Transcript Acute Gastrointestinal Bleeding

Practical Approach to Acute
Gastrointestinal Bleeding
Christopher S. Huang MD
Assistant Professor of Medicine
Boston University School of Medicine
Section of Gastroenterology
Boston Medical Center
Learning Objectives
• UGIB
– Nonvariceal (PUD) and variceal
– Resuscitation, risk assessment, pre-endoscopy
management
– Role of endoscopy
– Post-endoscopy management
• LGIB
– Risk assessment
– Role and timing of colonoscopy
– Non-endoscopic diagnostic and treatment options
Definitions
• Upper GI bleed – arising
from the esophagus,
stomach, or proximal
duodenum
• Mid-intestinal bleed –
arising from distal
duodenum to ileocecal
valve
• Lower intestinal bleed –
arising from colon/rectum
Stool color and origin/pace of bleeding
• Guaiac positive stool
– Occult blood in stool
– Does not provide any localizing information
– Indicates slow pace, usually low volume bleeding
• Melena
– Very dark, tarry, pungent stool
– Usually suggestive of UGI origin (but can be small
intestinal, proximal colon origin if slow pace)
• Hematochezia
– Spectrum: bright red blood, dark red, maroon
– Usually suggestive of colonic origin (but can be UGI origin
if brisk pace/large volume)
Case Vignette – CC:
• 68 yo male presents with a chief complaint of
a large amount of “bleeding from the rectum”
Case Vignette - HPI
• Describes bleeding as large volume, very dark
maroon colored stool
• Has occurred 4 times over past 3 hours
• He felt light headed and nearly passed out
upon trying to get up to go the bathroom
Case Vignette - HPI
• Denies abdominal pain, nausea, vomiting,
antecedent retching
• No history of heartburn, dysphagia, weight
loss
• No history of diarrhea or constipation/hard
stools
• No prior history of GIB
• Screening colonoscopy 10 years ago – no
polyps, (+) diverticulosis
Case Vignette – PMHx, Meds
•
•
•
•
Hepatitis C
CAD – h/o MI
PVD
AAA – s/p elective
repair 3 years ago
• HTN
• Hypercholesterolemia
• Lumbago
• Medications:
–
–
–
–
–
Aspirin
Clopidogrel
Atorvastatin
Atenolol
Lisinopril
Case Vignette – Physical Exam
• Physical examination:
– BP 105/70, Pulse 100, (+) orthostatic changes
– Alert and mentating, but anxious appearing
– Anicteric
– Mid line scar, benign abdomen, nontender liver
edge palpable in epigastrium, no splenomegaly
– Rectal examination – no masses, dark maroon
blood
Case Vignette - Labs
• Labs
– Hct 21% (Baseline 33%)
– Plt 110K
– BUN 34, Cr 1.0
– Alb 3.5
– INR 1.6
– ALT 51, AST 76
Initial Considerations
• Differential diagnosis?
– What is most likely source?
– What diagnosis can you least afford to miss?
• How sick is this patient? (risk stratification)
– Determines disposition
– Guides resuscitation
– Guides decision re: need for/timing of endoscopy
Differential Diagnosis – Upper GIB
•
•
•
•
•
•
•
•
•
Peptic ulcer disease
Gastroesophageal varices
Erosive esophagitis/gastritis/duodenitis
Mallory Weiss tear
Vascular ectasia
Neoplasm
Dieulafoy’s lesion
Rare, but cannot
Aortoenteric fistula
afford to miss
Hemobilia, hemosuccus pancreaticus
Most
common
Differential Diagnosis – Lower GIB
•
•
•
•
•
•
Most common
Diverticulosis
diagnosis
Angioectasias
Hemorrhoids
Colitis (IBD, Infectious, Ischemic)
Neoplasm
Post-polypectomy bleed (up to 2 weeks after
procedure)
• Dieulafoy’s lesion
History and Physical
History
Physical Examination
•
•
•
•
•
•
•
•
•
•
•
Localizing symptoms
History of prior GIB
NSAID/aspirin use
Liver disease/cirrhosis
Vascular disease
Aortic valvular disease,
chronic renal failure
• AAA repair
• Radiation exposure
• Family history of GIB
Vital signs, orthostatics
Abdominal tenderness
Skin, oral examination
Stigmata of liver disease
Rectal examination
– Objective description of
stool/blood
– Assess for mass, hemorrhoids
– No need for guaiac test
History and Physical
History
Physical Examination
•
•
•
•
•
•
•
•
•
•
•
Localizing symptoms
History of prior GIB
NSAID/aspirin use
Liver disease/cirrhosis
Vascular disease
Aortic valvular disease,
chronic renal failure
• AAA repair
• Radiation exposure
• Family history of GIB
Vital signs, orthostatics
Abdominal tenderness
Skin, oral examination
Stigmata of liver disease
Rectal examination
– Objective description of
stool/blood
– Assess for mass, hemorrhoids
– No need for guaiac test
Take Home Point # 1
Always get objective description of
stool
Avoid noninformative terms such as
“grossly guaiac positive”
Take Home Point #2
If you need a card to tell you whether
there’s blood in the stool, it’s NOT an
acute GIB
Narrowing the DDx: Upper or Lower Source?
