by Moira Carrol, Gurpreet Mudan, and Suzanne Bentley
A 61-year-old man with a history of liver cirrhosis secondary to chronic EtOH abuse presents to the Emergency Department (ED) with a complaint of vomiting bright red blood that began prior to arrival. He arrives actively vomiting; a significant amount of blood is noted in his emesis basin. He is now complaining of dizziness and appears pale.
Gastrointestinal bleeding (GIB) can be generalized into two categories based on the site of bleeding. Upper GIB (UGIB) is defined as any bleeding that occurs proximal to the ligament of Trietz near the terminal duodenum. Lower GIB (LGIB) is any bleeding that occurs distal to the ligament extending to the rectum. Most GIB seen in the ED is attributed to UGIB with an incidence of 90 per 100,000 population. LGIB, on the other hand, presents with a rate of 20 per 100,000 population. LGIB is more commonly seen in the elderly but has a wide range of presentations and causes. As a result, the approach to LGIB has been less standardized.
Upper Gastrointestinal Bleeding (UGIB)
The most common causes of UGIB include peptic ulcer disease (PUD), erosive gastritis or esophagitis, esophageal or gastric variceal bleed and Mallory Weiss tears. Among these, PUD is the most common cause of UGIB presentations. Other less common causes include gastric malignancy, aortoenteric fistula, hematobilia and Dieulafoy’s lesion, which is a large tortuous artery that can run very close to the gastric mucosa and can cause devastating bleeding.
Lower Gastrointestinal Bleeding (LGIB)
LGIB is less common than UGIB in the ED. In fact, UGIB is identified in 11% of cases, whereas a lower GI source is found only in 9%. Diagnosis is sometimes elusive. LGIB can be the result of diverticulitis, the most common cause of LGIB, or from hemorrhoids, colitis, anal fissures, inflammatory bowel disease including Crohn’s disease and ulcerative colitis, colon cancer or angiodysplasia.
TABLE 1 – List of upper and lower G.I. bleeding causes
Critical Bedsides Actions and Emergency Department Approach
Just as the causes of acute GIB are diverse, so too are the possible presentations. As severe GIB can have a high risk of morbidity and mortality, patients with possible GIB should be identified quickly. In the ED, the patient should be evaluated for hemodynamic stability, as patients with brisk GI bleeding can rapidly decompensate. Assessment of patient stability includes evaluating the patient’s general appearance, volume status, and vital signs. If deemed hemodynamically unstable upon initial clinical evaluation, begin resuscitation of the patient immediately. Please check for the general approach in Figure 1.
First, do a rapid assessment and intervention of airway, breathing, and circulation (ABCs). Then, place two large bore IVs in preparation for IV crystalloid fluids infusion and possible blood product transfusion. Draw initial labs including a complete blood count, type and screen and type and crossmatch in case the patient will require blood product transfusion.
Indications for transfusion include hemodynamic instability despite crystalloid resuscitation, Hemoglobin (Hb) Hb < 9 g/dL in high-risk patients, Hb < 7 in low-risk patients. High-risk patients are considered those who are likely to rebleed or have severe hemorrhage, whereas low-risk patients are less likely. Various decision tools exist to help risk stratify patients based on multiple clinical criteria and lab values. Consider FFP to correct coagulopathy if present in a patient on anticoagulation or with severe liver dysfunction. Placing the patient on a cardiac monitor continually to assess changes in heart rate, blood pressure, and oxygen saturation is imperative.
History and Physical Examination Hints
After initial stabilization, the next step is to determine the probable cause of the bleeding in order to treat appropriately and disposition the patient. The history and physical can guide you towards identifying the likely source of the bleeding and direct the necessary treatments and consultations. UGIB can often be definitively managed by gastroenterologists. Lower GI bleeding, however, might require interventions by general surgeons, gastroenterologists or interventional radiologists.
