Inpatient / Gastroenterology
GI Bleed
# Acute *** GI Bleed
Checklist
-- ABCs: does patient need massive transfusion protocol? intubate if large volume hematemesis, AMS, need for balloon tamponade; ICU if unstable, need for central line; make sure patient has adequate access before arriving on the floor - 2 or more 18G or larger IVs
-- Chart Check: prior bleed, EGD/Colo, baseline Hgb, AC medications
-- Admission Criteria: symptomatic, anemia, hypotension, need for transfusion
-- HPI Intake: prior bleeds, onset of current bleed, AC and indication, symptoms, last meal, other meds
-- Can't Miss: brisk bleed, need for intubation due to AMS or hematemesis
-- Admission Orders: keep NPO for possible procedure, resuscitate with IVF and transfuse pRBCS as needed, CBC, BMP, lactate, coags, T+S, continuous telemetry, hold home meds that increase risk (beta blockers, anticoagulation, HTN meds, etc), consult GI/IR/surgery depending on severity of bleed
-- Initial Treatment to Consider: pRBCs if Hgb <7 or rapid bleed, PPI if c/f PUD, octreotide if c/f varices, consider reversing AC if INR >2.5
Intake
-- Prior Bleeds: ***
-- Onset of Current Bleed: ***
-- Symptoms: *** weakness, AMS, lightheadedness
-- Last Ate: ***
-- AC and Indication: ***
-- Meds: *** NSAID, ASA, PPI, iron tablets, bismuth
Assessment:
-- History: *** onset, prior bleed, anticoagulation, last took meds, last ate, NSAID use
-- Clinical: *** melena, hematochezia, abdominal pain, AMS, lightheaded, syncope
-- Exam: *** tachycardia, hypotension, melena, hematochezia, abdominal pain, evidence of peritonitis, cirrhosis signs (jaundice, AMS, asterixis, milkmaids, palmar erythema, angioectasias)
-- Data: *** Hgb, INR, BUN
-- Etiology/DDx: *** UGIB: PUD or gastritis (NSAID, H Pylori, EtOH, stress, steroids), varices (esophageal, gastric), trauma (Mallory Weiss), vascular malformation (Dieulafoy's, AVM, angioectasia), neoplasm, iatrogenic, epistaxis; LGIB: diverticulosis, hemorrhoid, vascular malformation, colitis, IBD, neoplasm/polp, ischemia
The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.
Plan:
Workup
-- Labs: *** f/u CBC (Hgb), BMP (BUN), coags (INR), VBG (with iCal)
-- Imaging: *** (CT A/P, CT angiography)
-- Consults: *** (GI, IR, Surgery depending on extend and needed intervention)
-- Monitoring: continuous telemetry, CBC q ***, maintain type and screen, strict I/O for UOP
Treatment
-- Access: currently *** (at least two large-bore IV 18G or larger)
-- IVF: *** bolus to treat initial hypotension, continue while NPO
-- Transfuse: s/p ***, transfuse for Hgb <7, Plt <50; consider IV Vit K and FFP for INR >1.7 (unless cirrhosis); massive transfusion 1:1:1 (watch calcium, pH, temp)
-- Medications: *** IV pantoprazole 40mg BID (if EGD shows PUD, to PO PPI for 8 weeks) ; octreotide 50 mcg IV once, then 50 mcg/hour IV infusionif portal HTN with varices (continue for 3-5 days after EGD); ceftriaxone 1g daily if variceal bleed (7 days for ppx against bacterial infections); hold AC - restart 1-2 days after hemostasis, ideally within 7 days
-- Procedure: NPO pending *** scope, IR embolization; consider erythromycin 250mg IV once 30-90 min before EGD; Colo pred is usually 4-6L PO miralax until effluent is clear
-- Consider reversal of AC if needed (usually if INR >2.5 in the setting clinically significant bleed)
If You Remember Nothing Else
UGIB is most commonly caused by PUD and LGID is most commonly caused by diverticulosis. In patients with cirrhosis, variceal bleeding is the most feared bleed and has its own unique treatments and pathways. History and labwork help push our diagnosis toward upper vs lower GI bleed (ex: BUN/Cr >30 has +LR of 25 for UGIB), but blood appearance is overall a poor indicator of the source of the bleed. Upper GI bleeding is generally considered to be more life threatening; GI will often start with an EGD within 24 hours of presentation while the patient preps for a colonoscopy. In the meantime, prioritize the ABCs, access, and resuscitation above all else. When hemostasis is achieved, you can (and should) restart AC/ASA within a few days.
Clinical Pearls
- UGIB is defined as originating above the ligament of Treitz (which suspends to the duodenum) and is responsible for 70-80% of GI hemorrhage; in general see melena (+LR 25), hematemesis, but only see hematochezia if brisk bleed; BUN/Cr is often >30 (+LR 7.5)
- Hematochezia is the most common sign of overt LGIB; melena can happen if the bleeding is coming from the small bowel or the proximal colon.
