Gastrointestinal Bleeding by Dr. Michael Manfredi.
My name is Michael Manfredi, and I will be presenting the topic Gastrointestinal Bleeding.
The objectives of this video are to identify the classifications of gastrointestinal
bleeding, describe how to perform a physical exam on a patient with gastrointestinal bleeding,
and identify labs and studies that may be helpful in diagnosing a patient with gastrointestinal
bleeding.
Gastrointestinal bleeding is classified based on its origin. Upper gastrointestinal bleeding
is defined as bleeding that occurs proximal to the ligament of Treitz. Lower gastrointestinal
bleeding occurs distal to the ligament of Treitz. The incidence of GI bleeding in children
is not well established in the general population. In upper GI bleeding, most studies have been
done in the pediatric critical care setting. Reports range from 6.4% to 25% of all ICU
admissions. For lower GI bleeding, a study looking at pediatric tertiary care admissions
to the Emergency Department showed that lower GI bleeding occurred in 0.3% of all admissions.
Of those 0.3% admissions, four patients had severe life-threatening GI bleeding.
When initially evaluating a patient with GI bleeding, you should focus on the assessment
of vital signs and begin stabilization, if necessary. History of present illness, doing
a focused medical history, physical examination, lab and diagnostic testing. The general goals
to an evaluation of a patient with gastrointestinal bleeding involves assessing hemodynamic status,
determine if the patient is actively bleeding, determine the location of bleeding as well
as possible etiology.
You receive a page from a nurse that your patient in room 907 just had a large bloody
stool. What questions should you ask on the phone? Your first goal is to assess hemodynamic
stability of your patient. While you're walking to the room, you can ask the nurse is the
patient on the monitors? If not, can you please place her on monitors? If so, is the patient
tachycardic. Also ask the nurse to save the stool, if possible, for your review.
Hemodynamic stability should be assessed immediately. Tachycardia may be an early sign of intravascular
volume depletion. Remember, hypotension is a late sign and may not be present even with
significant blood loss. In the setting of normal blood pressure, if possible, obtain
orthostatic blood pressure.
Once you arrive in your patient's room, what should you focus upon during your initial
targeted physical exam? Capillary refill is a quick way to assess intravascular volume.
A delayed capillary refill suggests intravascular volume depletion. Oxygen saturation may be
decreased due to decreased oxygen carrying capacity. It is important to evaluate for
signs of shock. This includes vitals, as discussed previously, cool, clammy extremities and poor
mentation. If your patient is hemodynamically unstable or showing signs of shock, this is
a red flag. And you should call for backup including your fellow, attending or the ICU.
However, if your patient is hemodynamically stable without signs of shock, you should
make them NPO, ensure that they have IV access, and proceed with further history and examination.
The history of present illness for a patient with lower GI bleed first involves determining
if there is actually blood or is there another cause a bright red or black stools. You should
always perform a stool heme occult test or stool guaiac test.
Evaluate the color of the blood. Bright red indicates the site of bleeding is probably
in the left colon. Dark red stool indicates the bleeding is from the right colon. If melena
or maroon colored stool, then bleeding is proximal to the ileocecal valve. You should
also look at the consistency of the stool. Diarrhea is more likely consistent with colitis.
Hard stool is more likely consistent with fissures and constipation. You should always
assess the duration of symptoms to see if it is an acute or chronic problem. Remember
a very brisk upper GI bleed can present with bright red blood in the stool.
While not pertinent to this case, there are parallel questions if you've been called about
bloody emesis. For a patient with upper GI bleeding, determine whether the emesis contains
blood. Remember, red food coloring, fruit flavored drinks, vegetables, and some medications
can resemble blood.
A pH-buffered gastric occult test can identify blood in the vomit. You should also look for
the color of the blood. In the emesis, bright red blood indicates a fresh bleed whereas
coffee ground emesis indicates older blood. In a patient with upper GI bleeding, it is
still important to look at the stool color. You should see if there's melena versus maroon
colored stool versus bright red blood or hematochezia. You should also assess the amount of blood,
for example, drops of blood, versus teaspoons of blood, versus tablespoons of blood. Again,
always assess the duration of symptoms to see if there's an acute or chronic problem.
