1. Gastrointestinal Bleeding
Rajeev Jain, M.D.

2. GI Bleeding Clinical Presentation Acute Upper GI Bleed
Acute Lower GI Bleed

3. Core Principles in GI Bleeding Management
Assessment and stabilization of hemodynamic status
Determine the source of bleeding
Stop active bleeding
Treatment of underlying abnormality
Prevent recurrent bleeding
The core principles in the management of GI bleeding are listed in this slide. Many of these assessments & interventions will be performed concurrently. 1st and foremost, the pt needs to be assessed in regards to their hemodynamic status ….

4. GI Bleeding Management Definitions
Hematemesis: bloody vomitus (bright red or coffee-grounds)
Melena: black, tarry, foul-smelling stool
Hematochezia: bright red or maroon blood per rectum
Occult: positive stool occult test
Symptoms of anemia: angina, dyspnea, or lightheadedness

5. GI Bleeding Management Patient Assessment
Hemodynamic status
Localization of bleeding source
CBC, PT, and T & C
Risk factors
Prior h/o PUD or bleeding
Cirrhosis
Coagulopathy
ASA or NSAID’s

6. GI Bleeding Management Initial Patient Assessment
Vital Signs
Blood Loss
Severity of GI Bleed
Shock
(resting hypotension)
20-25%
Massive
Postural
(orthostatic hypotension)
10-20%
Moderate
Normal
<10%
Minor

7. GI Bleeding Management Resuscitation
2 large bore peripheral IV’s
Normal saline or LR
Packed RBCs
Correct coagulopathy

8. GI Bleeding Management Location of Bleeding
Upper
Proximal to Ligament of Treitz
Melena ( cc of blood)
Azotemia
Nasogastric aspirate
Lower
Distal to Ligament of Treitz
Hematochezia

9. Acute UGIB Demographics
Over 400,000 admissions annually
80% self-limited
Mortality 10-14%
Continued or recurrent bleeding - mortality 30-40%
Nonvariceal UGIB w/o complication*
Mean LOS 2.7 days, $3402 (2008 $)
Nonvariceal UGIB with complication*
Mean LOS 4.4 days, $5632 (2008 $)
Adam V, Barkun A. Value Health. 2008;11:1-3.

10. Risk Stratification Scoring Systems

11. Rockall Score Blatchford Score
The Blatchford score uses pre-endoscopic clinical and laboratory variables to predict the need for clinical intervention (blood transfusion, endoscopy, surgery).
The Rockall score has pre-endoscopic and endoscopic components; the total score seems to perform better for mortality than for rebleeding.

12. UGIB Risk Stratification – AIMS65
Large clinical database - CareFusion
187 US hospitals
Recursive partitioning
,222 pts to derive risk score
,504 pts to validate
Albumin < 3.0 g/dL,
INR > 1.5,
Altered mental status,
Systolic blood pressure 90 mm Hg or lower, and
Age older > 65 years.
Data from patients admitted from the emergency department with acute upper GI bleeding were extracted from a database containing information from 187 U.S. hospitals. Recursive partitioning was applied to
derive a risk score for in-hospital mortality by using data from 2004 to 2005 in 29,222 patients. The score was validated by using data from 2006 to 2007 in 32,504 patients. Accuracy to predict mortality was assessed by the area under the receiver operating characteristic (AUROC) curve.
Saltzman JR et al. Gastrointest Endosc 2011:

13. UGIB Risk Stratification – AIMS65
The 5 factors present at admission with the best discrimination were albumin less than 3.0 g/dL, international normalized ratio greater than 1.5, altered mental status, systolic blood pressure 90 mm Hg or lower, and age older than 65 years. For those with no risk factors, the mortality rate was 0.3% compared with 31.8% in patients with all 5 (P < .001). The model had a high predictive accuracy (AUROC = 0.80; 95% CI, ), which was confirmed in the validation cohort (AUROC = 0.77, 95% CI, ). Longer LOS and increased costs were seen with higher scores (P < .001).
Saltzman JR et al. Gastrointest Endosc 2011:

