Gastrointestinal haemorrhage

Reviewed and revised 3 May 2017

OVERVIEW

GI haemorrhage is divided into upper GI haemorrhage and lower GI haemorrhage based on the underlying cause and differences in the approach to management

CAUSES

Upper GI Bleeding

  • peptic ulcer disease (75% are gastric, rather than duodenal)
  • Varices (90% are oesophageal, rather than gastric)
  • Oesophagitis
  • Gastritis
  • Duodenitis
  • Mallory-Weiss tears
  • Portal hypertensive gastropathy

Lower GI Bleeding

  • Diverticular disease
  • Angiodysplasia
  • Colonic tumour/polyps
  • Meckel’s diverticulum
  • inflammatory bowel disease
  • Arteriovenous malformations
  • Haemorrhoids

Remember that brisk upper GI bleeding is a cause of lower GI bleeding!

INVESTIGATIONS

Laboratory

  • FBC (check Hb, platelets)
  • Coagulation profile
  • Blood gas and lactate (if haemodynamically unstable)
  • Other investigations as appropriate if underlying liver disease or other bleeding disorders suspected
  • Consider testing for H. pylori if appropriate

Upper GI Endoscopy

  • Both an investigation and a therapy
  • Urgent endoscopy for upper GI haemorrhage is typically indicated if:
    • Syncope (indicates hemodynamic instability)
    • Hematemesis (indicates that the stomach is filling with blood)
    • Hypotension
    • Transfusion requirements in excess of 4 units of PRBCs over 12 hrs
    • Age over 60
    • Multiple comorbidities
  • Predicts risk of rebleeding in peptic ulcer disease
    • Obvious bleeder: 85-90% risk
    • Obvious vessel: 35-55% risk
    • Clot: 30-40% risk
    • Reddish spot: 5-10% risk
    • Nothing found: 5% risk

Colonoscopy

  • not useful for significant bleeds acutely as rarely identifies the bleeding site due to stool and blood
  • useful for identifying underlying lesions following bowel preparation

Tc-99 Red Cell Scan

  • radiolabelling RBCs and observing where they go
  • identifies GI bleed ~80% of the time

Angiography

  • gold standard for lower GI haemorrhage, identifies bleeding point 85% of the time
  • To identify an upper GI bleed on an angiogram the rate of bleeding typically needs to be greater than 0.5ml/min

MANAGEMENT

Resuscitation

  • intubate if risk of aspiration from upper GI bleed (see Intubation of Upper GI haemorrhage)
  • high flow O2 to maintain SpO2 target (e.g. 15 L/min via non-rebreather mask)
  • large bore IV access
    • e.g. 2 x 16G IV cannulae in antecubital fossae
    • consider RICC line (8.5 Fr cannula – can rewire a 20G or larger cannula)
  • transfuse massively bleeding patients using local protocols
    • avoid both under and over transfusion
    • activate massive transfusion protocol if indicated
  • Correct underlying bleeding diathesis
  • Consider balloon tamponade (e.g. Sengstaken-Blakemore or Minnesota tube) to temporise variceal haemorrhage
  • Arrange for endoscopy for severe acute bleeding immediately after resuscitation
    • If patient still bleeding after initial endoscopy or rebleeds after repeat endoscopy, go to IR, then to surgery
  • Consults
    • endoscopist (usually gastroenterology)
    • consider interventional radiologist and GI surgeon

Blood products

  • Restrictive transfusion approach is appropriate unless massive GI haemorrhage
  • Do not give platelets if the patient is not bleeding
  • If they are bleeding, give platelets for count < 50,000
  • Give FFP to pts with fibrinogen < 1 g/L or INR > 1.5, but use PCC for patients taking warfarin and are actively bleeding
  • Do not use Factor VIIa until other methods have failed

Upper GI haemorrhage

  • Scoring systems
    • Before endoscopy, calculate a Blatchford Score consider discharge if the score is zero
    • After endoscopy, calculate a Rockall Score to help determine disposition
  • Proton pump inhibitors
    • do not administer to patients with non-variceal upper GI bleeding unless endoscopy reveals an ulcer
    • administer if the patient has stigmata of recent haemorrhage on endoscopy
  • Peptic ulcer disease
    • Endoscopic therapies (all equivalent effectiveness)
      • Adrenaline injection – cheap, easy to learn, and effective
      • Heat coagulation – with the added risk of perforation
      • Clipping – no risk of perforation, but technically difficult in some sites
    • Medications are used to prevent rebleeding post-endoscopy but do not have a role in management prior to endoscopy
      • PPI infusion is commonly used but likely has no advantage over twice-daily dosing
      • H2 receptor antagonists (e.g. ranitidine) are an alternative
      • No role for empiric tranexamic acid
  • Variceal bleed
    • endoscopic therapies include banding and sclerotherapy
    • administer terlipressin (lowers portal venous pressure) until definitive haemostasis or for 5 days (octreotide is an alternative option)
    • prophylactic antibiotics
    • if endoscopic treatment is unsuccessful:
      • TIPS (transjugular intrahepatic portosystemic shunt)
        • redistributes blood from the portal circulation reducing portal venous pressure
        • decreases the chances of treatment failure in refractory variceal bleeding (e.g. 50% to 3% in one study)
        • carries a high risk of hepatic encephalopathy, so is reserved for when other options have failed
      • consider other IR procedures such as balloon-occluded retrograde transvenous obliteration (BRTO)
      • consider surgical shunts (e.g.Warren distal splenorenal shunt) as a last resort

Lower GI Bleeding

  • upper GI endoscopy to rule out an upper GI source
  • proctosigmoidoscopy (e.g. haemorrhoids)
  • colonoscopy (may not be very helpful acutely, can be used to treat lesions if bleeding is minor)
  • rapid bleeding: angioembolisation OR surgery
  • mild bleeding: 99Tc-RBC scan -> angioembolisation OR surgery
  • surgical intervention may be indicated for:
    • diverticular disease
    • unmanageable polyps and malignancies
    • other lesions (e.g. AVMs or inflammatory bowel disease) that are not amenable to endoscopic management

Disposition

  • In general, massive GI haemorrhage should only leave the resuscitation bay to go to an endoscopy suite or the operating theatre
  • HDU/ICU admission for patients requiring urgent endoscopy is not typically required unless there will be an unavoidable delay or the patient’s current location is not suitable for resuscitation

OTHER INFORMATION

  • There is no role for a barium swallow in the modern assessment and management of GI haemorrhage as it cannot identify conditions such as  hypertensive gastropathy and gastritis/oesophagitis/duodenitis
  • Generally, postero-inferior duodenal wall ulcers and high lesser curve of stomach ulcers tend to rebleed most vigorously, due to the large arteries nearby

References and links

LITFL

FOAM and web resources


CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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