- Hello, my name is Vineet Chopra.
I am the chief of the Division of Hospital Medicine
at Michigan Medicine,
and today I'm going to talk
to you about acute gastrointestinal bleeding.
My talk comes from our new book,
the "Saint-Chopra Guide to Inpatient Medicine".
This was written by my colleague, Sanjay Saint,
and myself, and really is a guide
to thinking about how you approach the care
of hospitalized medical patients.
So acute GI bleeding is both common and serious.
And we classify it based upon it's location in terms
of where the bleed is coming from.
So we say upper GI bleeds are those that occur proximal
to the ligament of Treitz.
Whereas lower GI bleeds are ones that occur distal to that.
And we call GI bleeds different things depending
on certain definitions.
So we often will call a GI bleed hematemesis.
And when we say this what we mean
is that we're seeing blood,
including coffee grounds, in the vomitus.
Coffee ground emesis is almost always upper GI bleeding,
and it occurs because blood is being digested
by acid in the stomach.
So the coffee grounds are actually hemoglobin
being converted to hematin,
so it has a very dark and odorous smell.
Hematochezia, on the other hand,
is red or maroon-colored blood in the stool.
Almost always this is lower GI bleeding,
but in 10% of cases, this can be an upper GI bleed.
And the thing to remember in those 10% of patients
is that indicates that the bleeding
is happening so rapidly that blood is transiting through
the actual GI tract without changing color.
So in many ways, this is a life-threatening emergency.
And finally, melena.
Melena almost always indicates the presence
of black tarry stool.
And what that means is it's blood
coming in from the upper GI tract
having been digested by acid, hematin.
Melena, almost always means upper GI bleeding.
And the key thing about melena
is it often smells horrible.
So when you enter a patient's room,
you can actually smell this from the distance,
and it should be your first clue that
a patient may have an upper GI bleed.
The most common causes of upper GI bleeding
are difficult to remember, but in the Saint-Chopra guide,
we focus a lot on memory tricks, including mnemonics.
And the mnemonic I want you to remember for
an upper GI bleed are GUM BLEEDING.
Now the words gum, the first word, G-U-M,
has the most common causes, and here they are.
So the G stands for gastritis,
and this essentially means any inflammation
of the stomach lining.
Commonly, we'll see this in the setting
of a peptic ulcer disease or stress gastritis,
but it is a non-specific finding
and on endoscopy which indicates just irritation
of the stomach wall.
U is ulcers, and ulcers are a common cause
of GI bleeding, especially when they erode through
a blood vessel.
When you think of ulcers as a source of GI bleeding,
always think about cancer
and always think testing for Helicobacter pylori.
Because treatment and eradication of H.pylori
is key to healing of the ulcers.
The M is a Mallory-Weiss tear.
And this is a tear that occurs in the esophagus
in the setting of prolonged and forced vomiting.
Essentially, the increase in intra-abdominal pressure
forces tearing of the esophageal wall.
And so it's typically preceded by a history
of vomiting for several days or hours,
that is forceful and typically associated with retching.
B is biliary causes of bleeding.
And yes, bile can cause a GI bleed.
Bile typically will reflux back into the stomach,
especially in situations where the distal valve
of the stomach is incompetent.
Because you've had surgery there
or because you have some type of achalasia
or some type of motility problem in the stomach wall.
And so when bile reflux is back,
you get an alkaline gastritis,
and just like a regular gastritis,
that can cause erosion of the stomach wall
and bleeding, as well.
The L is really important, but not common.
Large varices.
Large varices can cause life-threatening bleeding
and these are an important source of upper GI bleeding,
especially in patients who have had
a history of this before or who have
a history of liver disease.
You should always be thinking about a variceal bleed.
The E is esophagitis or esophageal ulcers.
Again, we see this with reflux
and other causes of inflammation in the esophagus.
I also want you to remember infectious causes
of esophagitis, and the two ones that I think about
are often candidal, or candida, and herpes simplex.
And both of those should start making
you think about immune deficiencies
or other causes of superimposed infections in the esophagus.
E is an entero aortic fistula
and the classic tip there is called a herald bleed.
Entero aortic fistulas commonly occur in patients
who had prior aortic surgery.
So the classic setup is somebody walks in having had
an aortic surgical repair, typically aortic arch
or a wall repair, and they have a small amount
of GI bleeding and they look stable,
only to have a large amount of bleeding a few hours later.
The small amount of bleeding initially
is called the herald bleed.
And that's the one that you will be asked about
and you may look for when you're on the wards.
The D is duodenitis, which is a common cause
of GI bleeding, again,
related to peptic ulcer disease or NSAID use.
The Dieulafoy lesion is named after a French surgeon,
Paul George Dieulafoy, who first described this.
And what this is is a very large artery, or arterial,
in the mucosa that erodes through and starts to bleed.
Dieulafoy's also French for by the grace of God.
And so this is one of those things where
you have to be very careful and you have
to be very cautious about treating these patients,
'cause they can bleed very quickly.
I is inflammatory bowel disease
and you should always think about IBD
when you're thinking about GI bleeding.
Especially Crohn's disease that can affect any part
of the GI tract.
Not so much ulcerative colitis,
which can happen more on the lower part
of the GI tract, the rectum, and more distal areas.
Remember, with IBD you should be thinking about this
in specific age groups, as well,
given the bimodal distribution of some of these diseases.
The N is neovascularization.
And what this means is the formation
of immature or otherwise new blood vessels.
