An Approach To:
Gastrointestinal Bleeding
Amir SurmawalaPGY 2Bruyere Family Medicine
Upper vs. LowerObscure | Occult
ClassificationUpper gastrointestinal bleeding:Bleeding that originates from the gastrointestinal (GI) tract proximal to the ligament of Treitz (the junction of the duodenum and jejunum).
Lower gastrointestinal bleeding:Bleeding distal to the ligament of Treitz, and thus includes bleeding sources in the small bowel and colon. It is sometimes subcategorized as bleeding from the small bowel vs. bleeding from the colon.
Definitions
Hematochezia: passage of bright red blood per rectum
Melena: stools that appear black and tar-like (see picture)
Upper GI Bleeding - DDX Peptic Ulcer Disease (~50%): Gastric vs. Duodenal
Inflammatory: Esophagitis (CMV, Medication), Gastritis (10-20%), IBD (Crohn’s)
Varices: Esophagus (10-30%) vs. Stomach
Structural: Mallory-Weiss tear (10%); Boerhaave’s syndrome; Dieulafoy’s lesion; AVM; Aortoenteric fistula; Hemobilia
Tumor: Esophagus, Stomach, Duodenum
Other: Epistaxis, Hemoptysis, Coagulopathy
Duodenal ulcer with a visible vessel
Bleeding esophageal varix
Severe esophagitis
Lower GI Bleeding - DDX Upper GI Source with Brisk Bleeding (>1000mL)
Infectious: SECSY (Salmonella, E.coli - EHEC, EIEC, Campylobacter + C.diff, Shigella, Yersinia). Amoeba.
Inflammatory: Crohn’s and Ulcerative Colitis, Radiation Colitis
Ischemic: Ischemic colitis
Tumor: Colorectal, Small bowel, Polyp
Structural: Diverticulosis (R>L), Angiodysplasia, Intussusception, Meckel’s Diverticulum, Anorectal: Hemorrhoids, Anal Fissure
Blood vessel within a colonic diverticulum
Angiodysplasia of the colon
Ulcerative colitis
Ischemic colitis on colonoscopy
Immediate Resuscitation
1. ABC’s: 2 Large bore peripheral IVs, Crossmatch Blood, Start Transfusion if indicated
2. Immediate evaluation: NG, Postural changes, ECG, Trop, Urea
3. Reverse anticoagulation
4. Transfusion target: Start if Hgb <70 or hemodynamic instability. Target ~ 90
GI Bleed - History
Hematochezia > Hematemesis > Coffee ground emesis > Melena > Occult blood in stool
EtOH abuse, intoxication, emesis
Liver Disease
PMHx: PUD, H.pylori, Renal disease, Heart disease
Hematochezia, Occult Blood. Rarely Melena
Abd pain, fever, diarrhea
PMHx: IBD, cancer, diverticulosis
Meds: AC, NSAIDs
Last Meal
Constitutional symptoms
UPPER LOWER
GI Bleed - Physical
Signs of Cirrhosis
Bloody NG Aspirate (Occult Blood testing not validated)
Obvious signs of HEENT bleed
Mass, Hemorrhoid or fissure on rectal examination
ABC’s and Vitals
Signs of Hypovolemia: *Postural Changes (SBP >20, DBP>10, Pulse >30)
Abd. Exam, Rectal exam +ve for Occult Blood
UPPER LOWER
GI Bleed - Investigation
BUN/Creatinine ratio >20 OR Urea/Creatinine ratio >100
Due to degradation of blood cells and absorption of protein
Stool C&S, O&P, C.diff toxin
CBC, lytes, Cr, urea, type/crossmatch, PTT, INR, LFT’s, bilirubin, albumin
CXR, AXR, CT Scan
Upper and Lower Endoscopy
Angiography, RBC Scan
UPPER LOWER
Angiography vs. RBC Scan
If source not found via Endoscopy:
FASTER Bleed (>0.5ml/min): Angiography.
Embolization
SLOW Bleed (<0.5ml/min): 99Tc RBC Scan.
Detects 0.1ml/minhttp://www.wjgnet.com/1007-9327/full/v18/i11/WJG-18-1191-g004.jpg
Management As Per Etiology
UGIB Non-Variceal:
IV PPI (Pantoprazole 80mg bolus over 1h, then 8mg/hr infusion IV Erythromycin 250mg, 30min prior to Endoscopy (to facilitate gastric
emptying)
LGIB PEG Lavage to facilitate Endoscopy
Variceal: IV Octreotide (50mcg bolus, then 25-50mcg/hr infusion) If Cirrhosis - IV abx (Ceftriaxone OR Cipro x 10d.)
