Definition
• Bleeding from the GI tract
Approach
• Hemodynamically unstable patients should get 2 large-bore IVs (14–18 gauge), early transfusion of PRBC as well as FFP & Vit K if impaired coagulation
• ROS, PMH, previous GIB, alcohol use, liver dz
• Labs: CBC, BMP, LFTs, lipase, coagulation studies, type & screen
UPPER GI BLEED
Approach
• Glasgow–Blatchford score was designed to predict need for transfusion or urgent endoscopy. A score of zero identifies low-risk pts who can safely be discharged w/ outpt f/u (JAMA 2012;307(10):1072; Lancet2000;356(9238):1318).
Bleeding Peptic Ulcer Disease (PUD) or Gastritis
Definition
• Inflammation or ulceration of the stomach or duodenal lining caused by H. pylori infection (80% of duodenal ulcers & 60% gastric ulcers), NSAIDs (15–30%), ASA, alcohol, malignancy, smoking, stress, gastrinoma, anticoagulants, other medications
History
• Epigastric abdominal pain worse w/ food (gastric ulcer) or relieved by food (duodenal ulcer). If bleeding ulcer/gastritis: Black tarry stool, coffee ground emesis
Physical Findings
• Epigastric tenderness, melena or heme-positive stools, peritonitis or back pain if perforated
Evaluation
• Upright CXR for free air if perforation suspected
• Labs: CBC, LFTs, coagulation panel, elevated BUN; H. pylori serology (90% sens)
• NG tube not routinely indicated; may help GI to determine emergent vs. delayed EGD
Treatment
• For nonbleeding gastritis/PUD: All patients should start PPI or H2B. May use antacids, Maalox for sx relief. Empiric H. pylori tx not recommended.
• For bleeding or e/o cx: IVF resuscitation, PRBC if indicated, start IV proton pump inhibitor empirically (omeprazole 80 mg IV bolus, then drip)
• Emergent EGD if hemodynamically unstable (vs. surgical intervention in severe cases)
Disposition
• If ongoing bleeding, Blatchford >0, high risk: Admit for EGD
Variceal Bleeds
Definition
• Bleeding from esophageal or gastric varices (present in 40–60% of cirrhotics) due portal HTN (10–30% of UGIB)
History
• Bright red hematemesis, diffuse abdominal pain, nausea
Physical Findings
• Stigmata of liver failure (jaundice, spider angiomas, ascites, caput medusae), Ill-appearing hypotension, tachycardia, melena
Evaluation
• Labs: CBC, LFTs, coagulation panel, type & cross
Treatment
• Place 2 large bore IVs, initiate IV fluid resuscitation, PRBC if anemic or active bleeding
• Octreotide bolus & drip; often start IV PPI empirically for PUD until EGD confirms etiology
• Antibiotic prophylaxis for SBP if ascites present (ceftriaxone or levofloxacin)
• Emergent EGD if hemodynamically unstable, may need emergent TIPS if still bleeding
• Balloon tamponade w/ Minnesota or Blakemore tube if exsanguinating (after intubation)
Disposition
• Usually ICU admission
Pearls
• 30% bleed rate in 1st year, 70% rebleed rate, 30% mortality from the 2nd bleed
• Do not underestimate history: May not appear sick initially but can decompensate quickly
Mallory–Weiss Tear
Definition
• Tears in the mucosal membrane of the distal esophagus caused by retching against a closed glottis (10% of UGIB)
History
• Specks of bright red blood in emesis or mild hematemesis after forceful retching
Physical Findings
• Most have no physical findings, mild tachycardia
Evaluation
• Upright CXR if hemodynamically unstable to evaluate for subcutaneous or mediastinal air for Boerhaave syndrome (complete esophageal rupture)
Treatment
• Antiemetics, PO challenge
Disposition
• D/c w/ outpt EGD
Pearl
• Boerhaave syndrome can result from forceful emesis but pts are usually ill-appearing w/ shock & require surgical management. Consider barium swallow if high suspicion.
Aortoenteric Fistula
Definition
• Fistula b/w the aorta & GI tract, most commonly in duodenum
History
• H/o AAA, aortic graft (usually >5 y), may have sentinel bleed or large-volume GIB
Physical Findings
• Rapid GIB, hemodynamic collapse
Evaluation
• CBC, type & cross, emergent surgical consult, CT scan if stable
Treatment
• IV fluid resuscitation, PRBC if indicated (use uncrossed blood if unstable)
• Surgical repair
Disposition
• Surgical ICU admission
Pearl
• Mortality directly related to time to the OR
LOWER GI BLEED
Bleeding Diverticulosis
Definition: Bleeding diverticula (33% of LGIB), 50% are from ascending colon
History: Sudden onset, painless bright red rectal bleeding initiated by urge to defecate
Physical Findings: nl abdominal exam, BRBPR, no etiology found on rectal exam
Evaluation: Labs: CBC, LFTs, coagulation panel, type & cross
Treatment: IV fluid resuscitation, PRBC if indicated
Disposition: Admit for colonoscopy
Colorectal Cancer
Definition
• Cancer of the colon or rectum (19% of LGIB)
History
• Chronic blood in stool, change in bowel habits, anorexia, weight loss, lightheaded
Physical Findings
• Pale, heme occult positive stools
Evaluation
• Labs: CBC, LFTs, coagulations; CT if concern for obstruction or significant bleeding
Treatment
• IV fluid resuscitation, PRBC if indicated
• Surgical consultation if significant bleeding (rare)
Disposition
• If stable, d/c for outpt colonoscopy/oncology w/u
Colonic Angiodysplasia
Definition: Enlarged, fragile blood vessels, usually in cecum or proximal ascending colon (8% of LGIB)
History: >60 y/o, small frequent bleeds
Physical Findings: nl abdominal exam, BRBPR or heme occult positive stools
Evaluation: CBC, coagulation panel
Treatment: IV fluid resuscitation, PRBC if indicated; endoscopic cautery or IR embolization
Disposition: Admit for observation & colonoscopy
Hemorrhoids
Definition
• Dilated or bulging veins of the rectum & anus. Internal hemorrhoids may prolapse & become incarcerated (irreducible) or strangulated (ischemic).
History
• Bright red coated stool/toilet paper/dripping into the bowl, pain w/ defecation (external hemorrhoids), h/o hard stools/constipation/prolonged sitting
Physical Findings
• External hemorrhoids are visible on eversion of the anal orifice, internal hemorrhoids are visible at 2-, 5-, & 9-o’clock (when prone) w/ anoscopy, unless prolapsed
Evaluation
• CBC only if significant blood loss suspected or concerning underlying condition
Management
• Generally outpt w/ stool softener (Colace, Senna), Sitz baths (15 min TID & after BMs), suppositories for symptomatic relief
• Acute thrombosis (<48 h since onset of pain) can be excised at bedside in ED
• If prolapsed hemorrhoid is incarcerated w/ signs of strangulation, consult surgery
• All patients over 40 should be referred for colonoscopy to exclude concurrent malignancy
Pearl
• Does not cause anemia