GI Bleeding:From Mouth to Rectum and Everywhere in Between

Outline

•Epidemiology and Risk Factors•Signs and Symptoms•Physical Exam Findings•Etiologies•Diagnosis•Management

Will focus mostly on inpatients

Epidemiology

•Upper GI bleeds (UGIB)▫100,000 admissions/year to US hospitals▫10% mortality

•Variceal bleeds▫30% of identified varices will bleed in 1

year▫33% mortality with each bleed

•Lower GI bleeds (LGIB)▫Less common than UGIB▫3% mortality

Key Point: Mortality LGIB < UGIB < Variceal bleeds

Risk Factors Most Important Part of History!•NSAID Use•Cirrhosis•Anticoagulation/Coagulopathy•Age•Risk factors for colon cancer•Previous history of GI bleeding

Key Point:

Signs and SymptomsUpper GI Bleed Lower GI Bleed

▫ Lightheadedness/Syncope

▫ Diarrhea▫ Anemia▫ Hematemasis▫ Melena▫ Stigmata of cirrhosis▫ Heartburn

▫ Lightheadedness/Syncope

▫ Diarrhea▫ Anemia▫ Hematochezia

Physical Exam Findings

•Vital signs (more later)•Dry mucus membranes•Stigmata of cirrhosis•Fetid breath•DRE – gotta do it•Weak pulses•Cool skin•Encephalopathy

Common EtiologiesUpper GI Bleed Lower GI Bleed

• PUD – 55 %• Varices – 14 %• AVMs – 6%• Mallory Weiss Tears – 5%• Tumors/Erosions – 4%• Dieulafoy’s lesions – 1%• Others 15%

• Diverticular disease – 30%• Colitis – 18%

▫ Ischemic▫ Inflammatory▫ Infectious

• Neoplasms – 10%• AVMs – 8%• Hemorrhoids – 5%• Others – 20%

Khilani et all, Emerg Med 37(10):27-32, 2005

Diagnosis•Upper or Lower?

▫History▫Digital Rectal Exam▫Hemoglobin

•Still bleeding?▫Consider NG Lavage

•What’s the etiology?▫Diagnostic Testing

FreebeesThese can usually make the diagnosis

Diagnostic Testing•EGD – standard for UGIB•Colonoscopy – standard for LGIB•Push Enteroscopy – can image through SB•Capsule Endoscopy – good yield - can’t

intervene•Sigmoidoscopy – rarely used•Barium studies – good to look for

lesions/mass•Tagged red cell scans – poor yield

For more information, do a GI fellowship!

Management – General Principles•Risk stratify

▫Assess blood loss▫Blatchenford score▫Rockall score (after EGD)

•IV access•Volume replacement•Acid suppression therapy•Plan for diagnostic procedure

Beyond the scope of this discussion!

Management: Assess Blood Loss

Category

% loss HR BP Pulse Pressure

UOP

Stage 1 <15 % < 100

Normal Normal > 30

Stage 2 15-30%

> 100

Normal Decreased

20-30

Stage 3 30-40%

> 120

Decreased

Decreased

5-15

Stage 4 > 40% > 140

Decreased

Decreased

Negligible

If they are hypotensive, you are in trouble!

HR not useful if patients are on

AV node blockers

From Advanced Trauma Life Support Guidelines

Tachycardic means they have lost about 1 liter

of blood!Key Points

Management: Access and Volume•IV Access

▫Two large bore peripheral IVs is best•Volume replacement

▫Normal saline▫Blood products▫Consider FFT/Cryo/FFP

MGMT: Acid Suppression•Applies to UGIB from ulcers

Gralnek I.M et al. NEJM 2008

Key Point: PPIs can improve mortality

MGMT: Acid Suppression (con’t)

•Other questions: Continuous versus bolus? IV versus oral? Duration of treatment?

Management – Suspected Varices•Initial stabilization•Splanchnic Vasoconstricters:

Octreotide/Vasopressin•TIPS•Minnesota tube/Blakemoore tube•Antibiotic prophylaxis

•A whole other talk

Key Points•GI bleeding is a common hospital

diagnosis – Look for it

•Risk factors are the most important part of the history

•Vital signs can help risk stratify patients

•PPIs can reduce need for surgery, rebleeding, and death