence of gross bleeding will dictate the approach, but preparedness should be for the potential of massive bleeding.

Older patients with hemodynamic compromise or shock have a poor outcome (Table 91.1) and need urgent resuscitation and close monitoring. In situations of massive hematemesis, endotracheal intubation provides airway protection and facilitates endoscopic evaluation and therapy. Chest pain may imply a superimposed myocardial infarction or dissecting aneurysm, whereas a history of abdominal vascular surgery adds aortoenteric fistula to the differential diagnoses. GI bleeding is generally not associated with significant abdominal pain, and its presence could signify hematobilia, intestinal infarction, or intestinal perforation.


Further Evaluation and Management

Resuscitation may need to continue even after the initial volume deficit has been corrected if there is evidence of ongoing or renewed bleeding. Because of the laxative properties of fresh blood in the GI tract, repeated passage of liquid blood per rectum implies ongoing or recurrent bleeding. As bleeding stops, the stool becomes formed and converts from red or maroon blood to darker stool and eventually to brown stool that contains occult blood, which may persist for as long as 2 weeks after GI bleeding has ceased.








Table 91.1 Clinical Risk Factors for Mortality in Acute Upper Gastrointestinal Bleeding































Clinical feature Mortality (%)
Age ≥ 60 y 11
Age < 60 y 1
Shock on admission 23
No shock 4
Rebleeding in 72 h 30
No rebleeding 3
Failure to clear red nasogastric aspirate 50
Red-to-clear nasogastric return 8
Data derived from Branicki FJ, Boey J, Fok PJ, et al: Bleeding duodenal ulcer: a prospective evaluation of risk factors for rebleeding and death. Ann Surg 211:411, 1989; Hunt PS: Bleeding gastroduodenal ulcers: selection of patients for surgery. World J Surg 11:289, 1987; and MacLeod IA, Mills PR: Factors predicting the probability of further hemorrhage after upper gastrointestinal hemorrhage. Br J Surg 69:256, 1982, with permission.









Table 91.2 Complete Rockall Score for Risk Stratification of Acute Upper Gastrointestinal Bleeding













































Variable Points
Clinical Rockall score
   Age
      < 60 y 0
      60–79 y 1
      ≥80 y 2
   Shock
      Heart rate > 100 beats/min
1
      Systolic blood pressure < 100 mm Hg 2
   Coexisting illness
      Coronary artery disease, congestive heart failure, other major illness
2
      Renal failure, hepatic failure, metastatic cancer 3
   Endoscopic diagnosis
      No finding, Mallory–Weiss tear
0
      Peptic ulcer, erosive disease, esophagitis 1
      Cancer of the upper GI tract 2
   Endoscopic stigmata of recent bleeding
      Clean based ulcer, flat pigmented spot
0
      Blood in upper GI tract, active bleeding visible vessel, clot 2
Note:Patients with a clinical Rockall score of 0 or a complete Rockall score of < 2 are considered to be at low risk for rebleeding or mortality. Higher scores indicate higher risks.
Adapted from Gralnek IM, Barkum AN, Bardou M: Management of acute bleeding from a peptic ulcer. N Engl J Med 359:928–937, 2008.

In patients without hematemesis, a nasogastric (NG) tube aspirate of red blood may be a poor prognostic sign [3,4], but the lack of red blood or coffee ground material does not exclude an upper GI bleeding source [4]. Clinical variables at presentation in combination with endoscopic findings have been used to triage and risk-stratify patients, assess risk of poor outcomes, and aid in guiding management [3,4]. The Glasgow-Blatchford Score is a validated tool based solely on clinical variables scored from 0 to 23, with higher values predictive of higher risk. Scores of 0 are at low risk of rebleeding and mortality and can be considered for outpatient management [4,8]. The Rockall Score can be calculated prior to and after endoscopy (Table 91.2), with higher scores predictive of higher risk of a poor outcome [4,9]. While their exact role in clinical management continues to be evaluated, these scores will likely continue to have an increasing role in patient care.


Diagnostic Evaluation


Bedside Diagnosis

While hematemesis is clearly a symptom of upper GI bleeding, black tarry melenic stool predicts an upper GI bleeding source, and brighter colors of red in the stool are more often associated with a distal colonic bleeding source. However, color of bloody stool may not always be helpful in predicting the level of GI bleeding and is subject to interpretation variability of both patients and physicians. A pocket-sized color card is helpful in confirming the stool color, as described by the patient, and suggesting the level of bleeding in the GI tract [10]. When bright blood in the stool (implying a lower GI bleed) is associated with hemodynamic compromise, as many as 11% of patients may have an upper GI bleeding source, even if the NG aspirate is negative [3,4]. In this setting, an upper endoscopy may be the first endoscopic evaluation even though the presenting symptom is hematochezia.


