Gastrointestinal Bleeding Case File

Gastrointestinal Bleeding Case File

Eugene C. Toy, MD, Manuel Suarez, MD, FACCP, Terrence H. Liu, MD, MPH

Case 21

A 63-year-old man was hospitalized 6 days ago for an acute myocardial infarction. Today,  he began to complain of vague epigastric pain; however, an ECG and cardiac  enzymes test ruled out an MI. Several hours later, he began to feel dizzy and passed  a large amount  of dark  bloody stool per rectum. Shortly thereafter, he vomited  approximately 100 mL of blood. At this point, his blood pressure is 90/60 mm Hg  and pulse rate is 85 beats/minute. He is transferred to the ICU for further  monitoring.

⯈What are the priorities in this patient's management?

⯈What are the risk factors for this patient's condition?

⯈What are the factors that adversely affect the outcome? 

ANSWER TO CASE 21

Gastrointestinal Bleeding

Summary: A 63-year-old man who is hospitalized for a recent myocardial infarction develops signs and symptoms of acute upper GI hemorrhage. His vital signs are concerning for hemorrhagic shock.

Priorities in management: Establishing a secure airway and maintaining adequate circulating blood volume and definitive hemorrhage control. The patient should be resuscitated with the combination of crystalloids and blood products to optimize cardiac function and maintaining a normal coagulation process. This includes potential transfusions of packed red cells, platelets, and fresh-frozen plasma to correct any coagulation defects. Once the patient's physiologic status is stabilized, he should be prepared for upper GI endoscopy to diagnose and potentially treat his gastrointestinal bleeding.

Risk factors for this patient's condition: The patient is recovering from a recent myocardial infarction. The stress related to his current illness is a risk factor. In addition, patients with unstable cardiac conditions often receive antiplatelet therapy, which can increase his risk for bleeding complications.

Factors that adversely affect the outcome: There are many reported clinical and endoscopic factors that influence outcomes, some of which are applicable to this patient.

Clinical contributors to adverse outcome to patients with upper GI hemorrhage include shock on admission, comorbid illnesses, prior history of bleeding requiring transfusion, admission Hgb <8 g/dL, transfusion requirement of >5 U of PRBCs, blood in the NG aspirate that does not clear with lavage, and age > 65.

Endoscopic contributors of adverse outcome in acute upper gastrointestinal hemorrhage: visible vessel in ulcer base ( > 50% rebleeding risk) , active bleeding from ulcer base, adherent clot at ulcer base, location of ulcer (worse prognosis when located on posterior lesser curvature of stomach or posterior duodenal bulb), and ulcer diameter > 2 cm.

ANALYSIS

Objectives

1. To learn the initial management and diagnostic strategy for patients with upper gastrointestinal bleeding.
2. To learn the management of patient with nonvariceal and variceal upper gastrointestinal bleeding.
3. To learn the differences in the management approaches to patients with upper GI bleeding and lower GI bleeding.

Considerations

This patient has acute upper gastrointestinal hemorrhage. He is older and is at an increased risk for a low-flow state due to potentially diminished cardiac output (from his recent myocardial infarction). Additionally, he has been in the hospital for 6 days and is at risk for stress-related ulcer formation and hemorrhage. Antiplatelet therapy has most likely been prescribed for his cardiac condition, which further increases his risk for bleeding complications. The major goal at this time is to optimize the support of his hemodynamic status without creating increased physiological stress. In addition, pharmacological therapy needs to be initiated as his bleeding is determined as most likely nonvariceal or variceal in origin. Appropriate resuscitation followed by timely diagnosis and endoscopy would be important.

Approach To:

Gastrointestinal Bleeding

DEFINITIONS

UPPER GI BLEEDING: Bleeding source is proximal to the ligament of Treitz (esophagus, stomach, and duodenum).

LOWER GI BLEEDING: Bleeding source is distal to the ligament of Treitz (jenunum, ileum, colon, and rectum) .

OCCULT GI BLEEDING: Slow bleeding originating anywhere along the GI tract. Patients do not complain of bleeding symptoms and commonly present with anemia, fatigue, and hemoccult positive stool.

GASTRODUODENAL ULCERATION: Comprise the majority of upper GI bleeding episodes (50%), usually due to Helicobacter pylori (80%-90%) .

PORTAL HYPERTENSION-ASSOCIATED BLEEDING: Esophagogastric varices are present in 30% to 60% of patients with cirrhosis. Significant mortality is attributable to the first bleeding episode (30%-50%).

STRESS GASTRITIS: The physiologic stress from trauma, burns, major surgery, or severe medical illness is associated with the development of hemorrhagic gastritis, or stress erosions in the fundus or gastric body.