The common condition here to think about is aortic stenosis,
where you have underlying arterials and EBMs form,
and you can certainly have those rupture and bleed.
We call this Heyde's syndrome
and it's often associated with von Willebrand's factor,
that is no longer functional because
of the aortic stenosis and the stress on the blood vessels.
And G in the last one is gastric cancer.
And this is important to remember,
especially in patients who have associated symptoms
of either weight loss or a strong family history.
When you think about lower GI bleeding,
there's a more limited differential diagnosis.
And the way to remember this is the following.
That you may need a drain to collect the blood coming
from the lower GI tract.
So the pneumonic here is DRAIN
and let's walk through what this is.
The D stands for diverticulosis.
And by far and none, this is the most common cause
of painless GI bleeding in adults over 65 years of age.
Diverticulosis can also be self-limiting,
so it can come and go.
When you have pain with diverticulosis
and maybe a white count and fever,
you should start thinking about diverticulitis.
R is radiation proctitis and this
is bleeding coming from the lower part of the GI tract.
Typically in patients who have had radiation
for some underlying malignancy.
So in men think colon cancer or genitourinary cancers,
and in women think genitourinary cancers,
typically ovarian cancer,
where they may have had radiation performed, as well.
A is arteriovenous malformation.
We discussed this with aortic stenosis.
Typically seen in the lower GI tract.
And again, these are painless causes of lower GI bleeding.
I is significant for three conditions.
So there's ischemia, inflammation, and infection.
Ischemia is important to remember in older adults
and the classic picture there
is somebody who has an underlying atrial fibrillation
or atrial tachyrhythmia, who may have thrown
an embolism to the distal bowel
or the superior or inferior mesenteric artery,
leading to bowel ischemia.
Inflammation and infection can happen from
a number of reasons, and again,
one of the things to think about when you've got
no other clear explanation for lower GI bleeding.
And N, and the most important to think about
in older patients, as well, is neoplasm.
And so always think about getting a cancer history
and a screening history with respect
to colonoscopies, to understand if this might be a risk.
How do you know if someone needs to go
to the ICU with a GI bleed?
Well, you should ask if they need a visa.
Well, what is a visa?
The V is variceal bleeding.
So as I just discussed, this is one of those key things
that gets the gastroenterologist up at night
and into the hospital.
Patients who have known varices who present
with upper GI bleeding can literally exsanguinate
in a matter of a few minutes.
So it's important that you think about this
in an ICU setting.
I is any instability of vital signs.
Remember, by the time your vital signs start
to become unstable, you've already lost
a lot of blood volume, and so you should be looking
for tachycardia and hypotension in patients
who are presenting with symptoms and signs of GI bleeding
as an indicator of how much volume of blood they've lost.
S includes serious comorbidities.
And the reason this is important
is when somebody has underlying diabetes
or chronic kidney disease or congestive heart failure,
any trigger to blood loss can actually exacerbate
those underlying conditions
and cause multi-system organ damage.
So think of an older patient who presents with
an upper GI bleed, but has chest pain
because they have critical coronary artery disease
and have a lost a significant amount of blood.
So, serious comorbidities should almost always want you
to think about the ICU.
And the last one is a active GI bleeding or advanced age.
These are also worse prognostic indicators
for outcomes with GI bleed, and so if someone's actively
bleeding in front of you,
think about an ICU bed for that patient.
I wanna quickly highlight the approach to GI bleeding
and how you should think about that if you're on the wards.
The first evaluation focuses on resuscitation.
So what we would recommend
is two large-bore intravenous catheters,
making sure you have a type and cross,
a cardiac monitor, and oxygen.
People often ask me whether or not you should place
a central line in a unstable GI bleed,
and my answer is almost always no.
And that's because I want you
to remember Poiseuille's law
with respect to flow across a catheter.
You can get just as much flow across
a 16-gauge intravenous catheter
in the antecubital fossa as you can in a central line.
And so, always obtain peripheral access
with large-bore IVs as a first step.
Second, if you're gonna send the patient to the ICU,
you should be having them monitored
and watched by GI almost immediately.
So in my mind, an ICU admission is
an automatic gastroenterology consultation.
That should not wait for the morning,
that should be something that should be seen expeditiously.
And again, the key here is not necessarily
to have them scope someone quickly,
but the key is to have them assess whether
or not a scope might be helpful.
Because most importantly, you should not delay resuscitation
while awaiting a consult.
No GI physician is gonna give a patient anesthesia
when they're hemodynamically unstable.
So the key for you to remember is that
we will not advise or recommend diagnostic testing,
any kind of diagnostic testing,
until the patient is adequately at volume and resuscitated.
And that typically means at least two to four liters
of crystalloid infusions as well as blood products.
You wanna make sure the patient
is able to tolerate the procedure
so that they can have it safely,
even if they need it to stop their bleeding.
One last tip.
Remember that a unit of blood entering
or leaving the body will drop the hemoglobin
by approximately one gram per deciliter.
So when you're giving blood back
and you're looking for a response,
you should be looking for a one gram change upwards.
If you don't see that,
there may still be ongoing GI bleeding.
So thank you for your attention.
I hope this has been helpful.
This is just a small sample of what you'll find
in the "Saint-Chopra Guide to Inpatient Medicine".
I hope you like it.
And if you do, I would certain recommend
you considering buying the book.
You can buy it on this link
and please use this code to get 30% off.
Thanks very much.