1. GASTROINTESTINAL BLEEDING
Ajay Jain, MD, FACG, FRCPC
Gastroenterologist
Meridian Medical Group
INSGNA
March 5, 2011

2. Objectives Introduction Lower Gastrointestinal Bleeding (LGIB)
etiology
presentation
diagnostic testing
management
Upper Gastrointestinal Bleeding (UGIB)
evaluation
endoscopy

3. Introduction gastrointestinal bleeding (GIB) common clinical problem
source of GIB traditionally divided into either upper or lower
upper gastrointestinal bleeding (UGIB):
bleeding from any source proximal to ligament of Treitz
lower gastrointestinal bleeding (LGIB):
bleeding from any source distal to ligament of Treitz

4. Lower Gastrointestinal Bleeding
one-fifth to one-third as common as UGIB
less severe course compared with UGIB
annual incidence rate:
25 cases per 100,000 adult population at risk (UGIB rate : 150 cases per 100,000)
incidence increases with age
greater than 200-fold increase from 20s to 80s
mean age of patients with LGIB:
mortality rate 2 - 4%

5. LGIB - Etiology
Age, Mortality Rates, and Causes of Acute Lower Gastrointestinal Bleeding in the Elderly
Study
Mean Age
(yrs)
Mortality
(%)
Divertic-ulosis
Angio-
dysplasia
Cancer/
Polyp
Colitis/
Ulcer*
Ano-
rectal
Other
Boley (1979)
n = 183
>65 2 40 11 14 12 NA
Jensen (1988)
n = 80 65 20 37 5
Leitman (1989)
n = 65 63 27 24 15 10
Richter (1995)
n = 107 70 48 6 3
Jensen (2003)Ψ
n = 291 77 30 21 23
NA Not available
* Includes Inflammatory bowel disease, infectious colitis, radiation colitis, vasculitis and inflammation of
unknown origin
Ψ Expressed as % of colonic causes of bleeding

6. LGIB - Presentation Chief complaint may vary
passage of occasional bright red blood per rectum associated with formed, brown stool
patient usually hemodynamically stable
passage of relatively higher volumes of bright red blood (“hematochezia”)
patient may be hemodynamically unstable
passage of black, tarry stools (“melena”)
first evaluate for UGIB
if evaluation shows no upper GI source then consider bleeding from right colon or small bowel

7. LGIB Monitoring patients may be critically ill at presentation
not only at risk for direct consequences of GI tract pathology, but also for cardiac, pulmonary, renal and neurologic complications of acute blood loss
identify symptoms of hemodynamic compromise:
postural symptoms/fatigue/palpitations/chest pain/dyspnea
monitor vital signs (including postural vitals)
increase of > 10 beats/min or drop in BPs > 10mmHg indicative of at least a 15% acute blood loss volume
Ebert et al, Arch Int Med 1941; Am Coll Surg 1993

8. LGIB Initial resuscitation
restore euvolemia, prevent complications of acute blood loss
MI, CHF, CVA, etc.
transfuse packed red blood cells as necessary
correct coagulopathy
fresh frozen plasma & vitamin K
obtain relevant history while resuscitation is underway
duration of bleeding/presence or absence of abdominal pain/chest pain /fever
history of ulcer disease/IBD/radiation therapy to abdomen or pelvis
cardiopulmonary, renal, hepatic disease
current medications (ASA, NSAIDS, anticoagulants)

9. LGIB Initial resuscitation (cont’d) Physical examination
cardiac/pulmonary/abdominal and rectal examinations
Laboratory studies
CBC/electrolytes/BUN/CR/PT/PTT
type and cross
EKG

10. LGIB Not All Hematochezia is Due to a Colonic Source
first think of a colonic source of bleeding but remember that UGIB source may present with hematochezia, if the bleeding is brisk
in one series 11% of patients with hematochezia and hemodynamic compromise had an UGI source
Jensen et al, Gastroenterology 1988