ESOPHAGITIS: Gastroesophageal reflux disease (GERD) can predispose patients to mucosal ulceration and upper GI bleeding. Bleeding can also occur from erosion by a nasogastric tube (NGT), typically in the chronically hospitalized patient.

NSAID EROSIVE GASTROPATHY: NSAID-related ulcers can develop within 1 to 2 days of treatment and usually appear in the antral portion of the stomach. Ulcers typically present asymptomatically and resolve after cessation of treatment.

GASTRIC ANTRAL VASCULAR ECTASIA (GAVE): GAVE is a rare cause of upper GI bleeding overall. It is commonly referred to as "watermelon stomach" because of the watermelon striped-like appearance of mucosal erythema stemming from the pylorus (usually limited to the antrum). GAVE is associated with bone marrow transplants, scleroderma, and cirrhosis. A direct cause is not identified.

DIEULAFOY LESION: Dieulafoy is a large ectatic submucosal arteriole that erodes through the mucosal layer of the stomach. Most appear in the proximal stomach (up to 95 %), predominantly on the lesser curvature and within 6 cm of the gastroesophageal junction.

PERCUTANEOUS TRANS ARTERIAL EMBOLIZATION: This interventional radiology approach is an alternative to surgery in patients for whom endoscopic therapy has failed. The rate of technical success has been reported to range from 52 % to 98% with recurrent bleeding in 10% to 20% of patients.

CLINICAL APPROACH

The initial management and diagnostic strategy for patients with upper gastrointestinal bleeding is noted in Figure 21-1. The ABC's of resuscitation should be employed for all patients with upper GI bleeding. Hemodynamically unstable patients (SBP <90, orthostatic hypotension), those with evidence of severe bleeding (HCT drop of >6%) , or those with a transfusion requirement of >2 U PRBCs should be admitted to the ICU for resuscitation and close monitoring. Central venous pressure monitoring should be considered especially in patients with significant cardiopulmonary and renal comorbidities. The decision to initiate blood transfusions for patients should be based on individual patient's underlying conditions, hemodynamic and perfusion statuses rather than any predetermined hemoglobin values.

Figure 21-1. Management for acute upper gastrointestinal hemorrhage

Correction of coagulopathy (INR >1.5 or platelet count <50,000/mm³) with fresh frozen plasma or platelet transfusions is important in patients with ongoing bleeding. Patients receiving antiplatelet therapy should have platelet transfusions to provide functioning platelets, since numerically normal platelet counts do not necessarily indicate normal platelet functions. Decisions to reinitiate or terminate antiplatelet therapy should be based on the risks/benefits of individual patient's cardiovascular comorbidities versus bleeding risks.

After resuscitation, an initial attempt at determining whether the source is an upper or lower source should be made. In patients with massive upper GI tract bleeding, agitation, or impaired respiratory status, endotracheal intubation should be considered prior to the initiation of endoscopy. After the ABCs are stabilized and resuscitation is underway, an NGT should be placed. If the aspirate is coffee-ground or bloody in nature, an upper GI source is confirmed. Even if there is a clear aspirate, there still exists a small possibility that bleeding could be from the duodenum (closed pylorus). Absence of blood or coffee-ground emesis in the presence of an open pylorus (presence of bilious NG aspirate) localizes bleeding to the lower GI tract. In upper GI bleeding cases, the patient should proceed to upper endoscopy to definitively localize and potentially treat the lesion.

Upper GI endoscopy can identify the source and status of bleeding in 90% of cases. Early endoscopy (within 12 hours) is recommended for most patients with acute upper gastrointestinal hemorrhage, as it appears to improve the diagnostic sensitivity of the procedure. Endoscopic findings are often helpful to risk-stratify patients to low- or high risk for recurrent or life-threatening hemorrhage. This may assist in selecting patients who may be suitable for early hospital or ICU discharges or, alternatively, further ICU monitoring.

Administration of intravenous erythromycin (3 mg/kg IV over 20-30 minutes) 30 to 90 minutes prior to endoscopy can often improve visibility, shorten endoscopy time, and reduce the need for second-look endoscopy. Erythromycin is a motilin agonist in the GI tract, which promotes antegrade flow of gastric and duodenal contents.

Patients who are found to have mucosal ulcerations during esophagogastroduodenoscopy (EGD) should undergo biopsy of the gastric and antral mucosa to evaluate for H. pylori. Patients who are positive should receive triple therapy (clarithromycin 500 BID, amoxicillin 1 g BID, and a proton pump inhibitor [PPI]) for at least 1 week. PPI therapy should be stopped 1 week prior to repeat H. pylori testing (at 4 weeks) to prevent false-negative results.