Certain complaints are unique to GIB. One of the most important pieces of history is to assess complaints of active bleeding. Hematemesis is virtually diagnostic of UGIB. Hematemesis is defined as bloody vomit, either appearing as bright red blood or as coffee ground emesis. Melena, or dark, tarry stool, is also a sign of UGIB. In patients with UGIB, between 90-98% presented with either melena or hematemesis. Alternatively, hematochezia is defined as blood within or around the stool. However, hematochezia can sometimes be the result of a brisk UGIB. Diagnosis can also be confounded if there is slow peristalsis in the setting of an LGIB.
Therefore, start by assessing the context of the bleed as it can give you clues to its origin. For example, patients who have a bleed secondary to PUD might have a history of an ulcer, might complain of acid reflux or have a recent history of frequent NSAID use. Patients with gastric or esophageal varices might describe a history of or risk factors for liver disease, such as daily alcohol abuse, or have other pathognomonic signs of portal hypertension. A history of intractable vomiting in the setting of hematemesis may suggest Mallory Weiss tears as the cause.
Similarly, a patient who complains of blood in the stool with a history of constipation suggests bleeding caused by the diverticular disease. Recent diarrheal illness can be found in infectious colitis. An elderly patient presenting with weight loss or anorexia is concerning for malignancy. The duration and timing of the bleeding are important to determine. Brisk or continued bleeding can alert to the need for resuscitation or emergency intervention. Finally, the provider must characterize and quantify the bleeding. In a complaint with multiple pathologic causes, a good history and physical exam are paramount.
Emergency Diagnostic Tests and Interpretation
The most important lab tests for risk stratification for patients with acute GIB are the hemoglobin (Hb) and hematocrit (Hct), coagulation studies, and BUN to Creatinine ratio. A type&screen is recommended as well in case of expected blood transfusion. Initially, Hb and Hct may be within normal limits. The values might not immediately reflect blood loss after an acute hemorrhage and, therefore, should be repeated. Higher mortality and incidences of rebleeding were found in patients with Hb < 10 g/dL. Additionally, many recommend using the Hb and Hct to inform the decision to type and crossmatch blood versus only drawing a type and screen.
In a patient without kidney disease, a BUN to Creatinine ratio that is elevated to greater than or equal to 36 is strongly associated with UGIB. As blood is digested, the BUN is reabsorbed into the circulation leading to elevated serum levels. Below 36, however, the ratio has no positive or negative predictive value. BUN/Cr >36 can be helpful in the diagnosis of an occult UGIB in those patients who present without classic signs of GI bleeding.
The role of nasogastric (NG) lavage and aspiration in the diagnosis of GI bleeding has been controversial. NG aspiration positive for blood is highly predictive of a UGIB. However, it has not proven to be sensitive. Placement of an NG is not a benign procedure as there are risks including perforation and discomfort.
Fecal occult blood test
Performing a fecal occult blood test via a rectal exam is important in the setting of a GIB. This bedside test can confirm whether or not blood is present in the stool, confirming the presence of a GIB. Unfortunately, it is not specific to UGIB or LGIB; however, often the presence of melena or bright red blood can help guide diagnosis.
Upper endoscopy is overwhelmingly diagnostic and usually therapeutic for UGIB. Consultation with gastroenterology is necessary for the emergent scope of patients with continued bleeding and suspected UGIB. These specialists can immediately diagnose and treat the source of bleeding. Stable patients with suspected UGIB can undergo endoscopy as an inpatient. Early endoscopy, within the first 24 hours of presentation, is associated with shorter hospital stays and early instigation of appropriate treatment. However, most UGIB resolves without this intervention. Figure 2 shows a duodenal ulcer (Deep demarcated ulceration with a visible vessel on base (Forrest Iia) Source: Lai, WEO Endoscopy Atlas, Date: 2012-12-25.
Colonoscopy can be helpful in the diagnosis of LGIB and is an effective first-line test, but it is not a gold standard in the diagnosis of LGIB. A diagnosis is made by colonoscopy in 75% of cases. Typically, lower GI scopes are not performed emergently but can be performed later during hospitalization or as an outpatient. Figure 3 shows colonoscopy, bleeding from multiple diverticular outpouchings. Source: American Family Physicians, Wilkins et al. Diverticular bleeding (please see figure 2 in their manuscript).
