Presentation on the classification, causes, and treatment of GI bleeds.

1. GI Bleeds:
What does the
evidence show?
Brian A. Wells, MD, MPH, MSM
March 1st, 2013

2. Warm-up Question
Asymptomatic 24 year
old.
Is there an
abnormality?
Is it pathologic?
What is it likely to be?
How common is it?

3. Warm-up question
What classic sign is seen in this
CT?
Of what disease is it a sign?
Is the disease active?
I love the
alphabet.
You forgot to
thank Berg and
Lesniowski.

4. GI bleeds:
What does the evidence show?
There seems to be no study too
fragmented, no hypothesis too trivial, no
literature too biased or too egotistical, no
design too warped, no methodology too
bungled, no presentation of results too
inaccurate, too obscure, and too
contradictory, no analysis too self-
serving, no argument too circular, no
conclusions too trifling or too unjustified,
and no grammar and syntax too
offensive for a paper to end up in print.
- Drummond Rennie, MD, Deputy Editor
of JAMA

5. ―Medicine as a computational science… as a
probability science.‖

9. Why talk about GI bleeds?
• Frequent cause of hospitalization
• Upper GI Bleeding accounts for approximately 350,000 hospitalizations
per year.
• In a study, patients with UGI bleeds experienced significantly higher 12-
month health-resource utilization and costs than patients without UGI
bleeds.
• UGI-related healthcare utilization and total healthcare, medical, and
pharmacy costs incurred by the UGI-bleed cohort were significantly
greater (p< 0.0001) than those incurred by the general population cohort
(mean of $20,405 vs. 3,652), even after excluding the initial
hospitalization costs (mean of $11,228 vs. 3,652).
The economics of upper gastrointestinal bleeding in a US managed-care setting: a retrospective, claims-based analysis.
J Med Econ. 2010 Mar;13(1):70-7. doi: 10.3111/13696990903526676. http://www.ncbi.nlm.nih.gov/pubmed/20047365

10. GI Bleed – Trends and Economics
• From 1998 to 2006
– For patients with either a principal or secondary GI bleed
diagnosis, the number of hospitalizations for upper GI bleeding per
100,000 people decreased by 14%. However, hospitalizations for
lower GI bleeding increased 8%, yielding a 4% overall decrease in
the hospitalization rate per 100,000 people for GI bleeding.
– Possible reasons for the decrease in upper GI bleeding may include
the increased use of proton pump inhibitors to decrease gastric acid
secretion, antibiotic treatment of gastric ulcers caused by
Helicobacter pylori bacteria, and increased use of selective COX-2
inhibitors for arthritis or other pain.
Agency for Healthcare Research and Quality. Hospitalizations for Gastrointestinal Bleeding in 1998 and 2006.
HCUP Statistical Brief #65. Published online December 2008.

11. GI Bleed – Trends and Economics
• From 1998 to 2006
– The largest decreases in the rate of hospital stays for GI bleeding
were for upper GI ulcers (25% decrease) and gastritis/duodenitis
(31% decrease).
– The largest increases in the rate of hospital stays for GI bleeding
were for angiodysplasia, which is a relatively infrequent cause of GI
bleeding (38% increase), and hemorrhage of the rectum and anus
(41% increase).
– For patients with a principal diagnosis of GI bleeding, the number of
inpatient deaths decreased from 20,013 in 1998 to 16,344 in
2006, with a 23% decrease in inpatient death rate from 3.9% to
3.0%.
– For patients aged 30 to 44 years, the inpatient death rate for
gastrointestinal bleeding decreased by 31%, from 1.6% in 1998 to
1.1% in 2006.
Agency for Healthcare Research and Quality. Hospitalizations for Gastrointestinal Bleeding in 1998 and 2006.
HCUP Statistical Brief #65. Published online December 2008.