14. Acute UGIB Differential Diagnosis
Major Causes
Minor Causes
Peptic ulcer disease
Gastric ulcer
Duodenal ulcer
Mallory-Weiss tear
Varices
Esophagitis
Dieulafoy’s lesion
Vascular anomalies
Malignancy
Post-procedural
Cameron’s lesions
Hemobilia
Hemorrhagic gastropathy
Aortoenteric fistula
80-90% of UGIB are non-variceal with PUD accounting for the majority of the nonvariceal UGIB

15. Peptic Ulcer Disease Forrest Class Stigmata IA Arterial spurting IB
Arterial oozing
IIA
Visible vessel
IIB
Adherent clot
IIC
Pigmented flat spot
III
Clean based
Forrest JA, Finlayson ND, Shearman DJ: Endoscopy in gastrointestinal bleeding. Lancet  1974; 2:394-7

16. Endoscopic Appearance of Ulcers
Clean based ulcer
Nonbleeding visible vessel

17. Risk Stratification after Endoscopy

18. Prognostic Features at Endoscopy in Acute Ulcer Bleeding

19. Endoscopic Therapy of PUD
Thermal
Bipolar probe
Monopolar probe
Argon plasma coagulator
Heater probe
Mechanical
Hemoclips
Band ligation
Injection
Epinephrine
Alcohol
Ethanolamine
Polidocal

20. Endoscopic Therapy of PUD
Laine and Peterson New Eng J Med 1994;331:

21. Risk of Recurrent Bleeding after Endoscopic Therapy

22. Effect of Proton-Pump Inhibition on Peptic Ulcer Bleeding
After EGD
Gralnek et al. New Eng J Med 2008;359:

23. Management of PUD after EGD in High Risk Pts
Proton-pump inhibitor 80 mg IV bolus dose plus continuous infusion for 72 hrs
Admit to monitored bed or ICU setting
Initiate oral intake of clear liquid diet 6 hrs after EGD in pts with hemodynamic stability
Transition to oral PPI after completing IV course
Perform testing for H. pylori infection
For selected patients, discuss need for NSAIDs and antiplatelet therapy
Gralnek et al. New Eng J Med 2008;359:

24. Management of PUD after EGD in Low Risk Pts
Oral proton-pump inhibitor
Initiate oral intake with a regular diet 6 hrs after EGD in pts with hemodynamic stability
Perform testing for H. pylori infection
For selected patients, discuss need for NSAIDs and antiplatelet therapy
Consider early discharge in selected pts
Gralnek et al. New Eng J Med 2008;359:

25. Mallory-Weiss Tear

26. Esophageal Varices

27. Management of Acute Variceal Bleeding
Suspected Variceal Bleeding
Octreotide 50 ug bolus, 50 ug/hr
Conservative blood volume resuscitation
Antibiotics
Band ligation or sclerotherapy
Continue Octreotide for 5 days
Endoscopy
Early rebleeding
Failure to control
TIPS or surgery

28. Antibiotic Prophylaxis in GI Bleeding in Cirrhotic Patients
Fluoroquinolones or amoxicillin + clavulinic acid
Meta-analysis 1
Decrease rates of infection
SBP, bacteremia
Increased short-term survival
RCT 2
Reduction in early rebleeding
Meta analysis of 6 studies
1.Bernard et al.Hepatology. 29(6):
2.Hou et al. Hepatology. 39(3):

29. Variceal Band Ligation

30. Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Coronary Vein
IVC
Splenic Vein
Portal Vein