• Predictors of UGI source:
– Age <50
– Melenic stool
– BUN/Creatinine ratio
• If ratio ≥ 30, think upper GIB
J Clin Gastroenterol 1990;12:500
Am J Gastroenterol 1997;92:1796
Am J Emerg Med 2006;24:280
Utility of NG Tube
• Most useful situation: patients with severe
hematochezia, and unsure if UGIB vs. LGIB
– Positive aspirate (blood/coffee grounds) indicates
UGIB
• Can provide prognostic info:
– Red blood per NGT – predictive of high risk
endoscopic lesion
– Coffee grounds – less severe/inactive bleeding
• Negative aspirate – not as helpful; 15-20% of
patients with UGIB have negative NG aspirate
Ann Emerg Med 2004;43:525
Arch Intern Med 1990;150:1381
Gastrointest Endosc 2004;59:172
Take Home Point #3
Upper GI bleed must still be
considered in patients with severe
hematochezia, even if NG aspirate
negative
Initial Assessment
• Always remember to assess A,B,C’s
• Assess degree of hypovolemic shock
Class I
Class II
Class III
Class IV
Blood loss (mL) 750
750-1500
1500-2000
>2000
Blood volume
loss (%)
< 15%
15-30%
30-40%
>40%
Heart rate
<100
>100
>120
>140
SBP
No change
Orthostatic
change
Reduced
Very low,
supine
Urine output
(mL/hr)
>30
20-30
10-20
<10
Mental status
Alert
Anxious
Aggressive/dro Confused/unco
wsy
nscious
Resuscitation
• IV access: large bore peripheral IVs best (alt:
cordis catheter)
• Use crystalloids first
• Anticipate need for blood transfusion
• Threshold should be based on underlying condition,
hemodynamic status, markers of tissue hypoxia
• Should be administered if Hgb ≤ 7 g/dL
• 1 U PRBC should raise Hgb by 1 (HCT by 3%)
• Remember that initial Hct can be misleading (Hct remains
the same with loss of whole blood, until re-equilibration
occurs)
• Correct coagulopathy
Resuscitation
• IV access: large bore peripheral IVs best (alt:
cordis catheter)
Time
• Use crystalloidsbleed
first
• Anticipate40%need for blood transfusion
IVFs
40% on underlying 20%
• Threshold should be based
condition,
hemodynamic status, markers of tissue hypoxia
• Should be administered if Hgb ≤ 7 g/dL
• 1 U PRBC should raise Hgb by 1 (HCT by 3%)
• Remember that initial Hct can be misleading (Hct remains
the same with loss of whole blood, until re-equilibration
occurs)
• Correct coagulopathy
Transfusion Strategy
• Randomized trial:
– 921 subjects with severe acute UGIB
– Restrictive (tx when Hgb<7; target 7-9) vs. Liberal
(tx when Hgb<9; target 9-11)
– Primary outcome: all cause mortality rate within
45 days
NEJM 2013;368;11-21
Restrictive Strategy Superior
Restrictive
Liberal
P value
Mortality rate
5%
9%
0.02
Rate of further
bleeding
10%
16%
0.01
Overall
complication rate
40%
48%
0.02
Benefit seen primarily in
Child A/B cirrhotics
NEJM 2013;368;11-21
Resuscitation
• IV access: large bore peripheral IVs best (alt:
cordis catheter)
Weigh risks and benefits of
reversing anticoagulation
• Use crystalloids first
Assess degree of coagulopathy
• Anticipate need for blood transfusion
• Threshold should be based on underlying condition,
K – slow acting, longhemodynamic status, markers of Vitamin
tissue hypoxia
lived
• Should be administered if Hgb ≤ 7 g/dL
• 1 U PRBC should raise Hgb by 1 (HCT
FFP –by
fast3%)
acting, short lived
- Give 1 U(Hct
FFP for
every 4 U
• Remember that initial Hct can be misleading
remains
the same with loss of whole blood, until
re-equilibration
PRBCs
occurs)
• Correct coagulopathy
Resuscitation
• Early intensive resuscitation reduces
mortality
– Consecutive series of patients with
hemodynamically significant UGIB
– First 36 subjects = Observation Group (no
intervention)
– Second 36 subjects = Intensive Resuscitation
Group (intense guidance provided) – goal was to
decrease time to correction of hemodynamics, Hct
and coagulopathy
Am J Gastroenterol 2004;99:619
Early Intensive Resuscitation
Reduces UGIB Mortality
Intervention: Faster correction of
hemodynamics, Hct and coags.