- PUD is the most common source of UGIB (~30%), variceal bleeding is the most feared etiology due to possibility for rapid exsanguination; Diverticulosis is the most common source of LGIB (~30%)
- Melena requires that blood be in the GI tract for 14 hours; the dark discoloration of the stool is due to hematin, a dark pigment that forms when heme is oxidized in the GI tract. In UGIB, heme is usually oxidized by gastric acid. In LGIB, oxidation of heme occurs with the help of intestinal bacteria
- Patients will usually not recognize that melena represents bleeding and may not offer up such a change in their stools unless directly asked
- Iron supplements and bismuth supplements may also cause dark stool, which should be distinguished from melena.
- All in all, stool appearance is a poor indicator of the bleeding source
- Hgb drop lags 24-72 hours from onset of bleed as patients resuscitate themselves; Hgb will also drop after giving fluids (hemodilutation)
- Massive Transfusion Protocol - 1:1:1 ratio of pRBCs to FFP to platelets; based on hemodynamic instability and concern for brisk bleed and not based on a Hgb goal; goals are to prevent hypocalcemia, manage acidemia, avoid hypothermia, and avoid volume rload
- Nurses don't usually place large bore IVs unless explicitly told to - look at the patient's arms to see which they have when visitng the patient in the ED
- Consult GI for EGD within 24 hours (no benefit within 6 hours if patient HD stable UNLESS variceal bleeding); Patients generally need to be NPO for at least 6-8 hours for the best visualization
- GI interventions allow for bleeding source identification, biopsies, and hemostatic interventions (epinephrine injection, cauterization, vessel clipping, polypectomy, variceal banding)
- GI usually starts with EGD to evaluate for UGIB regardless of what blood looks like - often more life-threatening, colo takes time to prep for, and hematochezia which is usually suggestive of LGIB is brisk if actually UGIB so wouldn’t want to miss; trials suggest within 24 hours is just as good as within 6 hours if HD stable; if nothing identified on either and still concern for ongoing bleeding, it is often the small intestine - can consider video capsule or push enteroscopy
- Giving erythromycin before EGD increases gut motility and helps with visualization
- Consult Surgery or IR if patient is unstable or visualization attempts fail - can consider CT angiography to localize bleed and assist with an IR embolization
- If varcieal bleed does not stop or early rebleed - next steps would be for balloon tamponade and go to TIPS to reduce portal hypertension
- The Hgb of 7 transfusion goal is based on a trial in UGIB - thought for variceal bleeding is that overtransfusing leads to increased portal pressures from the extra volume and subsequent variceal dilation which worsens the bleed
- FFP has an INR of 1.6, so only works if INR is significantly higher than that
- TXA/Amicar does not help improve patient outcomes in GI bleed, and actually increases VTE risk
- You can restart AC/ASA pretty soon after procedure achieves hemostasis (~ 2 days or so); in general, the risk of clotting is considered by most to be more devastating than the risk of re-bleeding, but its always a balance
- Because of GI bleeding, more blood is broken down into protein, which raises the amount of ammonia in the body and the risk of hepatic encephalopathy
- Patients who achieve adequate hemostasis can usually be discharged after an observational period of ~24 hours depending on the risk of re-bleed
Trials and Literature
- Timing of Endoscopy for UGIB - 30 day mortality same if EGD performed within 6 hours of GI consult vs within 24 hours (8.9% vs 6.6%) if non-variceal and HDS (NEJM, 2020)
- Transfusion Strategies for Acute Upper GI Bleeding - in patients with Upper GI bleed, restrictive transfusion threshold of >7 reduced mortality at 45 days compared to liberal threshold >10 (95% vs 91%); the TRICC trial had previously showed that a restrictive strategy improved survival in critically ill patients, this showed it was beneficial specifically in bleeding; notably this trial excluded patients with massive bleed and those with low rebleed risk, and all patients had EGD within 5 hours which is unrealistic and also not something that happens in practice based on the above trial (NEJM, 2013)
- Meta-Analysis of ppx abx in pts with cirrhosis with UGIB - NNT 4 to prevent infection and NNT 22 to save a life
- Meta-Analysis of erythromycin for urgent EGD in UGIB - NNT 4 for improved visualization, NNT 9 to avoid repeat endoscopy, LOS decreased 2 days
- HALT-IT Trial - tranexamic acid (TXA) does not reduce death from GI bleed (4% in both groups), but VTE risk was "double" (0.8% vs 0.4%) (Lancet, 2020)
- Does This Patient Have a Severe Upper GI Bleed? Rational Clinical Exam (JAMA, 2012)
Other Resources
- Curbsiders Podcast - #355 GI Bleed
- Run the List Podcast - Upper GI Bleed, Lower GI Bleed
- Glass Health Orginals by Andrew Sanchez and Madellena Conte - Massive Transfusion Protocol
- ICU One-Pager - Hemorrhagic Shock
- Internet Book of Critical Care (IBCC) - Anticoagulant Reversal