31. Aortoduodenal Fistula
Aorta
Duodenum
Fistula
Graft

32. Acute UGIB Surgery Recurrent bleeding despite endoscopic therapy
> 6-8 units pRBCs

33. Management of Ulcer Bleeding: ACG Guidelines Initial Assessment and Risk Stratification
Hemodynamic status should be assessed immediately upon presentation and resuscitative measures begun as needed (Strong recommendation).
Blood transfusions should target Hgb ≥ 7 g / dl, with higher Hgbs targeted in patients with clinical evidence of intravascular volume depletion or comorbidities, such as coronary artery disease (Conditional recommendation).
Risk assessment should be performed to stratify patients into higher and lower risk categories and may assist in initial decisions such as timing of endoscopy, time of discharge, and level of care (Conditional recommendation).
Discharge from the ED without inpatient endoscopy may be considered in patients with urea nitrogen < 18.2 mg / dl; Hgb ≥ 13.0 g / dl for men (12.0 g / dl for women), systolic blood pressure ≥ 110 mm Hg; pulse < 100 beats / min; and absence of melena, syncope, cardiac failure, and liver disease, as they have < 1 % chance of requiring intervention (Conditional recommendation).
Laine & Jensen Am J Gastroenterol 2012; 107:345–360

34. Management of Ulcer Bleeding: ACG Guidelines Pre-endoscopic interventions
Intravenous infusion of erythromycin (250 mg ~ 30 min before endoscopy) should be considered to improve diagnostic yield and decrease the need for repeat endoscopy. However, erythromycin has not consistently been shown to improve clinical outcomes (Conditional recommendation).
Pre-endoscopic intravenous PPI (e.g., 80 mg bolus followed by 8 mg / h infusion) may be considered to decrease the proportion of patients who have higher risk stigmata of hemorrhage at endoscopy and who receive endoscopic therapy. However, PPIs do not improve clinical outcomes such as further bleeding, surgery, or death (Conditional recommendation).
If endoscopy will be delayed or cannot be performed, intravenous PPI is recommended to reduce further bleeding (Conditional recommendation).
Nasogastric or orogastric lavage is not required in patients with UGIB for diagnosis, prognosis, visualization, or therapeutic effect (Conditional recommendation).
Laine & Jensen Am J Gastroenterol 2012; 107:345–360

35. Management of Ulcer Bleeding: ACG Guidelines Timing of endoscopy
Patients with UGIB should generally undergo endoscopy within 24 h of admission, following resuscitative efforts to optimize hemodynamic parameters and other medical problems (Conditional recommendation).
In patients who are hemodynamically stable and without serious comorbidities endoscopy should be performed as soon as possible in a non-emergent setting to identify the substantial proportion of patients with low-risk endoscopic findings who can be safely discharged (Conditional recommendation).
In patients with higher risk clinical features (e.g., tachycardia, hypotension, bloody emesis or nasogastric aspirate in hospital) endoscopy within 12 h may be considered to potentially improve clinical outcomes (Conditional recommendation).
Laine & Jensen Am J Gastroenterol 2012; 107:345–360

36. Management of Ulcer Bleeding: ACG Guidelines - Endoscopy
Stigmata of recent hemorrhage should be recorded as they predict risk of further bleeding and guide management decisions. The stigmata, in descending risk of further bleeding, are active spurting, non-bleeding visible vessel, active oozing, adherent clot, fl at pigmented spot, and clean base (Strong recommendation).
Endoscopic therapy should be provided to patients with active spurting or oozing bleeding or a non-bleeding visible vessel (Strong recommendation).
Endoscopic therapy may be considered for patients with an adherent clot resistant to vigorous irrigation. Benefi t may be greater in patients with clinical features potentially associated with a higher risk of rebleeding (e.g., older age, concurrent illness, inpatient at time bleeding began) (Conditional recommendation).
Endoscopic therapy should not be provided to patients who have an ulcer with a clean base or a fl at pigmented spot (Strong recommendation).
Laine & Jensen Am J Gastroenterol 2012; 107:345–360