Time to endoscopy similar
(groups are essentially the same)
Am J Gastroenterol 2004;99:619
Early Intensive Resuscitation
Reduces UGIB Mortality
• Observation
group
– 5 MI
– 4 deaths
• Intense group
– 2 MI
– 1 death (sepsis)
Am J Gastroenterol 2004;99:619
Causes of Mortality in Patients
with Peptic Ulcer Bleeding
• Patients rarely
bleed to death
• Prospective
cohort study
>10,000 cases of
peptic ulcer
bleed
• Mortality rate
6.2%
• 80% of deaths
not related to
bleeding
Am J Gastroenterol 2010;105:84
Causes of Mortality in Patients
with Peptic Ulcer Bleeding
• Most common causes of non-bleeding
mortality:
– Terminal malignancy (34%)
– Multiorgan failure (24%)
– Pulmonary disease (24%)
– Cardiac disease (14%)
Am J Gastroenterol 2010;105:84
Take Home Point #4
Early resuscitation and supportive
measures are critical to reduce
mortality from UGIB
Risk Stratification
• Identify patients at high risk for adverse
outcomes
• Helps determine disposition (ICU vs. floor vs.
outpatient)
• May help guide appropriate timing of
endoscopy
Rockall Scoring System
• Validated predictor of mortality in patients with
UGIB
• 2 components: clinical + endoscopic
Variable
0
1
2
Age
<60
60-79
≥ 80
Shock
No
SBP ≥ 100
P<100
TachySBP ≥ 100
P>100
HypotensionSBP <100
Comorbidity No major
Cardiac
failure, CAD,
other major
3
Renal failure,
liver failure,
malignancy
Gut 1996;38:316
Clinical Rockall Score – Mortality Rates
60%
50%
40%
30%
20%
10%
0%
0
1
2
3
4
5
6
7
AIMS65
• Simple risk score that predicts in-hospital
mortality, LOS, cost in patients with acute
UGIB
lbumin <3.0
NR > 1.5
ental status altered
ystolic BP <90
+ years old
Gastrointest Endosc 2011;74:1215
AIMS65
Gastrointest Endosc 2011;74:1215
Blatchford Score
• Predicts need
for endoscopic
therapy
• Based on
readily available
clinical and lab
data
• Can use
UpToDate
calculator
Lancet 2000;356:1318
Blatchford Score
Gastrointest Endosc 2010;71:1134
Blatchford Score
• Most useful for safely discriminating low risk
UGIB patients who will likely NOT require
endoscopic hemostasis
• “Fast track Blatchford” – patient at low risk if:
BUN < 18 mg/dL
Hgb > 13 (men), 12 (women)
SBP >100
HR < 100
Pre-endoscopic Pharmacotherapy
• For Non-Variceal UGIB
– IV PPI: 80 mg bolus, 8 mg/hr drip
– Rationale: suppress acid, facilitate clot formation
and stabilization
– Duration: at least until EGD, then based on
findings
Pre-endoscopy PPI
• Reduces the proportion
of patients with high
risk endoscopic
stigmata (“downstages”
lesion)
• Decreases need for
endoscopic therapy
• Has not been shown to
reduce rebleeding,
surgery, or mortality
rates
High risk
Low risk
Endoscopic treatment required:
Omeprazole – 19% (23% of PUD)
Placebo – 28% (37% of PUD)
N Engl J Med 2007;356:1631
Endoscopy - Nonvariceal UGIB
• Early endoscopy (within 24 hours) is
recommended for most patients with acute
UGIB
• Achieves prompt diagnosis, provides risk
stratification and hemostasis therapy in highrisk patients
J Clin Gastroenterol 1996;22:267
Gastrointest Endosc 1999;49:145
Ann Intern Med 2010;152:101
When is Endoscopic Therapy
Required?