Definitive management is usually Endoscopic, Vascular or Surgical intervention
Tips on Occult GI Bleeding
Common foods and drugs that can cause the stool to appear bloody
Red coloration, similar to fresh blood
Certain antibiotics*
Beets
Flavored gelatin (red colored)
KoolAid or fruit punch (red colored)
Red licorice
Reddyed snack foods (eg, spicy "redhot" snacks)
Black coloration, similar to melena
Bismuth preparations (PeptoBismol, Maalox, Kaopectate)
Activated charcoal
Chocolate
Blueberries
Iron supplements
Large quantities of some dark green foods
Falsepositive results to fecal occult blood test
Rare red meat
Peroxidasecontaining vegetables (turnips, horseradish, broccoli, cauliflower, and cantaloupe)
* Several reports have described cases of very redappearing stools associated with cefdinir, apparently
¶
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The Tests FOBT
Guaiac based test (Guaiac changes color in the presence of pseudoperoxidase contained in Heme)
Detection: 10mg/gram of stool
iFOBT or FIT Antibody directed against human
hemoglobin
Detection: 0.3mg/gram of stool
More sensitive and specific for Lower GI blood loss; as well as for colon cancer screening
8/13/2015 Colorectal Cancer Association of Canada - CCAC
http://www.colorectal-cancer.ca/en/screening/fobt-and-fit/ 4/5
AutoFIT Personal Pack CollectionMaterials
Automated Analyzer OCAuto Micro 80 used forAuto FIT Testing
Automation allows for standardization and quality control in the laboratory as well as a closed systemenvironment ensuring safety from biohazards for technologists running the test.
Supplies include a collection device/bottle, absorbent paper, biodegradable collection paper, and asample mailing envelope. This personal pack/ kit will provide detailed instructions on how to collect thespecimen and it will also provide an educational brochure on the benefits of screening. Themanufacturer advises that AutoFIT can pick up as little as 0.3 ml of blood and that it significantlyimproves sensitivity and specificity over traditional guaiac based methods.14 Testing requires only onesingle sample collection with no dietary or medicinal restrictions resulting in increased patientcompliance, a primary goal of colorectal cancer screening methods and programs. Both FOBT andiFOBT can help direct the “right” patients to colonoscopy thereby leading to the earlier detection ofpolyps and colorectal cancer.15
A summary of the differences between gFOBT (traditional guaiac) and AutoFit is shown below as wellprovided by Somagen (www.somagen.com).
Feature AutoFIT Guaiac Test
Dietary Restrictions None Yes
Restriction on Medications None Yes
Number of Samples Required 1 3
Number of Days Required for SampleCollection 1 3
Specificity 99% 98%*
Sensitivity 100% 50%
Patient Compliance 91%** 23%
Methodology Automated Manual
Specimen Container Completely ClosedSystem
Open System, Risk ofExposure
Collection of Sample Easy, one step Subject to Patient Error
*Denotes strict adherence to sample collection regarding diet and medications** European J of Cancer Prevention 2006; 15: 384390
Disclosure:
The contents of this section were made possible through an unrestricted educational grant fromSomagen Diagnostics Inc. The Colorectal Cancer Association of Canada is proud to partner withSomagen and Polymedco in their effort to promote widespread, populationbased colorectal cancerscreening across all the provincial jurisdictions of Canada. Their mandate is to reduce colorectal cancermortality and incidence through the implementation of the most advanced immunoassay available todate. For more information on Somagen’s AutoFIT, please visit Somagen’s website atwww.somagen.com or www.fobttests.com.
References:
1. Leddin D, et al., Canadian Association of Gastroenterology and the Canadian Digestive Health Foundation: Guidelines oncolon cancer screening. Can J Gastroenterol 2004; 18: 9399
2. Screening for colorectal cancer: U.S. preventive Services Task Force recommendation statement. Ann Intern Med 2008;149: 627637
3. Levin, B, et al., Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: ajoint guideline from the American Cancer Society, the US MultiSociety Task Force On Colorectal Cancer, and theAmerican College of Radiology. CA Cancer J Clin 2008; 58: 130160
*Applies to CRC Screening Only*
Occult Bleed - Important Considerations
Patients with Iron deficiency require more extensive investigation: Upper + Lower scope, as well as small bowel evaluation.
It should never be assumed that anticoagulant or anti platelet agents are responsible for occult bleeding in patients
Iron deficiency anemia without FOBT +ve stool should be investigated for GI causes based on patient risk factors
References
Toronto Notes 2014: Gastroenterology Section
David Hui: Approach to Internal Medicine
UptoDate
Colorectal Cancer Association of Canada: http://www.colorectal-cancer.ca/en/screening/fobt-and-fit/