Tagged Red Blood Cell Scan
Tagged Red Blood Cell Scan is a second line study that can assist in the diagnosis of more indolent and continued bleeding. Scanning within the recommended two-hour window after the injection has high rates of positive diagnosis in 95-100% of cases but after the recommended time period the test is significantly less effective.
Only a few medications have been shown to be influential in the acute management of GIB. Pantoprazole is indicated for a UGIB in the setting of PUD. It is given as an 80 mg bolus followed by an infusion at a rate of 8 mg/hour. If variceal bleeding is known or suspected, consider starting Octreotide or other somatostatin analog. Octreotide is given as a 25-50 mcg bolus, then 25-30 mcg/hr infusion. In patients with cirrhosis, antibiotics such as Ceftriaxone, Amoxicillin-clavulanate or Quinolone should be given.
Sengstaken-Blakemore Tube is a device that is inflated in the esophagus to tamponade uncontrolled bleeding caused by varices. It is used as a measure of last resort because of the high complication rate. EM CRIT – VIDEOS – Blakemore Tube Placement for Massive Upper GI Hemorrhage.
Disposition of Patient with Gastrointestinal Bleeding
Finally, the patient with GI bleeding will need to have a disposition based on the resuscitation and findings of the workup. Unstable patients or those with active GIB and rapidly decreasing Hb and Hct levels on reassessment should receive a consult from the intensive care unit. If a patient and Hb/Hct remain stable, admission to a regular medical floor or possible discharge home with close, appropriate follow-up may be considered. Appropriate follow-up should be timely with a gastroenterologist. Prior to discharge, patients should be encouraged to avoid medications and behaviors that may increase the risk of bleeding again, such as NSAIDs and alcohol.
References and Further Reading
- Witting, Michael D., et al. “ED predictors of upper gastrointestinal tract bleeding in patients without hematemesis.” The American journal of emergency medicine 24.3 (2006): 280-285.
- Peter, David J., and James M. Dougherty. “Evaluation of the patient with gastrointestinal bleeding: an evidence based approach.” Emergency medicine clinics of North America 17.1 (1999): 239-261.
- Van Leerdam, M. E., et al. “Acute upper GI bleeding: did anything change&quest.” The American journal of gastroenterology 98.7 (2003): 1494-1499.
- Ji, Jeong-Seon, et al. “Clinical outcome of endoscopic management of duodenal Dieulafoy’s lesions: endoscopic band ligation versus endoscopic hemoclip placement.” Surgical endoscopy (2015): 1-6.
- Marx, John, Ron Walls, and Robert Hockberger. Rosen’s Emergency Medicine-Concepts and Clinical Practice. Elsevier Health Sciences, 2013.
- Hung, Oliver L., and L. Nelson. “Tintinalli׳ s Emergency Medicine: A Comprehensive Study Guide.” (2011).
- Saltzman, J. Approach to acute upper gastrointestinal bleeding in adults. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on November 1, 2015.)
- Rockall, T. A., et al. “Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom.” Bmj 311.6999 (1995): 222-226.
- Byers, Stacie E., et al. “Incidence of occult upper gastrointestinal bleeding in patients presenting to the ED with hematochezia.” The American journal of emergency medicine 25.3 (2007): 340-344.
- Ernst, Amy A., et al. “Usefulness of the blood urea nitrogen/creatinine ratio in gastrointestinal bleeding.” The American journal of emergency medicine 17.1 (1999): 70-72.
- Lee, John G., et al. “Endoscopy-based triage significantly reduces hospitalization rates and costs of treating upper GI bleeding: a randomized controlled trial.” Gastrointestinal endoscopy 50.6 (1999): 755-761.
- Bjorkman, David J., et al. “Urgent vs. elective endoscopy for acute non-variceal upper-GI bleeding: an effectiveness study.” Gastrointestinal endoscopy 60.1 (2004): 1-8.
- Palamidessi, Nicholas, et al. “Nasogastric aspiration and lavage in emergency department patients with hematochezia or melena without hematemesis.” Academic Emergency Medicine 17.2 (2010): 126-132.