lower GI bleed

1. Approach & management
Acute lower Gastrointestinal
Bleeding
DR ABDUL RUB
PGY3 MEM

2. Definitions
 Upper GI bleed – arising from the
esophagus, stomach, or proximal
duodenum
 Mid-intestinal bleed – arising from distal
duodenum to ileocecal valve
 Lower intestinal bleed – arising from
colon/rectum

3. Stool color and origin/pace of
bleeding
• Guaiac positive stool
– Occult blood in stool
– Does not provide any localizing information
– Indicates slow pace, usually low volume bleeding
• Melena
– Very dark, tarry, pungent stool
– Usually suggestive of UGI origin (but can be small
intestinal, proximal colon origin if slow pace)
• Hematochezia
– Spectrum: bright red blood, dark red, maroon
– Usually suggestive of colonic origin (but can be UGI origin
if brisk pace/large volume)

4. APPROACH TO A PATIENT WITH
GI BLEED
 68 yo male presents with a chief complaint of a
large amount of “bleeding from the rectum”
 Physical examination:
 BP 105/70, Pulse 100, (+) orthostatic changes
 Alert and mentating, but anxious appearing

5. Case – Physical Exam
 HOPI: Describes bleeding as large volume, very dark
maroon colored stool
 Has occurred 4 times over past 3 hours
 He felt light headed and nearly passed out upon
trying to get up to go the bathroom

6. Case - HPI
 Denies abdominal pain, nausea, vomiting,
antecedent retching
 No history of heartburn, dysphagia, weight loss
 No history of diarrhea or constipation/hard stools

7. Case – PMHx, Meds
 Hepatitis C
 CAD – h/o MI
 AAA – s/p elective repair 3
years ago
 HTN
 Hypercholesterolemia
Screening colonoscopy 10
years ago – no polyps, (+)
diverticulosis
• Medications:
– Aspirin
– Clopidogrel
– Atorvastatin
– Atenolol
– Lisinopril

8. examination
 Anicteric
 Mid line scar, benign abdomen, no tender liver edge
palpable in epigastrium, no splenomegaly
 Rectal examination – no masses, dark maroon blood

9. APPROACH STARTS FROM
HISTORY & PHYSICAL EXAM
History
 Localizing symptoms
 History of prior GIB
 NSAID/aspirin use
 Liver disease/cirrhosis
 Vascular disease
 Aortic valvular disease, chronic
renal failure
 AAA repair
 Radiation exposure
 Family history of GIB
Physical
Examination
• Vital signs, orthostatics
• Abdominal tenderness
• Skin, oral examination
• Stigmata of liver disease
• Rectal examination
– Objective description of
stool/blood
– Assess for mass, hemorrhoids
– No need for guaiac test

10. Case - Labs
 Labs
 Hct 21% (Baseline 33%)
 Plt 110K
 BUN 22, Cr 1.0
 Alb 3.5
 INR 1.6
 ALT 51, AST 76

11. Initial Considerations
 Differential diagnosis?
 What is most likely source?
 What diagnosis can you least afford to miss?
 How sick is this patient? (risk stratification)
 Determines disposition
 Guides resuscitation
 Guides decision re: need for/timing of endoscopy

12. Differential Diagnosis – Upper
GIB
 Peptic ulcer disease
 Gastroesophageal varices
 Erosive esophagitis/gastritis/duodenitis
 Mallory Weiss tear
 Vascular ectasia
 Neoplasm
 Dieulafoy’s lesion
 Aortoenteric fistula
 Hemobilia, hemosuccus pancreaticus
Rare, but
cannot afford to
miss
Rare, but
cannot afford to
miss
Most
commo
n
Most
commo
n

13. Differential Diagnosis – Lower
GIB
 Diverticular-20%
 AVM-10%
 Malignancy-2-26%
 Inflammatory Bowel Disease-10%
 Ischemic Colitis
 Acute Infectious Colitis
 Radiation Colitis/Proctitis
 Aortoenteric Fistula
Most common
diagnosis
Most common
diagnosis

14. Narrowing the DDx: Upper or
Lower Source?
 Predictors of UGI source:
 Age <50
 Melenic stool
 BUN/Creatinine ratio
 If ratio ≥ 30, think upper GIB
J Clin Gastroenterol 1990;12:500
Am J Gastroenterol 1997;92:1796
Am J Emerg Med 2006;24:280

