Emergency medicine gastrointestinal bleeding case file

Emergency Medicine Gastrointestinal Bleeding Case File

Eugene C. Toy, MD, Barry C. Simon, MD, Terrence H. Liu, MD, MHP, Katrin Y. Takenaka, MD, Adam J. Rosh, MD, MS

Case  37

A 43-year-old man is brought in on an EMS (emergency medical services) stretcher after a syncopal episode. After obtaining a palpated pressure of 80 mm Hg systolic and heart rate of 120 beats per minute, EMS placed an 18-gauge IV and initiated infusing normal saline en route to the hospital. The patient relates a 3- to 4-day history of dark, tarry stools (about 3-4 times per day). Today he passed out while having a bowel movement. He is currently complaining of mild epigastric pain and lightheadedness. He denies any hematemesis, hematochezia, chest pain, shortness of breath, and any similar past episodes. He admits to drinking 1 to 2 beers each day and is not regularly under the care of a physician.

On examination, his vital signs are temperature 36.6°C (97.9°F), blood pressure 92/45 mm Hg (after 900-mL IV fluid prior to arrival), heart rate is 113 beats/ minute, and respiratory rate is 24 breaths/minute. The patient is pale with dried, dark stool covering his legs. He has mild tenderness to palpation in the epigastrium but no rebound or guarding. He does not have spider angioma, gynecomastia, palmar erythema, or ascites. The rectal examination reveals grossly melanic stool.

⯈ What is the most likely diagnosis?

⯈ What is the best therapy?

ANSWER TO CASE: 37

Gastrointestinal Bleeding

Summary: This 43-year-old man presents tachycardic and hypotensive after several episodes of melena.

• Most likely diagnosis: Upper gastrointestinal (GI) bleed with hemorrhagic shock.
• Best therapy: Stabilization of the ABCs, including IV access and volume resuscitation. Consider the use of blood products and proton pump inhibitors. Endoscopy is indicated for early diagnosis and treatment.

ANALYSIS

Objectives

1. Learn the differences in presentations and outcomes between upper and lower GI bleeding.
2. Understand the priorities, evaluations, and management of patients with GI hemorrhage.

Considerations

This 43-year-old man is in class III hemorrhagic shock (see Case 7), because he is hypotensive and has a heart rate of 120. These findings correlate with up 1500 to 2000 mL of acute blood loss. The most important priorities are stabilization by addressing the ABCs, including placing two large-bore intravenous lines, giving boluses of normal saline, and monitoring the blood pressure, heart rate, pulse oximetry, and urine output. Laboratory evaluations should include complete blood count (CBC), electrolytes, renal and liver function tests, coagulation studies, in addition to the typing and cross matching of blood. The main priorities are to determine whether there has been significant blood loss, maintain hemodynamic stability, and determine if the bleeding is active. After stabilization, a focused history should be taken to determine the probable etiology of the gastrointestinal bleeding. Chronic nonsteroidal anti-inflammatory drug (NSAID) or aspirin use may indicate gastritis. His history and physical examination do not reveal obvious causes or signs of portal hypertension. Although the history of tar-colored stools suggest an upper GI bleeding source and directs the initial evaluation to this source, the possibility of bleeding distal to the ligament of Treitz (lower GI bleeding) cannot be excluded at this time. An initial room-temperature water lavage via a nasogastric (NG) tube may identify gross blood or “coffee-ground” fluid, which may establish the diagnosis of upper

GI bleeding, determine if the bleeding is active, and determine the rate of hemorrhage. Upper endoscopy is likely to be the most valuable diagnostic and treatment modality of choice for this patient. Differentiation of GI bleeding patients as possessing potential upper GI bleeding sources versus lower GI bleeding sources is important early on, because patients with upper GI bleeding have significantly greater potential for rapid and large volume hemorrhage in comparison to those with lower GI bleeding sources. Similarly, the differentiation of upper GI bleeding patients into those with variceal bleeding and those with non-variceal bleeding is helpful to begin empirical pharmacologic therapy with octreotide in those patients with suspected bleeding from a variceal source.