In situations where endoscopy fails to identify the site or control the bleeding, angiographic techniques can also be applied to diagnose and treat the upper GI bleeding. Although the role of angiography is better defined for lower GI bleeding, selective angiography is useful for localization and embolization of upper GI bleeding in up to 75% of patients with active bleeding.

Management of Upper GI Bleeding

Medical treatment for both variceal and nonvariceal acute GI hemorrhage:

1. Vasopressin: Vasopressin can dramatically decrease the splanchnic blood flow and reduce upper GI bleeding. However, vasopressin and vasopressin analogues are now in disfavor due to the systemic vasoconstrictive effects, and for that reason octreotide is a preferred adjunctive therapy in conjunction with EGD for variceal upper GI hemorrhage.

2. Acid suppression: Acid suppression with high-dose PPIs (pantoprazole 80 mg bolus followed by 8 mg/h infusion) given before or after endoscopy has been shown to significantly reduce the occurrence of rebleeding, decrease hospital stay, reduce the number of actively bleeding ulcers, and reduce transfusion requirements. In patients with NSAID-related ulcers, 4 weeks of outpatient PPI therapy is suggested.

Medical treatment for variceal acute GI hemorrhage:

1 . Octreotide: Prior to endoscopy, octreotide (loading dose 50 μg, followed by 25-50 μg/h X 5 days ) may be administered, which may reduce the risk of bleeding. Octreotide can also be used as adjunctive therapy if endoscopy is unsuccessful, contraindicated, or unavailable. Although it has been best studied in the variceal population, octreotide is also loosely indicated for treatment of acute nonvariceal upper gastrointestinal bleeding.

2. β-Blockers: Used as maintenance therapy after acute upper GI bleeding from portal hypertension has been controlled. Oral β-blockade plus endoscopic therapy has been shown to reduce the rebleeding rate over endoscopic therapy alone. Endoscopic band ligation followed by β-blockade is recommended treatment strategy for variceal bleeding.

Interventions for upper GI hemorrhage from variceal sources:

1. Sclerotherapy and band ligation: Endoscopic sclerotherapy and/or band ligation for esophageal varices is the mainstay of emergent treatment. However, the risk of rebleeding is significant-up to 50% with sclerotherapy and 35% with band ligation. Some evidence suggests that band ligation, when compared to sclerotherapy, is associated with fewer treatment-related complications. Lower rebleeding rates and improved survival have been reported with band ligation. For nonvariceal bleeding, endoscopic hemostasis may be achieved with the use of epinephrine injections followed by thermal therapy. Permanent hemostasis occurs in roughly 80% to 90% of patients.

2. Sengstaken-Blakemore tube: In rare circumstances where bleeding cannot be controlled endoscopically, the Sengstaken-Blakemore (SB) (Minnesota) tube can be used with the caveat that it must not be inflated for >48 hours due to the high risk of tissue necrosis. The gastric balloon is inflated first, and if bleeding is not controlled, the esophageal balloon is inflated. SB tube placement is helpful for the temporary control of bleeding so that arrangements can be made for definitive care (eg, TIPS or endoscopic therapy).

3. Transjugular intrahepatic portosystemic shunt (TIPS): Ideally applied in Child-Pugh class B or C cirrhotic patients. TIPS can provide a bridge to liver transplantation. In comparison to sclerotherapy or band ligation, rebleeding rates are lower with TIPS. However, TIPS is associated with an increased occurrence of hepatic encephalopathy but no difference in overall survival. Rebleeding following TIPS can occur when shunt thrombosis occurs.

Surgical treatment for upper GI hemorrhage:

1. Surgical shunts: Patients who are Child A are considered for surgical decompression (eg, distal splenorenal shunt) since the likelihood of occlusion for TIPS at 2 years outweighs the potential benefit of TIPS.

2. Operative exploration: Operative exploration for upper gastrointestinal hemorrhage is generally reserved for individuals who fail endoscopic treatment. Depending on the source of the hemorrhage, procedures may include bleeding vessel ligation, lesion resection, and/or acid reduction procedures (eg, vagotomy) to prevent future ulcer formation. Transplantation is a rare last resort for Child B and C patients in the emergent setting due to variceal bleeding.

CASE CORRELATION

• See also  Case 4  (Hemodynamic Monitoring), Case 5  (Vasoactive Drugs), Case 33  (Multiorgan Dysfunction),  and Case 41  (Hemorrhage and Coagulopathy).

COMPREHENSION QUESTIONS

21.1  A 55-year-old alcoholic with a history of alcoholic cirrhosis arrives to the ED vomiting copious amounts of blood, hypotensive (BP 88/50 mm Hg) , tachycardic (HR 115 beats/minute), and with an O2 saturation of 95%. He is intubated, resuscitated, and taken to the endoscopy suite for further therapy. Which of the following therapeutic modalities has the highest bleeding recurrence rate for the variceal population after initial endoscopic treatment?