During the history of present illness, certain symptoms can suggest certain etiologies to
the bleeding. For example, emesis prior to hematemesis may suggest a Mallory-Weiss tear.
Odynophagia or gastroesophageal reflux may suggest esophageal ulcers. Epigastric pain
may suggest peptic ulcer. Blood mixed in the stool suggests colitis, and blood streaks
on the outside aspect of stool may suggest an anal fissure and suggestive of constipation.
Painful stool suggests anal fissures, local proctitis, or pancolitis, or ischemic bowel.
Painless rectal bleeding is associated with polyps, Meckel diverticulum, or a vascular
anomaly. Therefore, abdominal pain can be seen in patients with inflammatory bowel disease,
colitis of any etiology or surgical abdomen.
Obtaining a focused medical history should include seeing what medications the patient
is on or what medications the patient has access to, getting a sense of what medications
are in the house, getting a history of NSAID use, or aspirin use, or any anticoagulant
medications. You should also assess any chronic medical conditions such as liver disease,
renal failure, or previous GI surgery. Again, pertinent family history of GI bleeding or
other associated conditions is also useful, such as a family history of inflammatory bowel
disease, intestinal polyps, or any bleeding diathesis.
If your patient is stable, you can now do a more thorough physical exam to look for
possible etiologies. This exam should include an ENT examination. You should examine the
nasopharynx for a source of bleeding, such as a nose bleed, or epistaxis, or tonsillar
bleeding. You should also examine the buccal mucosa. Freckles on the buccal mucosa can
suggest Peutz-Jeghers syndrome. If there are evidence of telangiectasias, this could be
suggestive of Osler-Weber-Rendu syndrome. Or aphthous mouth ulcers can suggest Crohn's
disease.
When you examine the skin, you should look for evidence of skin petechiae, ecchymosis,
or hemangiomas. This will suggest a coagulopathy or other vascular anomalies. In the setting
of the bloody diarrhea, purpura can also suggest Henoch-Schnonlein purpura. Spider angioma,
caput medusa, palmar erythema and/or jaundice can suggest liver disease or portal hypertension.
In your abdominal examination, evaluate bowel sounds for evidence of possible bowel obstruction.
Epigastric abdominal tenderness may suggest peptic disease. Hepatosplenomegaly and ascites
may suggest liver disease. It is important to do a rectal examination in a patient suspected
for GI bleeding. You should look for evidence of any perianal disease. It is possible to
appreciate polyps on digital rectal examination. You should also look for evidence of hemorrhoids.
And at the end of your exam, you should test stool for guaiac.
Initial laboratory evaluation of a patient with a suspected GI bleed should include a
CBC, chemistry, coagulation panel, ESR and CRP. You should also send a type and screen
to the lab. When performing a CBC, remember, initial hemoglobin values may be unreliable.
Delay in hemodilution may falsely produce near normal values. Therefore CBC should be
formed serially. Anemia with normal erythrocyte indices suggest acute causes for bleeding.
Alternately, iron deficiency anemia suggests chronic blood loss. Leukopenia or thrombocytopenia
may suggest chronic liver disease and portal hypertension or hemolytic uremic syndrome.
Abnormal PT or PTT may suggest liver disease or coagulopathy. DIC can be considered in
the appropriate clinical setting. Remember BUN or creatinine are elevated in acute GI
bleeding and can also be seen in hemolytic uremic syndrome and Henoch-Schonlein purpura.
Elevated ESR or CRP can be seen in inflammatory or infectious colitis. Remember, urgent imaging
probably has limited utility in suspected GI bleed. Studies you may consider once the
patient has been stabilized include an abdominal X-ray if you suspect small bowel obstruction
or a foreign body.