15. Utility of NG Tube
 Most useful situation: patients with severe
hematochezia, and unsure if UGIB vs. LGIB
 Positive aspirate (blood/coffee grounds)
indicates UGIB
 Can provide prognostic info:
 Red blood per NGT – predictive of high risk
endoscopic lesion
 Coffee grounds – less severe/inactive bleeding
 Negative aspirate – not as helpful; 15-20% of
patients with UGIB have negative NG
aspirate
Ann Emerg Med 2004;43:525
Arch Intern Med 1990;150:1381
Gastrointest Endosc 2004;59:172

16. Initial Assessment
 Always remember to assess A,B,C’s
 Assess degree of hypovolemic shock

17. Resuscitation
 IV access: large bore peripheral IVs best
 (alt: cordis catheter)
 Use crystalloids first
 Anticipate need for blood transfusion
 Threshold should be based on underlying
condition, hemodynamic status, markers of tissue
hypoxia
 Should be administered if Hgb ≤ 7 g/dL
 1 U PRBC should raise Hgb by 1 (HCT by 3%)
 Remember that initial Hct can be misleading (Hct
remains the same with loss of whole blood, until
re-equilibration occurs)
 Correct coagulopathy

18. Resuscitation
 IV access: large bore peripheral IVs best
(alt: cordis catheter)
 Use crystalloids first
 Anticipate need for blood transfusion
 Threshold should be based on underlying
condition, hemodynamic status, markers of tissue
hypoxia
 Should be administered if Hgb ≤ 7 g/dL
 1 U PRBC should raise Hgb by 1 (HCT by 3%)
 Remember that initial Hct can be misleading (Hct
remains the same with loss of whole blood, until
re-equilibration occurs)
 Correct coagulopathy

19. Transfusion Strategy
 Randomized trial:
 921 subjects with severe acute GIB
 Restrictive (tx when Hgb<7; target 7-9) vs. Liberal (tx
when Hgb<9; target 9-11)
 Primary outcome: all cause mortality rate within 45 days
NEJM 2013;368;11-21

20. Restrictive Strategy Superior
Restrictive Liberal P value
Mortality rate 5% 9% 0.02
Rate of further
bleeding
10% 16% 0.01
Overall
complication
rate
40% 48% 0.02
NEJM 2013;368;11-21
Benefit seen
primarily in Child A/B
cirrhotics

21. Resuscitation
 IV access: large bore peripheral IVs best
(alt: cordis catheter)
 Use crystalloids first
 Anticipate need for blood transfusion
 Threshold should be based on underlying
condition, hemodynamic status, markers of tissue
hypoxia
 Should be administered if Hgb ≤ 7 g/dL
 1 U PRBC should raise Hgb by 1 (HCT by 3%)
 Remember that initial Hct can be misleading (Hct
remains the same with loss of whole blood, until
re-equilibration occurs)
 Correct coagulopathy
Weigh risks and benefits of
reversing anticoagulation
Assess degree of coagulopathy
Vitamin K – slow acting, long-
lived
FFP – fast acting, short lived
- Give 1 U FFP for every 4 U
PRBCs
Weigh risks and benefits of
reversing anticoagulation
Assess degree of coagulopathy
Vitamin K – slow acting, long-
lived
FFP – fast acting, short lived
- Give 1 U FFP for every 4 U
PRBCs

22. Correction of Coagulopathy
 FFP transfusion
 Synthetic liver dysfunction
 Warfarin
 Consider Vitamin K
 Dilutional coagulopathy
 Goal INR <1.5
 Platelet transfusion
 in bleeding pt if less than 50K
 Platelet dysfunction
 Anti-platelet agents or uremia
 Goal platelets >50, 000/mm³

23. action
Early resuscitation and
supportive measures are critical
to reduce mortality from GIB
Early resuscitation and
supportive measures are critical
to reduce mortality from GIB

24. Resuscitation
 Early intensive resuscitation reduces mortality
 Consecutive series of patients with hemodynamically
significant GIB
 First 36 subjects = Observation Group (no intervention)
 Second 36 subjects = Intensive Resuscitation Group
(intense guidance provided) – goal was to decrease
time to correction of hemodynamics, Hct and
coagulopathy
Am J Gastroenterol 2004;99:619

25. Risk Stratification
 Identify patients at high risk for adverse outcomes
 Helps determine disposition (ICU vs. floor vs.
outpatient)
 May help guide appropriate timing of endoscopy

26. Lower GI Bleed
 Bleeding arising from the colorectum
 In patients with severe hematochezia, first consider
possibility of UGIB
 10-15% of patients with presumed LGIB are found to
have upper GIB