12. GI Bleeds
• Unfortunately, far too extensive to cover everything
in the time we have
• Will attempt to give an overview of upper and lower
• Will talk about
– Classification
– Etiology
– Management

13. Types of GI Bleeds (i.e. our agreed-upon
definitions)
• Upper v. Lower
• Divided by the ligament of Treitz
– The suspensory muscle of duodenum, also known as the ligament of
Treitz (named for Vaclav Treitz), connects the duodenum to
the diaphragm.
– It arises from the right crus as it passes around the
esophagus, continues as connective tissue around the stems of
the celiac trunk and SMA and inserts into the third and fourth
portions of the duodenum and frequently into the duodenojejunal
flexure as well.
• Upper
– 70% of GI bleeds (some variation in this data, will also find values
like 60/40 in the literature)
• Lower
– 30% of GI bleeds

14. Fun Slide!
• An abnormally low and fixed position of the
ligament of Treitz is a known cause of ______?

15. Upper GI Bleed
• Upper gastrointestinal bleeding is a common
medical condition that results in high patient
morbidity and medical care costs.
• In a study, the annual incidence of hospitalization
for acute upper gastrointestinal bleeding was
approximately 100 per 100,000 adults; the
incidence was twice as common in males as in
females and increased with age
Longstreth, GF. Epidemiology of hospitalization for acute upper gastrointestinal hemorrhage: a population-based study.
Am J Gastroenterol. 1995;90(2):206.

16. Upper GI Bleed
• The most common causes of upper gastrointestinal
bleeding include the following:
– Gastric and/or duodenal ulcers (20% - 30%)
– Esophagogastric varices with or without portal
hypertensive gastropathy (10%)
– Esophagitis (5%)
– Erosive gastritis/duodenitis (5 – 10%)
– Mallory-Weiss syndrome (3%)
– Angiodysplasia
– Mass lesions (polyps/cancers) (1%)
– Dieulafoy's lesion

17. Upper GI Bleed
• Less common causes of upper gastrointestinal bleeding
include:
– Hemobilia
– Hemosuccus pancreaticus
– Aortoenteric fistula
– Cameron lesions
• Because of the overall incidence of upper gastrointestinal
bleeding is high, the less common causes of upper
gastrointestinal bleeding are still frequently encountered,
and as such their recognition and appropriate management
are important.

18. Duodenal Ulcer

19. Varices

20. Esophagitis

21. Esophageal Malignancy

22. Upper GI Bleed
• 50% present with hematemesis
• NGT with positive blood on aspirate
• 11% of brisk bleeds have hematochezia
• Melena (black tarry stools)—this develops with
approximately 150-200cc of blood in the upper GI
tract.
– Stool turns black after 8 hours of sitting within the
GI tract.

23. Lower GI Bleed
• The causes of lower gastrointestinal bleeding
(LGIB) may be grouped into several categories:
– Anatomic (diverticulosis)
– Vascular (angiodysplasia, ischemic, radiation-induced)
– Inflammatory (IBD, infectious)
– Neoplastic (polyp, carcinoma)
– Other (hemorrhoid, ulcer, post-biopsy or polypectomy)
Strate, LL. Lower GI bleeding: epidemiology and diagnosis. Gastroenterol Clin North Am. 2005;34(4):643.

24. Lower GI Bleed
• In a meta-anaysis including several large
studies, the following bleeding sources were
identified:
Cause % Cause %
Angiodysplasia 0% – 3% Other causes 1% – 9%
Anorectal 6 – 16% Other colitis (infectious, 3% – 29%
(hemorrhoids, anal antibiotic associated,
fissure, rectal ulcer) colitis of unclear
etiology)
Diverticulosis 5 – 42% Postpolypectomy 0% – 13%
IBD 2% – 4% Radiation colitis 1% – 3%
Ischemia 6 – 18% Small bowel/upper GI 3% – 13%
Unknown – 6 – 23%
Strate LL. Lower GI bleeding: epidemiology and diagnosis. Gastroenterol Clin North Am 2005; 34:643.