A. Sclerotherapy alone

B. Band ligation alone

C. Sclerotherapy and band ligation

D. TIPS

E. Operative portal-systemic shunt

21.2  A 60-year-old man with a history of H. pylori antral ulcer treated with triple therapy 5 weeks ago comes to clinic for follow-up. He says his clinical condition has improved. He continues to take omeprazole for symptoms of GERD (last dose was this morning). What is the best laboratory measure for confirmation of eradication of H. pylori in this patient?

A. Repeat endoscopy with histologic examination

B. Anti-IgG against H. pylori

C. Urea breath test performed as soon as feasible

D. Campylobacter-like organism (CLO) test

E. Stop omeprazole for a week before urea breath best

21.3  A 65-year-old cirrhotic woman is brought to the emergency department with acute hematemesis and altered mental status. She is hypotensive, tachycardic, and vomiting blood. After intubation and fluid resuscitation, she is taken to the endoscopy suite where multiple large varicosities are seen at the GE junction. The gastroenterologist infuses octreotide and vasopressin, attempts band ligation, sclerotherapy, and a Minnesota tube, all of which slow but do not stop the bleeding. Her laboratory studies reveal the following: Hgb 5.8 g/dL, platelets 90,000/mm³; INR 2.8; AST/ALT 86/90 IU/L, albumin 1.8 g/L; total bilirubin 2.1 mg/dL; BUN/Cr 80/2.6 mg/dL. After 8 U of PRBCs, 6 U of FFP, and 10 pack of platelets, she remains borderline hypotensive (95/60 mm Hg) and has continued bleeding. What would be the next best intervention?

A. Try another Sengstaken-Blakemore tube

B. Continue fluid resuscitation and transfusion

C. TIPS

D. Hepatic transplantation

E. Distal splenorenal (Warren) shunt

ANSWERS TO QUESTIONS

21.1  A. Multiple randomized trials have compared sclerotherapy versus sclerotherapy and band ligation versus band ligation alone. Meta-analyses suggest that rebleeding rates are highest in patients who undergo sclerotherapy alone (particularly patients with large varices). There is no additional benefit with regard to rebleeding if band ligation is accompanied by sclerotherapy in the same setting versus band ligation alone. For this reason, band ligation is the preferred first endoscopic modality, with 35% chance of rebleeding. TIPS is superior to endoscopic therapy, with rebleeding rates far less than band ligation and sclerotherapy. Operative portal-systemic shunts are associated with low rebleeding rates but high procedure-associated mortality.

21.2  E. This patient is >4 weeks out of treatment for H. pylori but continues to take a PPI which can cause false-negative results. The patient should be instructed to stop taking his omeprazole for a week and then return to clinic to perform a urea breath test to confirm eradication of his infection.

21.3  C. TIPS is the best option for this patient who is classified as a Child-Pugh class C cirrhotic. Of the other interventions, option (A) is incorrect because it is a temporizing measure. (B) is incorrect because the patient is likely developing a consumptive coagulopathy and progressing into DIC. (D) is not a good choice because it is not likely for her to receive a donor liver in an acute situation, and (E) is incorrect as Warren shunts are indicated only in Child A patients.

CLINICAL PEARLS

⯈ Incidence of upper GI bleeding is approximately 170/100,000 patients a year, greater than lower Gl bleeding. 

⯈ The mortality rate of upper GI bleeding is between 5% and 11%. 

⯈ Priorities in management for acute upper GI bleeding include securing an airway, volume resuscitation, and early upper endoscopy. 

⯈ The majority of upper GI bleeding cases are due to gastroduodenal ulceration, the majority of which can be managed endoscopically. 

⯈ Variceal  hemorrhage is best managed by  endoscopic techniques with TIPS as an alternative. Surgical shunts have fallen out of favor in the acute setting and TlPS is a viable bridge to hepatic transplantation.

References

Jutabha R, Jensen D. Approach to upper gastrointestinal bleeding in adults. www.uptodate.com. October 8, 2010, accessed J uly 2 , 2 0 1 3 . 

Mulholland MW, Lillemoe KD, Doherty G M , et al. Greenfield Surgery : Scientific Principles and Practice . 4th ed. Philadelphia, PA: Williams and Wilkins; 2005 . 

Shuhart M, Kowldley K, Neighbor B. GI bleeding. http://www. uwgi.org/guidelines/ch_07/ch07txt.htm (Online Review) . April S , 201 1 , accessed J uly 2 , 20 1 3 . 

Townsend CM, Beauchamp RD, Evers BM, Mattox KL. Sabiston Textbook of Surgery . 1 8th ed. S t . Louis, MO: W. B. Saunders Company; 2008.

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