A bleeding scan can be useful in the patient with significant bleeding that precludes endoscopy
or in whom endoscopy was undiagnostic. A bleeding scan is a technetium 99 tagged erythrocyte
scan which detects rapid bleeding at a rate of 0.1 to 0.5 milliliters per minute. This
can be performed at 30 minute Intervals for up to 24 hours. When a patient has maroon
colored stool, and you suspect a Meckulus diverticulum, you can perform a Meckel's scan.
This is a technesium 99 pertechnetate scan that is used to detect gastric mucosa. Angiography
can be helpful in detecting vascular anomalies of upper GI bleeding. However, keep in mind
this requires bleeding rates of 0.5 to 1 milliliter per minute. Angiography has the added benefit
of being therapeutic, this involves injection of coils into bleeding vessels or vascular
malformations to occlude it.
NG tube lavage is no longer required in patients with suspected upper GI bleeding. Recent studies
showed that NG tube lavage did not affect mortality, length of stay, surgery, or need
for blood transfusions. Therefore, it is no longer indicated. Barium tests are not useful
in the acute setting. Barium can obscure views when performing endoscopy.
As we've already mentioned, treatment begins with ensuring patients being made NPO have
stable IV access, obtain blood type and cross-match red blood cells. Your next steps to initiate
include stabilizing the patient with IV fluids and blood products, if necessary. Target hemoglobin
should be greater or equal to 7 grams per deciliter. Correct any coagulopathy and target
INR less than 2.5. Platelet counts less than 50,000 in the presence of active bleeding
may require transfusion. You should consult with your attending and/or fellow if your
initial lab studies indicate the need for a transfusion or if your hemodynamics indicate
the need for volume resuscitation.
If you suspect an upper GI bleed, you will also treat with intravenous PPI infusion at
a rate of 1 milligram per kilogram bolus with a maximum of 80 milligrams. Then a continuous
infusion of 0.1 milligrams per kilogram per hour with a max of 8 milligrams per hour.
This is the treatment of choice for most common causes of upper GI bleeding including ulcers,
gastritis, and the esophagitis. If IV access is limited, you can also consider giving IV
doses in a BID manner. PPI therapy neutralizes gastric acid and promotes hemostasis by stabilizing
blood clots. This may reduce further bleeding. It also has been proven to decrease the proportion
of patients with high risk stigmata of hemorrhage at the time of endoscopy.
Keep in mind, a Cochrane Review of PPIs in adults show that PPIs do not reduce bleeding
rates, or the need for surgery, or overall mortality. PPIs have been shown to be efficacious
in studies looking in Asian populations which reduce all cause mortality and reductions
in rebleeding and surgery are greater in Asian studies. This is thought to be secondary to
the higher incidence of H.pylori infections in Asian studies.
Octreotide treatment has also been used for non-variceal upper GI bleeding. This is a
somatostatin analog. It inhibits mesenteric vasodilation induced by glucagon. It indirectly
causes splanchnic vasoconstriction and decreases portal blood flow. This reduces gastroduodenal
mucosal blood flow and decreases gastric acid secretion by inhibiting gastrin and histamine.
It also decreases pepsin secretion and stimulates mucus production in the stomach.
Octreotide is given as a 1 microgram per kilogram bolus with a max of 50 micrograms, then 1
to 2 micrograms per kilogram per hour with a maximum of 50 micrograms per hour. In a
meta-analysis looking at octreotide in the treatment of non-variceal upper GI bleeding,
the overall relative risk for further bleeding favored the use of a octreotide. However,
it is important to note that in the 7 investigator-blinded trials, the relative risk was less favorable.
Therefore, octreotide may reduce the risk of continued bleeding from non-variceal upper
GI bleeding and can be considered an adjunctive therapy.
In summary, your initial goals for evaluating a GI bleed are to assess if the patient is
hemodynamically stable. Ensure adequate IV access, send screening labs, including
a type and screen. Assess for upper versus lower source of GI bleeding based on your
history and physical exam. Resuscitate with fluids and blood products as needed. Consider
starting a PPI infusion in conjunction with your attending. That concludes our video on
GI bleeding. Thank you for watching.