11. LGIB Not All Hematochezia is Due to a Colonic Source (cont’d)
nasogastric (NG) tube is reasonable to use to evaluate for possible UGIB
note presence or absence of both blood and bile
if significant blood seen on NG tube, consider performing upper endoscopy
presence of bile confirms that duodenal contents sampled; if bile absent an upper GI endoscopy should be considered
NG tube has been shown to be useful test in this regard with accuracy of 94-98%
no role for upper GI barium x-ray
Luk et al, JAMA 1979; Cuellar et al, Arch Intern Med, 1990

12. LGIB Sources of Colonic Bleeding Diverticulosis
arterial bleeding, painless, ceases spontaneously in most cases

13. LGIB Sources of Colonic Bleeding Diverticular Bleeding
87 year-old woman who presented with lower gastrointestinal bleeding.
The bleeding was finally localized to a single diverticulum, shown here

14. LGIB Sources of Colonic Bleeding Angiodysplasia vascular malformations
frequently involves proximal colon
Arrow indicates point of bleeding

15. LGIB Sources of Colonic Bleeding
Colonic Neoplasia (large adenoma or adenocarcinoma)
may present with blood per rectum but more often present with change in bowel habits, abdominal pain or other related symptom
Sessile (flat) polyp
Bleeding polyp
Colon cancer

16. LGIB Sources of Colonic Bleeding Inflammatory Colitides/Ulceration
inflammatory bowel disease, infectious colitis, radiation colitis, vasculitis
33 year-old man with Crohn’s colitis involving
the proximal colon, with severe inflammation,
edema and ulcers
Normal
vascular pattern
Normal
transverse colon

17. LGIB Sources of Colonic Bleeding Anorectal
hemorrhoids, anal fissure, idiopathic rectal ulcer

18. LGIB Diagnostic Testing Colonoscopy clearly test of choice
no evidence that colonic purge will increase the rate of bleeding or cause renewed bleeding if it has ceased
overall diagnostic yield of colonoscopy 70-80%
not only allows identification of bleeding source but also can apply therapy to stop bleeding
endoscopic therapies (discussed in greater detail with UGIB)
Thermal (heater probe, argon plasma coagulation)
Injection (epinephrine, ethanolamine etc.)
Mechanical (band ligation, hemoclips, endoloops)
Forde et al, Gastrointest Endosc 1981

19. LGIB Diagnostic Testing (cont’d) Angiogram
use if unable to find bleeding site
diagnostic yield: 40-80%
usually need to have a bleeding rate of >0.5mL/min to identify extravasation of contrast into bowel
risk of complications greater than colonoscopy
contrast-induced renal failure, contrast allergy, bleeding after arterial puncture, embolism from dislodged thrombus
therapy can be applied (embolization or intra-arterial injection)
Nuclear Medicine Red Blood Cell (RBC) Scan
can potentially identify slower rate of bleeding
diagnostic yield 26-72%
Gomes et al, AJR 1986; Suzman et al, Ann Surg 1996

20. LGIB Role of Surgery Evaluation of Small Intestine
if bleeding does not cease, and site of bleeding known, directed surgery (ie. limited colonic resection) can be performed with better outcomes compared with subtotal colectomy or “blind” right hemicolectomy
Evaluation of Small Intestine
LGIB but no colonic source identified
rule-out UGIB first
if absent upper and lower GI source, exam small intestine:
video capsule endoscopy
enteroclysis
Meckels scan

21. ALGORITHM
TO ACUTE
LGIB
(Part 1)
SEE NEXT SLIDE

22. ALGORITHM TO ACUTE LGIB

23. Upper Gastrointestinal Bleeding
can divide causes into
variceal and non-variceal UGIB (focus on non-variceal UGIB)
Healthcare burden/cost of UGIB from peptic ulcer disease
250,000 to 300,000 hospital admissions
$2.5 billion in US each year
despite advances in diagnosis and treatment, mortality of UGIB remains from 5 – 14%
mortality higher in patients > 60 yrs and in patients with multiple comorbid conditions
Rockall et al, Lancet 1995; Rockall et al, Gut 1996