25. Diverticulosis

26. Colonic Polyps

27. Malignancy

28. Hemorrhoids

29. Lower GI Bleed
• Blood originating from the left colon typically is bright red.
• By comparison, bleeding from the right side of the colon usually appears
dark or maroon-colored and may be mixed with stool.
• However, rapid transit of blood from the right side of the colon or
massive upper GI bleeding can appear red, and bleeding from the
cecum may rarely present with melena.
• Thus, although helpful, the distinctions based upon stool color are not
absolute.
• Patients with high-risk features including hemodynamic instability
(shock, orthostatic hypotension), persistent bleeding, and/or significant
comorbid illnesses should be admitted to an intensive care unit for
resuscitation, close observation, and possible therapeutic interventions.

30. Lower GI Bleed
• In patients with severe hematochezia, it is important to
exclude upper GI bleeding, particularly if the bleeding is
associated with orthostatic hypotension.
• Patients suspected of having an upper GI bleed should
undergo an upper endoscopy once appropriately
resuscitated.
• Nasogastric lavage may be carried out if there is doubt as to
whether a bleed originates from the upper GI tract. A
nasogastric lavage that yields blood- or coffee ground-like
material confirms upper GI bleeding.
• However, false negative aspirates can occur if bleeding has
ceased or arises beyond a closed pylorus.

31. Lower GI Bleed
• Acute LGIB: <3d
• Chronic LGIB: > several days
• Hematochezia
• Blood in Toilet
• Clear NGT aspirate
• Normal Renal Function
• Usually Hemodynamically stable
– <200ml : no effect on HR**
– >800ml: SBP drops by 10mmHg, Hr increases by 10
– >1500ml: possible shock
OR
– 10% Hct: tachycardia
– 20% Hct: orthostatic hypotension
– 30% Hct: shock
Stops spontaneously (80 - 85% of the time)
**Barnet J and H Messmann H. Nat Rev Gastroenterol Hepatol 6, 637-646 (2009).

32. Obscure GI Bleed
• Obscure gastrointestinal bleeding accounts for approximately 5% of
patients with gastrointestinal bleeding.
• In approximately 75% of these patients, the source is in the small bowel.
The remainder of cases are due to missed lesions in either the upper or
lower gastrointestinal tract.
• Most common presentation is iron deficiency anemia
• Etiology:
– Younger than 40
• Tumors
• Meckel’s diverticulum
• Dieulafoy’s lesion
• Crohn’s Disease
• Celiac Disease
– Greater than 40
• Angioectasia
• NSAID enteropathy
• Celiac
Gerson LB. Clin Gastroenterol & Hepatol 2009;7:828-833.

33. Localization of Bleeding
• History
• NG Tube
• EGD
• Colonoscopy
• Radionuclide imaging
– Bleeding at a rate of 0.1 to 0.5 mL/minute
– Most sensitive radiographic test for GI bleeding
– Can only localize bleeding to a general area of the abdomen (accuracy 24 –
91%)
• Angiography
– Bleeding at a rate of 0.3 to 0.5 mL/minute can be detected with CT
angiography (Sn/Sp/Acc 82%/95%/100%)
– Requires active blood loss of 1 to 1.5 mL/minute for normal angiography
– No bowel preparation; accurate anatomic localization
– Superselective embolization is feasible in 80 percent, and bleeding is
successfully controlled in 97 percent; however, risk of intestinal infarct.

34. Management of Upper GI Bleed
• Assess the severity of the bleed
• Identify potential sources of the bleed
• Determine if there are conditions present that may
affect subsequent management.
• Patients should be asked about prior episodes of
upper GI bleeding, since up to 60 percent of
patients with a history of an upper GI bleed are
bleeding from the same lesion
• Medication and symptom review
(NSAIDS, anticoagulants, pain
location, tachycardia, etc.)