Upper Endoscopy

When bleeding is suspected to originate proximal to the jejunum, esophagogastroduodenoscopy (upper endoscopy) is the diagnostic procedure of choice. This identifies the bleeding source in 80% to 90% of cases with a high degree of accuracy, provides therapeutic options, and carries low morbidity [3,4]. Endoscopy has the added advantage of detecting prognostic signs (Table 91.2) and classifies bleeding stigmata as high or low risk for rebleeding based on the Forrest grade (Table 91.3) [11].

Even when an exact diagnosis cannot be made, localizing the bleeding to a specific region within the upper GI tract can be helpful to the surgeon (if resection is indicated) or interventional radiologist (if embolization of the bleeding vessel is recommended). Erythromycin or metoclopramide can be administered intravenously to induce gastric emptying and clear the stomach of blood and clots prior to endoscopy [12,13]; repeated lavage with saline through a wide-bore orogastric tube also may be used for this purpose. However, routine gastric lavage may not be necessary and is not endorsed by the authors. Complications related to endoscopy are higher when the procedure is performed on an emergency basis.








Table 91.3 Risk Factors for Continued Bleeding or Rebleeding from Peptic Ulcer








































Endoscopic finding Forrest grade Proportion that continues to bleed or rebleed (%)
Arterial bleeding IA 90
Nonbleeding visible vessel IIA 40–50
Adherent clot IIB 10–25
Oozing IB < 20
Flat pigmented spot IIC < 10
Clean ulcer base III < 5
Ulcer of posterior-inferior duodenal bulb (gastroduodenal artery)   a
Ulcer of lesser-curve gastric body (left gastric artery)   a
aPercent unknown but frequent finding at surgery for ongoing bleeding.
Note: Forrest grades IIC and III are considered low risk for rebleeding.
Data from NIH Consensus Conference: Therapeutic endoscopy and bleeding ulcers. JAMA 262:1369, 1989; Swain CP: Pathology of bleeding lesions, in Sugawa C, Schuman B, Lucas C (eds): Gastrointestinal Bleeding. New York, Igaku-Shoin, 1992, p 26; Lane L: Rolling review: upper gastrointestinal bleeding. Aliment Pharmacol Ther 7:207, 1993; Forrest JA, Finlayson ND, Shearman DJ: Endoscopy in gastrointestinal bleeding. Lancet 2:394–397, 1974.

The timing of endoscopy in upper GI bleeding continues to be evaluated. Endoscopy within 12 hours of presentation increased the use of endoscopic therapy but did not reduce rebleeding rates or improve survival rates [14]. However, endoscopy within 24 hours did demonstrate a reduction in the length of hospital stay and need for surgical intervention [15,16]. Patients with bloody NG aspirate did benefit from
endoscopy within 12 hours to reduce the blood transfusion requirements and length of hospital stay [14]. Therefore, endoscopy offered within 24 hours of upper GI bleeding presentation appears appropriate, with consideration for early endoscopy within 12 hours for patients with bloody NG aspirate or clinical suspicion for high-risk lesions [17]. The benefit of a repeat “second-look” endoscopy is an area of investigation, especially in the presence of factors associated with an increased risk of rebleeding (history of peptic ulcer disease, previous ulcer bleeding, presence of shock at presentation, ulcers > 2 cm, large underlying bleeding vessel ≥ 2 mm diameter, and ulcers located in lesser curve of stomach or posterior/superior duodenal bulb) [18,19]. A meta-analysis in 2003 concluded that second-look endoscopy was associated with a decreased risk of recurrent bleeding but did not alter subsequent surgery rates or mortality [20]. Scheduled repeat endoscopy therefore is not routinely recommended, but can be considered on an individual case basis if clinical signs of recurrent bleeding are present or if there are questions about adequate hemostasis [21,22].


Enteroscopy

If a small bowel lesion is suspected after a negative upper endoscopy, a longer endoscope can be used to evaluate the proximal small bowel (push enteroscopy), which allows visual inspection and endoscopic hemostasis of bleeding lesions as far distal as the proximal jejunum [23]. Further evaluation of small bowel bleeding lesions can be provided by capsule endoscopy. Disadvantages of capsule endoscopy in acute bleeding include the lack of accurate localization of visualized lesions, and the fact that the test is not performed in real time [23]. Bleeding lesions beyond the reach of a push enteroscope can potentially be approached using single- and double-balloon enteroscopy, techniques that allow for visualization of most of the small bowel. Balloons at the endoscope tip and an overtube can be consecutively inflated and deflated while inserting and pulling out the endoscope to allow bowel to pleat over the overtube, thus allowing deep endoscope insertion into the small bowel, either through the mouth or the anus [23].


