Gastroenterology

All right folks, the chief complaint we all know and love: “rectal bleeding”. It may strike fear in your heart or bring you comfort in its algorithmic approach. However, GI bleeds can present in a variety of ways from the “sick” to “not sick”. So, grab your GUAIAC cards and let’s get started.

UPPER GI BLEED (proximal to the ligament of Treitz)

  • History and Physical (obviously)
    • NSAID use?
    • Hx of ETOH abuse?
    • On blood thinners?
    • Hx of cirrhosis? More specifically any history of varices?
      • Bleeding varices are…bad
      • Look for ascites, jaundice, caput medusa, telangiectasias
      • Chart review…most patients with diagnosis of cirrhosis will have had a screening EGD to evaluate for varices
    • Hematemesis, melena, hematochezia…oh my
      • Hematemesis likely to be upper GI source, but melena or hematochezia could be upper or lower
    • Do HEENT exam
      • Swallowed blood from epistaxis can masquerade as hematemesis
  • Differential
    • Varices, Mallory-Weiss tear, Boerhaave, PUD, gastritis, portal hypertensive gastropathy, gastric antral vascular ectasia (watermelon stomach…yum), the list goes on an on
  • Management
    • ABCs
      • Worry about securing airway early on in case of brisk UGI bleed, especially from varices
    • RESUSCITATION
      • 2 large bore IVs (14-16 gauge if possible, 18 gauge works too)
      • With large bleeds, these patients are going to be hemodynamically unstable and require aggressive fluid resuscitation
        • Consider MTP
        • Always have at least 2U PRBCs on hold
        • Keep Hemoglobin >7
          • Initial hemoglobin often deceiving, base your decision to transfuse on the patients clinical presentation and hemodynamics
    • Correct coagulopathy
      • FFP or PCCs if INR >1.6
      • Platelet goal >50,000 if active bleeding
    • Meds
      • PPI
        • Protonix 40mg BID
        • No improvement in mortality with PPI drip
        • Reduces risk of rebleeding and need for surgery, but no change in 30 day mortality
      • Octreotide
        • 50mcg bolus followed by 50mcg/hr infusion for 3-5 days
        • Inhibits vasodilatory substances like glucagon thus indirectly causing splanchnic vasoconstriction
        • No mortality benefit, but may reduce rebleeding risk when combined with endoscopy
      • Antibiotics
        • 1g Ceftriaxone IV
        • Reduces risk of inpatient bacterial infections and improves mortality
    • Tamponade
      • Last resort in intubated patients
      • Sengstaken-Blakemore vs Minnesota tubes
    • NG lavage
      • Controversial
      • If positive, it is highly likely an UGI source, if negative it doesn’t mean much
    • Consults
      • GI for endoscopy
        • Preferably within 24 hours of admission, 12 hours if suspected variceal bleed
        • Usually start with EGD if unclear source of bleed
          • Less prep time for patient…can be done earlier
      • Interventional radiology/general surgery
        • Consider if high risk for EGD or if EGD unlikely to be therapeutic

LOWER GI BLEED (distal to ligament of Treitz)

  • History and physical
    • Hx of GI bleeds?
    • Prior colonoscopies?
    • Risk factors for UGI bleed? (hematochezia/melena can often be due to UGI bleed)
    • Bleeding diathesis?
    • Type of bleeding? Melena vs hematochezia
    • Rectal exam
      • Hemorrhoids? Fissures? Foreign body? Active bleeding?
    • GUIAIC testing
      • Some debate here, initially intended primarily for colorectal cancer screening
        • High false positive/negative rates
      • Many consults still want this done, but more useful to tell if gross melena or hematochezia
  • Differential
    • Upper GI bleed
    • Diverticulosis, colitis (ischemic, infectious), cancer, inflammatory bowel disease, hemorrhoids, rectal foreign body, aortoenteric fistula (bad), etc, etc
  • Workup
    • CBC, CMP, type and screen, coags (PTT/PT/INR)
  • Management
    • Two large bore IVs
    • IVF resuscitation
      • Consider early MTP if hemodynamically unstable and/or active bleeding
    • Imaging
      • Consider CTA if having abdominal pain
    • GI consult for endoscopy and possible IR consult for embolization

PEARLS:

  • GI bleeds are often initially undifferentiated and treated the same
    • i.e hard to tell if melena is upper vs lower GI bleed and hematochezia could be from brisk UGI source
  • Thorough history and physical
    • Especially to uncover risk factors that predispose to bleeding, history of cirrhosis, alcohol abuse, prior GI bleeds, or endoscopy results
    • Look for active hematemesis and do a rectal exam to assess for gross melena or hematochezia
  • Resuscitate with IV fluids, blood, and consider massive transfusion protocol
  • Give PPI, consider antibiotics if hx of cirrhosis or alcohol abuse to prevent SBP, octreotide if history of varices
  • Consult GI/IR/surgery early for definitive management (endoscopy, ligation/resection, embolization, etc)

Citations:

“Upper Gastrointestinal Bleeding: Evidence-Based Treatment.” ALiEM, 10 Sept. 2019, http://www.aliem.com/upper-gastrointestinal-bleeding-treatment/.

Ziebell, Christopher M., et al.. “Upper Gastrointestinal Bleeding.” Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e Eds. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2016, http://accessmedicine.mhmedical.com.ezproxy.rush.edu/content.aspx?bookid=1658&sectionid=109430182.

Lo, Bruce M.. “Lower Gastrointestinal Bleeding.” Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e Eds. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2016, http://accessmedicine.mhmedical.com.ezproxy.rush.edu/content.aspx?bookid=1658&sectionid=109430249.

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