Gastrointestinal bleeding

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Gastrointestinal bleeding
Other namesGastrointestinal hemorrhage, GI bleed
antibiotics[5][6]
Prognosis~15% risk of death[1][7]
FrequencyUpper: 100 per 100,000 adults per year[8]
Lower: 25 per 100,000 per year[2]

Gastrointestinal bleeding (GI bleed), also called gastrointestinal hemorrhage (GIB), is all forms of

shortness of breath, pale skin, or passing out.[1][9] Sometimes in those with small amounts of bleeding no symptoms may be present.[1]

Bleeding is typically divided into two main types:

hemorrhoids, cancer, and inflammatory bowel disease among others.[2][1] Small amounts of bleeding may be detected by fecal occult blood test.[1] Endoscopy of the lower and upper gastrointestinal tract may locate the area of bleeding.[1] Medical imaging may be useful in cases that are not clear.[1]

Initial treatment focuses on

antibiotics may be considered in certain cases.[5][6][11] If other measures are not effective, an esophageal balloon may be attempted in those with presumed esophageal varices.[2] Endoscopy of the esophagus, stomach, and duodenum or endoscopy of the large bowel are generally recommended within 24 hours and may allow treatment as well as diagnosis.[4]

An upper GI bleed is more common than lower GI bleed.[2] An upper GI bleed occurs in 50 to 150 per 100,000 adults per year.[8] A lower GI bleed is estimated to occur in 20 to 30 per 100,000 per year.[2] It results in about 300,000 hospital admissions a year in the United States.[1] Risk of death from a GI bleed is between 5% and 30%.[1][7] Risk of bleeding is more common in males and increases with age.[2]

Classification

Causes of gastrointestinal bleeding

Gastrointestinal bleeding can be roughly divided into two clinical syndromes: upper gastrointestinal bleeding and lower gastrointestinal bleeding.[2] About 2/3 of all GI bleeds are from upper sources and 1/3 from lower sources.[12] Common causes of gastrointestinal bleeding include infections, cancers, vascular disorders, adverse effects of medications, and blood clotting disorders.[2] Obscure gastrointestinal bleeding (OGIB) is when a source is unclear following investigation.[13]

Upper gastrointestinal

Upper gastrointestinal bleeding is from a source between the

Mallory-Weiss tears, cancer, and angiodysplasia.[2]

A number of medications are found to cause upper GI bleeds.

anticoagulants may also increase the risk.[14] The risk with dabigatran is 30% greater than that with warfarin.[15]

Lower gastrointestinal

Lower gastrointestinal bleeding is typically from the colon, rectum or anus.[2] Common causes of lower gastrointestinal bleeding include hemorrhoids, cancer, angiodysplasia, ulcerative colitis, Crohn's disease, and aortoenteric fistula.[2] It may be indicated by the passage of fresh red blood rectally, especially in the absence of bloody vomiting. Lower gastrointestinal bleeding could also lead to melena if the bleeding occurs in the small intestine or proximal colon.[1]

Signs and symptoms

Gastrointestinal bleeding can range from small non-visible amounts, which are only detected by laboratory testing, to massive bleeding where bright red blood is passed and

feeling tired, dizziness, and pale skin color.[16]

A number of foods and medications can turn the stool either red or black in the absence of bleeding.

activated charcoal.[2] Blood from the vagina or urinary tract may also be confused with blood in the stool.[2]

Diagnosis

Diagnosis is often based on direct observation of blood in the stool or vomit. Although

Blatchford score[4] or Rockall score.[14] The Rockall score is the more accurate of the two.[14] As of 2008 there is no scoring system useful for lower GI bleeds.[14]

Clinical

Gastric aspiration and or lavage, where a tube is inserted into the stomach via the nose in an attempt to determine if there is blood in the stomach, if negative does not rule out an upper GI bleed[18] but if positive is useful for ruling one in.[12] Clots in the stool indicate a lower GI source while melana stools an upper one.[12]

Laboratory testing

Recommended laboratory blood testing includes: cross-matching blood, hemoglobin, hematocrit, platelets, coagulation time, and electrolytes.[4] If the ratio of blood urea nitrogen to creatinine is greater than 30 the source is more likely from the upper GI tract.[12]

