Chapter 39. Gastrointestinal Bleeding

Gastrointestinal (GI) bleeding is a common problem in emergency medicine and should be considered life threatening until proven otherwise. Acute upper GI bleeding is more common than lower GI bleeding. Upper GI bleeding is defined as that originating proximal to the ligament of Treitz. Upper GI bleeds can result from peptic ulcer disease, erosive gastritis and esophagitis, esophageal and gastric varices, and Mallory-Weiss syndrome. Lower GI bleeds result from diverticular disease, followed by colitis, adenomatous polyps, and malignancies. Less common causes include vascular ectasia (AV malformation and angiodysplasia), Meckel diverticulum, inflammatory bowel disease, and trauma. What may initially appear to be lower GI bleeding may be upper GI bleeding in disguise.

Most patients complain of hematemesis, hematochezia, or melena. Others will present with hypotension, tachycardia, angina, syncope, weakness, and confusion. Hematemesis or coffee-ground emesis suggests an upper GI source. Melana suggests a source proximal to the right colon. Hematochezia indicates a more distal colorectal lesion; however, approximately 10% of hematochezia may be associated with UGI bleeding. Weight loss and changes in bowel habits are classic symptoms of malignancy. Vomiting and retching, followed by hematemesis, is suggestive of a Mallory-Weiss tear. A history of medication or alcohol use should be sought. This history may suggest peptic ulcer disease, gastritis, or esophageal varices. Spider angiomata, palmar erythema, jaundice, and gynecomastia suggest underlying liver disease. Ingestion of iron or bismuth can simulate melena, and certain foods, such as beets, can simulate hematochezia; however, stool heme (guaiac) testing will be negative.

The diagnosis may be obvious with the finding of hematemesis, hematochezia, or melena. A careful ear, nose, and throat (ENT) examination can exclude swallowed blood as a source. Nasogastric (NG) tube placement and aspiration may detect occult upper GI bleeding. A negative NG aspirate does not conclusively exclude an upper GI source. Guaiac testing of NG aspirate can yield both false-negative and false-positive results. Most reliable is gross inspection of the aspirate for a bloody, maroon, or coffee-ground appearance, reserving guaiac testing to confirm that what appears to be blood actually is. A rectal examination is mandatory to detect the presence of blood, its appearance (bright red, maroon, or melanotic), and the presence of masses. All patients with significant GI bleeding require type and crossmatch for blood. Other important tests include a complete blood count, electrolytes, blood urea nitrogen, creatinine, glucose, coagulation studies, and liver function tests. The initial hematocrit level may not reflect the actual amount of blood loss. Upper GI bleeding may elevate the blood urea nitrogen level. Routine abdominal radiographs are of limited value. Controversy remains as to whether angiography, scintigraphy, colonoscopy, or multidetector CT and in which order, is initial diagnostic procedure in the evaluation of lower GI bleeding.

1. Emergency stabilization (airway, breathing, and circulation) takes priority. Administer oxygen, insert large-bore intravenous catheters, and institute continuous monitoring.

2. Replace volume loss immediately with isotonic crystalloids (eg, normal saline or Ringer lactate). The decision to transfuse blood is based on clinical factors (continued active bleeding and no improvement in perfusion after 2 L crystalloids) rather than initial hematocrit values. The threshold for blood transfusion should be lower in the elderly.

3. Replace coagulation factors, as needed.

4. A nasogastric tube is recommended in most patients with significant GI bleeding, regardless of the presumed source. If bright red blood or clots are found, perform gentle gastric lavage.

5. Consider early therapeutic endoscopy for significant upper GI bleeding. Flexible sigmoidoscopy or colonoscopy can aid in the diagnosis and treatment of some lower GI bleeding sources. It is estimated that 80% of lower GI bleeding will resolve spontaneously.

6. Proton pump inhibitors (eg, Pantoprazole 80 milligrams bolus followed by a infusion of 8 milligrams/h) reduce rebleeding and the need for surgery for the treatment of bleeding peptic ulcers and are recommended as an adjunct to endoscopic therapy. Histamine-2 antagonists are not beneficial in acute UGI hemorrhage.

7. Consider octreotide 25 to 50 micrograms bolus followed by 25 to 50 micrograms/h intravenously for patients with uncontrolled bleeding awaiting endoscopy or when endoscopy is unsuccessful.

8. Balloon tamponade with the Sengstaken-Blakemore tube or its variants should only be considered an adjunctive or temporizing measure and are rarely used due to the high complication rate.

9. A surgical and gastroenterology consult should be obtained in patients with uncontrolled bleeding. Patients who do not respond to medical and endoscopic intervention may require emergency surgical intervention.

10. Most patients with GI bleeding will require hospital admission and early referral to an endoscopist.