37. Management of Ulcer Bleeding: ACG Guidelines - Endoscopy
Epinephrine therapy should not be used alone. If used, it should be combined with a second modality (Strong recommendation).
Thermal therapy with bipolar electrocoagulation or heater probe and injection of sclerosant (e.g., absolute alcohol) are recommended because they reduce further bleeding, need for surgery, and mortality (Strong recommendation).
Clips are recommended because they appear to decrease further bleeding and need for surgery. However, comparisons of clips vs. other therapies yield variable results and currently used clips have not been well studied (Conditional recommendation).
For the subset of patients with actively bleeding ulcers, thermal therapy or epinephrine plus a second modality may be preferred over clips or sclerosant alone to achieve initial hemostasis (Conditional recommendation).
Laine & Jensen Am J Gastroenterol 2012; 107:345–360

38. Management of Ulcer Bleeding: ACG Guidelines - Therapy after initial endoscopy
After successful endoscopic hemostasis, intravenous PPI therapy with 80 mg bolus followed by 8 mg/h continuous infusion for 72 h should be given to patients who have an ulcer with active bleeding, a non-bleeding visible vessel, or an adherent clot (Strong recommendation).
Patients with ulcers that have flat pigmented spots or clean bases can receive standard PPI therapy (e.g., oral PPI once daily) (Strong recommendation).
Routine second-look endoscopy, in which repeat endoscopy is performed 24 h after initial endoscopic hemostatic therapy, is not recommended (Conditional recommendation).
Repeat endoscopy should be performed in patients with clinical evidence of recurrent bleeding and hemostatic therapy should be applied in those with higher risk stigmata of hemorrhage (Strong recommendation).
If further bleeding occurs after a second endoscopic therapeutic session, surgery or interventional radiology with transcathether arterial embolization is generally employed (Conditional recommendation).
Laine & Jensen Am J Gastroenterol 2012; 107:345–360

39. International Consensus on Nonvariceal Upper Gastrointestinal Bleeding: Postdischarge ASA and NSAIDs
In patients with previous ulcer bleeding who require an NSAID, it should be recognized that treatment with a traditional NSAID plus PPI or a COX-2 inhibitor alone is still associated with a clinically important risk for recurrent ulcer bleeding.
In patients with previous ulcer bleeding who require an NSAID, the combination of a PPI and a COX-2 inhibitor is recommended to reduce the risk for recurrent bleeding from that of COX-2 inhibitors alone.
Barkun AN, et al. Ann Intern Med. 2010;152:

40. International Consensus on Nonvariceal Upper Gastrointestinal Bleeding: Postdischarge ASA and NSAIDs
In patients who receive low-dose ASA and develop acute ulcer bleeding, ASA therapy should be restarted as soon as the risk for cardiovascular complication is thought to outweigh the risk for bleeding.
In patients with previous ulcer bleeding who require cardiovascular prophylaxis, it should be recognized that clopidogrel alone has a higher risk for rebleeding than ASA combined with a PPI.
Barkun AN, et al. Ann Intern Med. 2010;152:

41. Acute LGIB Differential Diagnosis
Diverticulosis
Colitis
IBD (UC>>CD)
Ischemia
Infection
Vascular anomalies
Neoplasia
Anorectal
Hemorrhoids
Fissure
Dieulafoy’s lesion
Varices
Small bowel
Rectal
Aortoenteric fistula
Kaposi’s sarcoma
UPPER GI BLEED

42. Acute LGIB Diagnoses in pts with hemodynamic compromise.
Zuccaro. ASGE Clinical Update

43. Diverticulosis

44. Diverticular Bleeding

45. Hemorrhoids

46. Bleeding AVM

47. Radiation Proctitis

48. Acute LGIB Meckel’s Diverticulum
Incidence %
Etiology Incomplete obliteration of the vitelline duct.
Pathology 50% ileal, 50% gastric, pancreatic, colonic mucosa
Complications
Painless bleeding (children, currant jelly)
Intussusception

49. Acute LGIB Evaluation
Zuccaro. ASGE Clinical Update

50. Acute LGIB Key Points Resuscitation UGI source Most bleeding ceases
Colonoscopy
No role for barium studies

51. SUMMARY GI Bleeding Management
Assessment and stabilization of hemodynamic status
Determine the source of bleeding
Stop active bleeding
Treatment of underlying abnormality
Prevent recurrent bleeding