24. UGIB
Natural History
majority of patients with UGIB will spontaneously cease
70-80% will stop within first 48 hrs of onset; of those 10-20% will have recurrence of UGIB
at initial presentation ~20% will continue to bleed
mortality greatest in these patients and also patients that have recurrent bleeding

25. UGIB - Etiology Etiology % Peptic ulcer disease 50+ Esophageal varices10
Mallory-Weiss tear
5-10
Esophagitis
8-10
Neoplasm
2-5
Angiodysplasia
Miscellaneous

26. UGIB - Etiology
20-30% of patients will have two or more diagnoses of UGIB
no disease entity is found in 10-15% of patients (prognosis is excellent)
bleeding peptic ulcer disease most common etiology and is also the most widely studied
excellent randomized control trials regarding best treatment modalities, outcomes, risk of rebleeding and natural progression

27. UGIB Initial evaluation monitor hemodynamic status
IV access; vigorous volume replacement
confirm UGI source of bleeding by
history (hematemesis – fresh blood or coffee ground emesis, melena)
nasogastric aspiration is 80% sensitive for actively bleeding UGI source
False negative aspirates occur when the tube is improperly positioned or when reflux of blood from a duodenal source prevented by pylorospasm or obstruction
Cuellar et al, Arch Intern Med 1990

28. UGIB
Endoscopy
when UGIB suspected, test of choice for identifying and treating the bleeding lesion is upper endoscopy
no role for barium studies in acute UGIB
greatest benefit in the ~20% of patients with continued or recurrent bleeding
endoscopy can improve morbidity and mortality
endoscopic therapy with coagulation and/or injection therapy effective in the setting of actively bleeding ulcers
active bleeding can be controlled in 85-90% of patients, with less than 3% complication rate
mortality decreased by nearly one third
concurrent use of proton pump inhibitors (eg. IV prevacid or protonix) of significant benefit in decreasing recurrent bleeding
Sacks et al, JAMA 1990; Laine et al, Gastro 1990

29. UGIB
Endoscopy
management decision for other 80% who will not have further bleeding can be altered by aggressive diagnosis
requires ability to separate high-risk patients from low-risk patients
clinical indicators of higher mortality from UGIB
variceal bleeding
advanced age
comorbid illnesses
large volume bleeding
persistent or recurrent bleeding despite medical therapy

30. Risk of Recurrent Bleeding
UGIB
Endoscopy
best predictor of recurrent bleeding in peptic ulcer disease is the endoscopic appearance of the ulcer
Risk of Recurrent Bleeding By Endoscopic Criteria
Endoscopic Finding
Risk of Recurrent Bleeding
Mortality
Active Bleeding
55%
11%
Visible Vessel
43%
Adherent Clot
22% 7%
Flat Spot
10% 3%
Clean Base 5% 2%
Freeman et al, Gastrointest Endosc 1993

31. UGIB
Endoscopy
Clean based ulcer
Adherent clot

32. UGIB Endoscopy Small ulcer with a prominent visible vessel
2 cm ulcer with pulsatile,
arterial bleed

33. UGIB
Endoscopy
Laine et al (Gastro 1992) showed that patients with a clean based ulcer had only a 2% risk of recurrent bleeding and could be safely fed and immediately discharged from hospital
reduces hospital stay → reduces healthcare costs
Lee et al (Gastrointest Endosc 1999) showed that “endoscopic triage” significantly decreased costs and resulted in median savings of $2068

34. UGIB Endoscopic Management
several endoscopic therapeutic techniques available to attempt hemostasis in patients with UGIB
Thermal
Heater Probe
Multipolar electrocautery (MPEC)/bipolar electrocautery
Argon plasma coagulation
Injection
Epinephrine
Alcohol
Ethanolamine
Other
Mechanical
Band Ligation
Hemoclips (Endoclip)
Detachable Snare (Endoloop)

35. UGIB Endoscopic Management
several endoscopic therapeutic techniques available to attempt hemostasis in patients with UGIB
Thermal
Heater Probe
Multipolar electrocautery (MPEC)/bipolar electrocautery
Argon plasma coagulation (APC)
Injection
Epinephrine
Alcohol
Ethanolamine
Other
Mechanical
Band Ligation
Hemoclips (Endoclip)
Detachable Snare (Endoloop)