Approach To:

GI Bleeding

CLINICAL APPROACH

GI bleeding is classified as upper or lower based on whether it arises proximal or distal to the ligament of Treitz. Common causes of upper GI bleeding include peptic ulcer disease, esophageal or gastric varices, Mallory-Weiss tear, esophagitis, and gastritis (Figure 37–1). The most common etiologies of lower GI bleeding are upper GI bleeding, hemorrhoids, diverticulosis, angiodysplasia, malignancy, inflammatory bowel disease, and infectious conditions (Figure 37–2). In children, Meckel diverticulum, polyps, volvulus, and intussusception are the common causes of GI bleeding.

GI bleeding is also classified as either overt or occult. Overt bleeding is clinically obvious bleeding that presents as hematemesis, coffee-ground emesis, melena, or hematochezia, and occult GI bleeding is when a patient presents either with clinical anemia and/or microcytic anemia from chronic GI tract blood loss. From the

Figure 37–1. Algorithm for upper GI bleeding.

Figure 37–2. Algorithm for lower GI bleeding.

standpoint of emergency medical care, overt GI bleeding needs to be addressed on an urgent basis to resuscitate and control the bleeding source; whereas, occult GI bleeding may require treatment of symptomatic anemia and referral to a gastroenterology and/or surgical specialist to identify and treat the chronic bleeding source.

When taking a history, the clinician should focus on the nature, duration, and amount of bleeding. Classically, patients with an upper GI bleed present with hematemesis and melena, while hematochezia suggests a lower GI source. However, this is not always the case, depending on the speed and amount of bleeding. It is important to ask about syncope, weakness, chest pain, dyspnea, and confusion because these symptoms suggest significant blood loss. In addition, risk factor assessment may help determine the cause of the bleeding (Table 37–1).

During the physical examination, careful attention should be paid to the vital signs and for evidence of hypovolemic shock (tachypnea, tachycardia, hypotension). Cool, pale, or diaphoretic skin suggests hypovolemia, and pale conjunctiva, nail beds, or mucous membranes suggest anemia. If stigmata of chronic liver disease (jaundice, caput medusae, spider angiomata, palmar erythema, and gynecomastia) are present, variceal bleeding should be considered as a potential bleeding possibility. The abdominal examination should focus on searching for peritoneal signs, such as guarding and rebound, although most patients with GI bleeding do not exhibit abdominal pain.

Bedside testing includes a rectal examination to check for hemorrhoids, anal fissures, and occult blood in the stool. All patients should have a nasogastric tube with

room temperature normal saline (NS) or water lavage. If blood is present (bright red or “coffee ground”), an upper GI source is more likely.

After IV access is obtained, blood should be sent for complete blood count, electrolytes, blood urea nitrogen (BUN)/creatinine, coagulation studies, and type and screen or cross-match. In patients with chest pain, dysrhythmia, or risk factors for coronary artery disease, an electrocardiogram (ECG) should be obtained.

Treatment

Treatment begins with stabilizing the ABCs. Intubation may be necessary to protect the patient’s airway and in preventing aspiration. IV access (large-bore peripherals or central) is a high priority. Volume resuscitation should begin with 2 L of NS or lactated Ringer solution. For patients who are hemodynamically unstable after crystalloid infusion, have ongoing blood loss, or whose hemoglobin is less than 7 mg/dL, packed red blood cells (PRBCs) should be transfused. Fresh-frozen plasma and vitamin K may be indicated in patients with coagulopathies caused by liver disease or anticoagulation therapy. As a general rule, a proton pump inhibitor should be given to patients with upper GI bleeding to decrease rebleeding rates. Surgery is indicated for massive or refractory bleeding.

In patients with variceal bleeding, somatostatin analog such as octreotide, or vasopressin, can be helpful. However, vasopressin has fallen out of favor because of the side effects and the risk of end-organ ischemia.

In patient with massive variceal bleeding, balloon tamponade with a Sengstaken- Blakemore tube may be useful for the temporary control of bleeding, while arrangements for definitive therapy are made.