Imaging

A

CT angiography is useful for determining the exact location of the bleeding within the gastrointestinal tract.[19] Nuclear scintigraphy is a sensitive test for detecting occult gastrointestinal bleeding when direct imaging with upper and lower endoscopies are negative. Direct angiography allows for embolization of a bleeding source, but requires a bleeding rate faster than 1mL/minute.[20]

Prevention

In patients with significant varices or cirrhosis

H. pylori is recommended.[14] Transjugular intrahepatic portosystemic shunting (TIPS) may be used to prevent bleeding in people who re-bleed despite other measures.[14]

Among patients admitted to the ICU with high risk of bleeding, a PPI or H2RA appears useful.[22][23]

Treatment

The initial focus is on resuscitation beginning with airway management and fluid resuscitation using either intravenous fluids and or blood.[4] A number of medications may improve outcomes depending on the source of the bleeding.[4]

Peptic ulcers

Based on evidence from people with other health problems

Proton pump inhibitor (PPI) treatment before endoscopy may decrease the need for endoscopic hemostatic treatment, however it is not clear if this treatment reduces mortality, the risk of re-bleeding, or the[clarification needed] and the need for surgery.[24] Oral and intravenous formulations may be equivalent; however, the evidence to support this is suboptimal.[25] In those with less severe disease and where endoscopy is rapidly available, they are of less immediate clinical importance.[24] There is tentative evidence of benefit for tranexamic acid which inhibits clot breakdown.[26] Somatostatin and octreotide, while recommended for varicial bleeding, have not been found to be of general use for non variceal bleeds.[4] After treatment of a high risk bleeding ulcer endoscopically giving a PPI once or a day rather than as an infusion appears to work just as well and is less expensive (the method may be either by mouth or intravenously).[27]

Variceal bleeding

For initial fluid replacement, colloids or

antibiotics decrease the chance of bleeding again, shorten the length of time spent in hospital, and decrease mortality.[5] Octreotide reduces the need for blood transfusions[29] and may decrease mortality.[30] No trials of vitamin K have been conducted.[31]

Blood products

The evidence for benefit of blood transfusions in GI bleed is poor with some evidence finding harm.

alcoholics FFP is suggested before confirmation of a coagulopathy due to presumed blood clotting problems.[2] Evidence supports holding off on blood transfusions in those who have a hemoglobin greater than 7 to 8 g/dL and moderate bleeding, including in those with preexisting coronary artery disease.[7][10]

If the INR is greater than 1.5 to 1.8 correction with fresh frozen plasma or

massive transfusion protocol may be used, but there is a lack of evidence for this indication.[14]

Procedures

The Blakemore esophageal balloon used for stopping esophageal bleeds if other measures have failed

The benefits versus risks of placing a

esophageal perforation.[2]

Colonoscopy is useful for the diagnosis and treatment of lower GI bleeding.[2] A number of techniques may be employed including clipping, cauterizing, and sclerotherapy.[2] Preparation for colonoscopy takes a minimum of six hours which in those bleeding briskly may limit its applicability.[36] Surgery, while rarely used to treat upper GI bleeds, is still commonly used to manage lower GI bleeds by cutting out the part of the intestines that is causing the problem.[2] Angiographic embolization may be used for both upper and lower GI bleeds.[2] Transjugular intrahepatic portosystemic shunting (TIPS) may also be considered.[14]

Prognosis

Death in those with a GI bleed is more commonly due to other illnesses (some of which may have contributed to the bleed, such as cancer or cirrhosis) than the bleeding itself.

NSAIDs need to be carefully considered.[4] If aspirin is needed for cardiovascular disease prevention, it is reasonable to restart it within seven days in combination with a PPI for those with nonvariceal upper GI bleeding.[20]

Epidemiology

Gastrointestinal bleeding from the upper tract occurs in 50 to 150 per 100,000 adults per year.[8] It is more common than lower gastrointestinal bleeding which is estimated to occur at the rate of 20 to 30 per 100,000 per year.[2] Risk of bleeding is more common in males and increases with age.[2]

References

External links