35. Management of Upper GI Bleed
• Medications
– Acid suppression with intravenous PPI at presentation
until confirmation of the cause of bleeding
– Prokinetics like erythromycin to improve gastric
visualization prior to endoscopy
– Somatostatin or octreotide for variceal bleeding
– Antibiotics for patient with cirrhosis (20% have infections;
50% develop an infection while hospitalized)

36. Management of Upper GI Bleed
• Risk scoring
– Rockall score is based upon age, the presence of
shock, comorbidity, diagnosis, and endoscopic stigmata
of recent hemorrhage
– Modified Glasgow Blatchford score (used on first
presentation), is calculated using only the blood urea
nitrogen, hemoglobin, systolic blood pressure, and pulse
(assess likelihood of the need for urgent endoscopic
intervention).
– AIMS65 - high accuracy for predicting inpatient mortality
• Albumin < 3, INR >1.5, AMS, SBP < 90, Age > 65

37. Management of Upper GI Bleed
• Provision of supplemental oxygen by nasal cannula
• Nothing per mouth
• Two large caliber (16 gauge or larger) peripheral
catheters or a central venous line
• Placement of a pulmonary artery catheter should
be considered in patients with hemodynamic
instability or who need close monitoring during
resuscitation

38. Evidence for Transfusion
• Withholding transfusions until hemoglobin levels
are lower than 7%, rather than 9%, improves
overall survival by 45% in patients with acute upper
gastrointestinal (GI) bleeding, according to a study
published in the January 3 issue of the New
England Journal of Medicine.
Transfusion Strategies for Acute Upper Gastrointestinal Bleeding. N Engl J Med. 2013;368:11-21, 75-76.

39. Management of Lower GI Bleed
• Patients with high-risk features, particularly those with hemodynamic
instability, ongoing active bleeding, and significant comorbid illnesses
should be managed in the intensive care unit with aggressive
resuscitation and early interventions.
• A gastroenterologist, a general surgeon, and possibly an interventional
radiologist should be involved early in the hospital course of high-risk
individuals.
• Two large caliber (18 gauge or larger) peripheral catheters or a central
venous line should be inserted for intravenous access.
• Patients with heart failure or valvular disease may benefit from
pulmonary catheter monitoring to minimize the risk of fluid overload.

40. Management of GI Bleed
• Oxygen
• IV Access-central line or two large bore
peripheral IV sites
• Isotonic saline for volume resuscitation
• Start transfusing blood products if the patient
remains unstable despite fluid boluses.
• Airway Protection
• Altered Mental Status and increased risk of
aspiration with massive upper GI bleed.

41. Management of GI Bleed
• ICU admit indications
– Significant bleeding (>2u pRBC) with hemodynamic instability
• Transfusion
– Brisk Bleed, transfusing should be based on hemodynamic status,
not lab value of Hgb.
– Cardiopulmonary symptoms-cardiac ischemia or shortness of breath,
decreased pulse ox
• 1 unit PRBC increases Hgb by 1mg/dL and increase Hct by 3%
• FFP for INR greater than 1.5
• Platelets for platelet count less than 50K

42. Obscure GI Bleed
• Work Up
– EGD, Colonoscopy both negative
– Repeat
– Proximal jejunum? Distal ileum?
– Angiography
AGA Institute. AGA Institute Medical Position Statement on Obscure Gastrointestinal Bleeding.
Gastroenterology 2007;133:1694-1696

43. Basic Admission Orders
• Admit to ICU/intermediate care/telemetry s/o …
• Dx: Upper/Lower G.I. Bleed
• Condition:
• VS:
• Allergies:
• Activity: Bedrest
• Nursing: Is/Os, ? Foley
• Diet: NPO

44. Basic Admission Orders (Cont.)
• IVF: NSS @ ?cc/h
• Medications: I.V. Protonix, convert medications to
i.v., hold anti-hypertensives
• Labs: serial H/H, type and cross, coags, Chem 7,
LFTs
• Consults: GI, +/- Surgery

45. Thank you!