Sigmoidoscopy/Colonoscopy

When a distal lower GI bleeding source is suspected, early sigmoidoscopy may be helpful if the bleeding is not of a magnitude that would prevent adequate visualization. For most situations, however, colonoscopy replaces sigmoidoscopy in the diagnostic approach. Early colonoscopy provides a higher yield of the bleeding source compared to radiologic studies, especially when performed within 24 hours of presentation [24,25]. In patients with severe hematochezia and diverticulosis, urgent colonoscopy (within 6 to 12 hours of hospitalization or diagnosis of hematochezia) after rapid bowel purge can provide endoscopic treatment of diverticular hemorrhage and may prevent recurrent bleeding and decrease the need for surgery [26]. Only 20% of patients with lower GI bleeding, however, have a lesion amenable to endoscopic intervention [27]. Even when the exact cause of bleeding cannot be determined, colonoscopy may localize fresh blood to a segment of colon and direct further therapies such as angiotherapy or surgery. Patients with subacute bleeding or hemorrhage that has ceased can undergo adequate bowel preparation followed by semiurgent colonoscopy [28].


Radionuclide Bleeding Scan

The technetium-99m–labeled red blood cell scan performed at the bedside offers a noninvasive diagnostic approach to patients suspected of having GI bleeding originating beyond the reach of an endoscope, especially in unstable patients where bowel preparation or endoscopy cannot be safely performed. Although bleeding rates as low as 0.1 mL per minute can be detected by this method, the patient should have evidence of ongoing bleeding during the study [7]. If the test localizes bleeding, angiography or endoscopy (push enteroscopy, colonoscopy, double-balloon enteroscopy, capsule endoscopy) is needed to confirm the site, to further define the cause, and to offer therapy for ongoing bleeding [7]. If the test is negative, colonoscopy followed by capsule endoscopy is usually performed to evaluate potential colonic and small bowel bleeding sources [23].


Mesenteric Arteriography

Because a more rapid bleeding rate is necessary for a positive arteriogram (0.5 mL per minute), this procedure typically is performed after active bleeding is documented on a radionuclide bleeding scan [7]. However, because of the intermittent nature of bleeding and the variable timing of mesenteric arteriography, a positive red blood cell scan does not always result in a diagnostic arteriogram [7]. Arteriography is also useful for upper GI bleeding sources not visualized on upper endoscopy because of rapid bleeding or a blood-filled stomach.


Therapeutic Procedures for Hemostasis

Evidence-based recommendations for the therapy of GI bleeding are summarized in Table 91.4.


Endoscopic Therapy (Endotherapy)

Endotherapy offers a convenient and expedient method for treatment of GI bleeding. Although endotherapy was primarily used for the treatment of upper GI and peptic ulcer bleeding, these modalities can also be applied to patients with lower GI bleeding [4,29,30,31]. Endotherapy is indicated for all patients with high-risk lesions because of the significant risk of persistent or recurrent bleeding (22% to 55%) and even death
if left untreated [3,4,32]. Randomized trials demonstrate that endotherapy for upper GI bleeding decreases further bleeding, shortens hospital stay, decreases transfusions, decreases emergency surgery, decreases mortality, and lowers costs [17]. Optimal therapy for adherent clots remains controversial; a recent meta-analysis demonstrated reduced rebleeding rates (RR 0.35, 95% CI 0.14–0.82) with endoscopic removal of clot and treating of the uncovered lesion, but no change in length of hospitalization, need for surgery, transfusion requirements, and mortality compared to only medical therapy [33,34,35].








Table 91.4 Summary of Evidence-Based Findings for Therapy of Gastrointestinal (Gi) Bleeding






  • Octreotide infusion is an effective adjunct to endoscopic therapy for variceal bleeding [51,57,58].
  • Endoscopic variceal band ligation is the therapy of choice for esophageal variceal bleeding [71].
  • Identification of patients at high risk for rebleeding and mortality, and early diagnostic endoscopy with hemostatic therapy in patients with high-risk stigmata of rebleeding improve outcome in acute nonvariceal upper GI bleeding [8,9,11,101].
  • Intravenous proton pump inhibitors, especially when administered as an infusion after a bolus dose, are superior to intravenous histamine-2 receptor antagonists in the reduction of rebleeding after successful endoscopic therapy in acute nonvariceal upper GI bleeding [105,106,108].
  • Early colonoscopy for acute lower GI bleeding may identify a bleeding source more often compared to radiologic studies, but the choice of diagnostic test may not affect patient outcome [25].

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Sep 5, 2016 | Posted by in CRITICAL CARE | Comments Off on Upper and Lower Gastrointestinal Bleeding

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