Various modalities exist to identify the source of bleeding. In upper GI bleeding patients, endoscopy is the study of choice because the procedure can also be therapeutic through use of lasers, electrocoagulation, sclerosant injections, clip placements, and band ligations. For lower GI bleeds, anoscopy, sigmoidoscopy, or colonoscopy are preferred for the localization of bleeding sources. Tagged red blood cell (RBC) scans are an alternative in stable patients. When lower GI bleeding that is massive or continuous, angiography can be useful to localize the bleeding, and for some cases angiography-directed embolizations can be applied to stop the bleeding.

In general, patients with lower GI bleeding rarely exhibit hemodynamic instability unless the process has gone on unrecognized. Similarly, most lower GI bleeding episodes are self-limiting. The treatments for lower GI bleeding are therefore less urgent than treatments for upper GI bleeding, and the majority of patients with lower GI bleeding can be managed outside of an ICU environment following their management in the emergency department. The number one priority following the initial the management of lower GI bleeding patient is localization of the bleeding site, so that endoscopic, interventional radiology procedure, or surgical therapy can be implemented in the unusual event that the bleeding does not stop.

COMPREHENSION QUESTIONS

37.1 Which of the following conditions is a risk factor for peptic ulcer disease?

A. Age greater than 50

B. Estrogen replacement therapy

C. Acetaminophen use

D. Chlamydia trachomatis

E. Helicobacter pylori infection

37.2 A 43-year-old man complains of acute onset of vomiting bright red blood. He denies alcohol use and history of peptic ulcer disease. He complains of dizziness, appears anxious, and his blood pressure is 120/70 mm Hg and heart rate is 90 beats per minute. Which of the following is the best next step in managing his condition?

A. Morphine sulfate

B. Endoscopic examination

C. Chest radiograph

D. Intravenous fluid resuscitation

E. Orotracheal intubation

37.3 In the patient described in Question 37.2, which of the following modalities is best to identify the source of bleeding?

A. Tagged RBC scan

B. Endoscopy

C. Angiography

D. Laparotomy

E. Serial hemoglobin determination

37.4 A 58-year-old woman is brought into the ED complaining of bright red bleeding per rectum that was of acute onset. She denies abdominal pain. She is hemodynamically stable. Which of the following is the most likely etiology of her condition?

A. Varices

B. Gastritis

C. Diverticulosis

D. Mallory-Weiss tear

E. Peptic ulcer disease

ANSWERS

37.1 E. Risk factors for peptic ulcer disease include H pylori infection, NSAID use, alcohol use, heredity, and tobacco use.

37.2 D. Stabilization of the patient is always the first priority. The ABCs come first; assuming that his airway and breathing are stable, then circulation is next. Fluid administration very likely will be helpful, as the patient’s dizziness and anxiety are signs of hypovolemic shock.

37.3 B. Endoscopy is the preferred modality to identify the source of bleeding in upper GI bleeding. Tagged red cell studies are more commonly used for the evaluation of lower GI bleeding.

37.4 C. This patient’s clinical presentation is suggestive of lower GI bleeding. Common causes of lower GI bleeding are diverticulosis, upper GI bleeding, hemorrhoids, angiodysplasia, malignancy, inflammatory bowel disease, and infectious conditions. Bleeding with diverticulosis is described as painless and abrupt, “as though a water faucet was suddenly turned on.” The other choices are common causes of upper GI bleeding.

CLINICAL PEARLS

⯈ Although most GI bleeds resolve spontaneously, each case is potentially life threatening. The main priorities are to determine whether there has been significant blood loss and to maintain hemodynamic stability.

⯈ In upper GI bleeds, endoscopy is the study of choice because it can also be used to treat. Anoscopy, sigmoidoscopy, or colonoscopy are preferred in lower GI bleeds.

⯈ In general, all patients with GI bleeding are admitted. If hemodynamically unstable or actively bleeding, they should be admitted to an ICU setting.

References

Abrkun AN, Bardou M, Kuipers EJ, et al. International consensus recommendations on the management of patients with nonvaiceal upper gastrointestinal bleeding. Ann Intern Med. 2010;152:101-113. 

Barnert J, Messmann H. Diagnosis and management of lower gastrointestinal bleeding. Nat Rev Gastroenterol Hepat, 2009;6:637-646.

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