27. Lower GI Bleed
 Differential Diagnosis
- Diverticulosis (# 1 cause)
- Angioectasias
- Hemorrhoids
- Colitis (IBD, Infectious, Ischemic)
- Neoplasm
- Post-polypectomy
- Dieulafoy’s lesion
- Diverticulosis (# 1 cause)
- Angioectasias
- Hemorrhoids
- Colitis (IBD, Infectious, Ischemic)
- Neoplasm
- Post-polypectomy
- Dieulafoy’s lesion
Large volume,
painless
Large volume,
painless
Smaller volume, pain,
diarrhea
Smaller volume, pain,
diarrhea

28. LGIB – Risk Stratification
 Predictors of severe* LGIB:
 HR>100
 SBP<115
 Syncope
 nontender abdominal examination
 bleeding during first 4 hours of
evaluation
 aspirin use
 >2 active comorbid conditions
 HR>100
 SBP<115
 Syncope
 nontender abdominal examination
 bleeding during first 4 hours of
evaluation
 aspirin use
 >2 active comorbid conditions
0 factors: ~6% risk
1-3 factors: ~40%
>3 factors: ~80%
0 factors: ~6% risk
1-3 factors: ~40%
>3 factors: ~80%
Arch Intern Med 2003;163:838
Am J Gastroenterol 2005;100:1821
* Defined as continued bleeding within first 24 hours (transfusion of 2+ Units,
decline in HCT of 20+%) and/or recurrent bleeding after 24 hours of stability

29. LGIB – Risk Factors for Mortality
• Age
• Intestinal ischemia
• Comorbid illnesses
• Secondary bleeding (developed during admission for a
separate problem)
• Coagulopathy
• Hypovolemia
• Transfusion requirement
• Male gender
Clinical Gastro Hepatol 2008;6:1004

30. Role of Colonoscopy
 Like UGIB, ~80% of LGIBs will resolve
spontaneously; of these, ~30% will
rebleed
 Lack of standardized approach
 Traditional approach:
 elective colonoscopy after resolution of
bleeding, bowel prep – low therapeutic benefit
 Angiography for massive bleeding,
hemodynamically unstable patient
 Urgent colonoscopy approach
 Similar to UGIB – identify stigmata of hemorrhage,
perform therapy

31. Radiographic Studies
Tagged RBC scan
 Noninvasive, highly sensitive
(0.05-0.1 ml/min)
 Ability to localize bleeding
source correctly only ~66%
 More accurate when
positive within 2 hours (95-
100%)
 Lacks therapeutic
capability
Coordinate with IR so that positive
scan is followed closely by
angiography
Coordinate with IR so that positive
scan is followed closely by
angiography

32. Role of Surgery
 Reserved for patients with life-threatening bleed
who have failed other options
 General indications: hypotension/shock despite
resuscitation, >6 U PRBCs transfused
 Preoperative localization of bleeding source
important

33. Algorithmic Evaluation of Patient with
Hematochezia
Hematochezi
a
Hematochezi
a
Assess
activity of
bleed
Assess
activity of
bleed
NG lavageNG lavage
Prep for
Colonoscopy
Prep for
Colonoscopy
PositivePositive
EGDEGD
NegativeNegative
active inactive
Risk for
UGIB
Hemodynamic
ally stable?
Hemodynamic
ally stable?
No risk for
UGIB
negative
Treat
lesion
Treat
lesion
positiv
e

34. Evaluation ACUTE LOWER GI BLEED
Study
Yield
%
Comments
Colonoscopy 69-80 Therapeutic
Arteriography 40-78
1 ml/min,
risks
Tagged RBC Scan 20-72 Localization
Zuccaro. ASGE Clinical Update. 1999.

35. Take Home Points
 Always get objective description of stool color (best
way – examine it yourself)
 Don’t order guaiac tests on inpatients
 Severe hematochezia can be from UGIB, even if NG
lavage is negative

36. Take Home Points
• All bleeding eventually stops (and majority of
nonvariceal bleeds will stop spontaneously, with the
patient alive)
• Early resuscitation and supportive care are key to
reducing morbidity and mortality from GIB

37. Always get objective description
of stool
Always get objective description
of stool
Take Home Point
Avoid noninformative terms such as
“grossly guaiac positive”
Avoid noninformative terms such as
“grossly guaiac positive”

38. If you need a card to tell you whether
there’s blood in the stool, it’s NOT an
acute GIB
If you need a card to tell you whether
there’s blood in the stool, it’s NOT an
acute GIB
Take Home Point

39. Take Home Point
Upper GI bleed must still be
considered in patients with
severe hematochezia, even if
NG aspirate negative
Upper GI bleed must still be
considered in patients with
severe hematochezia, even if
NG aspirate negative

40. THANKS