GI bleeding (Washington Manual)

S/S

1.     Hematemesis

2.     coffee-ground emesisà aspiration of blood or coffee-ground material from NG  tube suggest an upper GI source of blood loss

3.     Melena, black sticky stoolàupper GI

4.     Hematochezia, bloody stoolàlow GI

5.     patients with lower GI bleeding have less hemodynamic compromise compared to those with upper GI bleeding

6.     Disorders of coagulation: liver disease, von Willebrand disease, vitamin K deficiency, and DIC

7.     Medications: warfarin, heparin, aspirin, NSAID, clopidogrel (Plavix), thrombolytic agents, antithrombotic agents such as glycoprotein IIb/IIIa receptor antagonists (abciximab [ReoPro], eptifibatide [Integrilin], tirofiban [Aggrastat]), direct thrombin inhibitors

PE, LAB

1.     Color of stool

2.     NG aspirate

3.     Intravascular volume and hemodynamic status: a sudden increase in pulse rate or decrease in BP may be an early indicator of recurrent or ongoing blood loss

4.     orthostatic hemodynamic changes: drop in SBP >10 mm Hg, rise in HR >15 bpmàloss of 10% to 20% of the circulatory volume;
supine hypotension suggests a >20% loss
BP <100 mm Hg or HR >100 bpmàthat requires urgent volume resuscitation

5.     CBC, PT/PTT, Blood group, cross-matching of 2~4 units of blood, liver function tests, serum creatinine

Diagnosis

1.     Esophagogastroduodenoscopy (EGD): high diagnostic accuracy, therapeutic capability, and low morbidity

2.     Colonoscopy: performed within the initial 24 hours is greatest

3.     early diagnostic endoscopy does not reduce mortality, therapeutic endoscopy reduces transfusion requirements, need for surgery, and length of hospital stay

4.     Anoscopy

5.     Push enteroscopy: evaluation of the proximal small bowel

6.     Capsule endoscopy

7.     Single- and double-balloon enteroscopy

8.     Intraoperative enteroscopy

9.     TRBC scanning: positiveàrequire invasive intervention, high in-hospital morbidity

10.    Arteriography: localization and potential therapy, when bleeding > 0.5 mL/min

TX

1.     Restoration of intravascular volume

2.     Oxygen administration

3.     Transfusion should be continued until hematocrit reaches ≥25%; patients with cardiac or pulmonary disease may require transfusion to a hematocrit of ≥30%

4.     Correction of coagulopathy: Discontinuation of the anticoagulant, FFP 4U,
Vit-K (10 mg SC or IM) may be indicated for prolonged PT from warfarin or hepatobiliary disease, but takes several hours to days,
Protamine infusion (1 mg antagonizes ~100 units of heparin) can be used for immediate reversal of anticoagulation from heparin
Platelet infusion may be indicated when the platelet count is <50,000/m m³

5.     Airway protection

6.     Nonvariceal upper GI bleeding: IV PPI or oral high-dose PPI (omeprazole, 40 mg PO bid) reduce the rate of recurrent bleeding and the need for surgery. Mortality is reduced in peptic ulcer bleeding, but not other causes. PPI therapy, oral or IV, is better than IV histamine-2 receptor antagonist (H₂RA) therapy

7.     Variceal bleeding:
--octreotide infusion should be initiated immediately (50- to 100-mcg bolus, followed by infusion at 25 to 50 mcg/hr), and continued for 3 to 5 days.
--Vasopressin (0.3 units/min IV, titrated by increments of 0.1 units/min q30 min until hemostasis is achieved, side effects develop, or the maximum dose of 0.9 units/min is reached), rarely used because of significant cardiovascular complications including cardiac arrest and myocardial infarction
--Nitroglycerin is administered only if the systolic BP is >100 mm Hg, at a dose of 10 mcg/min IV, increased by 10 mcg/min q10-15 min until the systolic BP falls to 100 mm Hg or a maximum dose of 400 mcg/min is reached

8.     Antibiotic: fluoroquinolone (norfloxacin or ciprofloxacin), ceftriaxone (1 g/d) for patients with advanced cirrhosis or when quinolone-resistant

9.     Therapeutic endoscopy within 12 to 24 hours, single dose of erythromycin (250 mg IV) administered 30 to 60 minutes prior to upper endoscopy may induce gastric emptying of clots and debris, and improve visualization

10.    Variceal ligation or banding is the endoscopic therapy of choice for esophageal varices, lower rates of rebleeding and fewer complications compared to sclerotherapy

11.    Transjugular intrahepatic portosystemic shunt (TIPS) à
expandable metal stent deployed between the hepatic veins and the portal vein
Indications: refractory variceal bleeding unresponsive to variceal ligation or sclerotherapy, bleeding from gastric varices in portal hypertension
screening for shunt stenosis with duplex Doppler ultrasound

12.    Emergent total colectomy for massive, unlocalized, colonic bleeding
Total or partial colectomy for diverticular bleeding
Splenectomy for bleeding gastric varices from splenic vein thrombosis
Shunt surgery (portacaval or distal splenorenal shunt)
  (a) fails endoscopic or pharmacologic therapy,
  (b) unable to return for follow-up visits,
  (c) high risk of death from recurrent bleeding
     (cardiac disease or difficulty in obtaining blood products)
  (d) lives far from medical care