36. UGIB Endoscopic Management – Thermal all thermal devices generate heat
directly (heater probe) or
indirectly by tissue absorption of light energy (laser) or
passage of electrical current through tissue (multipolar probes, APC)
heating leads to edema, coagulation of tissue protein, contraction of vessels, resulting in hemostatic bond
multipolar electrocautery (MPEC) has been compared with sham treatment in patients with active bleeding or nonbleeding visible vessel
shown to reduce re-bleeding, emergency surgery, mean hospital stay and cost of hospitalization

37. Thermal small ulcer with a prominent visible vessel
site after eradication of the vessel using heater probe

38. UGIB Endoscopic Management
several endoscopic therapeutic techniques available to attempt hemostasis in patients with UGIB
Thermal
Heater Probe
Multipolar electrocautery (MPEC)/bipolar electrocautery
Argon plasma coagulation
Injection
Epinephrine
Alcohol
Ethanolamine
Other
Mechanical
Band Ligation
Hemoclips (Endoclip)
Detachable Snare (Endoloop)

39. UGIB Endoscopic Management – Injection
devices passed through working channel of endoscope that allow injection of liquid agents into target site of interest
injection of various solutions achieves hemostasis by mechanical tamponade
in sham controlled trials, injection therapy reduced rebleeding, transfusion requirement, emergency surgery and hospital stay
Nelson et al, Gastointest Endosc 1999; Chung et al, Br Med J 1988

40. UGIB Endoscopic Management
several endoscopic therapeutic techniques available to attempt hemostasis in patients with UGIB
Thermal
Heater Probe
Multipolar electrocautery (MPEC)/bipolar electrocautery
Argon plasma coagulation
Injection
Epinephrine
Alcohol
Ethanolamine
Other
Mechanical
Band Ligation
Hemoclips (Endoclip)
Detachable Snare (Endoloop)

41. UGIB Endoscopic Management – Mechanical Band ligation Hemoclips
preloaded elastic band(s) with a release mechanism affixed to tip of endoscope
esophageal variceal band ligation effective in control of active hemorrhage in 86 to 91%
Hemoclips
preloaded metal clips deployed through biopsy channel of scope (mechanism of hemostasis is mechanical compression)
achieved hemostasis in 84 to 100% of patients with variety of UGIB sources
Detachable Snares
loop placed around target tissue and loop tightened and then released
were developed to prevent and treat post-polypectomy bleeding
Laine et al, Ann Intern Med 1995; Binmoeller et al, Endoscopy 1993

42. Band ligation
Esophageal varices in a 74 year-old man with alcoholic cirrhosis
Two neighboring esophageal varices which have been successfully banded
In another day or two the banded areas will sloughed off

43. Detachable Snares

44. Detachable Snares

45. Hemoclips Erythematous ulcer base with a visible vessel
Two hemostatic clips were
successful applied to the vessel, and
there was no further bleeding

46. ALGORITHM
TO UGIB

47. ALGORITHM TO UGIB

48. Summary LGIB resuscitation, hemodynamic stability a priority
colonoscopy procedure of choice for evaluation of acute LGIB
upper endoscopy should be performed when an upper source is suspected or when evaluation of colon is negative
if colonoscopy and upper endoscopy are negative, evaluation of small bowel should be considered
angiogram and/or a bleeding scan may be appropriate in the setting of massive bleeding
pre-operative localization of bleeding attempted prior to surgical intervention

49. Summary UGIB resuscitation, hemodynamic stability a priority
determine if (based on available information), if variceal vs non-variceal UGIB
upper endoscopy procedure of choice for evaluation of UGIB
“endoscopic triage”
endoscopic therapeutic options (thermal, injection, mechanical)
use of IV proton pump inhibitors (eg. Prevacid or protonix) in the high risk group of significant benefit in reducing recurrent bleeding