• ~80% bleeds spontaneously resolve
• Endoscopic stigmata of recent hemorrhage
major
Stigmata
Continued/rebleeding rate
Active bleeding
55-90%
Nonbleeding visible vessel
40-50%
Adherent clot
Variable, depending on
underlying lesion: 0-35%
Flat pigmented spot
7-10%
Clean base
< 5%
Major Stigmata – Active Spurting
Kelsey, PB (Dec 04 2003). Duodenum - Ulcer, Arterial Spurting, Treated with Injection
and Clip. The DAVE Project. Retrieved Aug, 1, 2010, from
http://daveproject.org/viewfilms.cfm?film_id=39
Major Stigmata - NBVV
Adherent Clot
• Role of endoscopic
therapy of ulcers with
adherent clot is
controversial
• Clot removal usually
attempted
• Underlying lesion can
then be assessed,
treated if necessary
Minor Stigmata
Flat pigmented spot
Clean base
Low rebleeding risk – no endoscopic therapy
needed
Endoscopic Hemostasis Therapy
• Epinephrine injection
• Thermal electrocoagulation
• Mechanical (hemoclips)
• Combination therapy
superior to monotherapy
Kelsey, PB (Nov 08 2005). Stomach - Gastric Ulcer, Visible Vessel. The DAVE Project.
Retrieved Aug, 1, 2010, from http://daveproject.org/viewfilms.cfm?film_id=306
Baron, TH (May 01 2007). Duodenum - Bleeding Ulcer Treated with Thermal
Therapy, Perforation Closed with Hemoclips. The DAVE Project. Retrieved Aug, 1,
2010, from http://daveproject.org/viewfilms.cfm?film_id=620
Nonvariceal UGIB –
Post-endoscopy management
• Patients with low risk ulcers can be fed
promptly, put on oral PPI therapy.
• Patients with ulcers requiring endoscopic
therapy should receive PPI gtt x 72 hours
– Significantly reduces 30 day rebleeding rate vs
placebo (6.7% vs. 22.5%)
– Note: there may not be major advantage with high
dose over non-high dose PPI therapy
N Engl J Med 2000;343:310
Arch Intern Med 2010;170:751
Nonvariceal UGIB –
Post-endoscopy management
• Determine H. pylori status in all ulcer patients
• Discharge patients on PPI (once to twice daily),
duration dictated by underlying etiology and
need for NSAIDs/aspirin
• In patients with cardiovascular disease on low
dose aspirin: restart as soon as bleeding has
resolved
– RCT demonstrates increased risk of rebleeding (10% v
5%) but decreased 30 day mortality (1.3% v 13%)
Ann Intern Med 2010;152:1
Nonvariceal UGIB –
Post-endoscopy management
• Determine H. pylori status in all ulcer patients
• Discharge patients on PPI (once to twice daily),
duration dictated by underlying etiology and
dying is more important
need forNot
NSAIDs/aspirin
than
not rebleeding
• In patients with
cardiovascular
disease on low
dose aspirin: restart as soon as bleeding has
resolved
– RCT demonstrates increased risk of rebleeding (10% v
5%) but decreased 30 day mortality (1.3% v 13%)
Ann Intern Med 2010;152:1
Variceal Bleeding
• Occurs in 1/3 of patients with cirrhosis
• 1/3 initial bleeding episodes are fatal
• Among survivors, 1/3 will rebleed within 6
weeks
• Only 1/3 will survive
1 year or more
Predictors of large esophageal varices
•
•
•
•
Severity of liver disease (Child Pugh)
Platelet count < 88K
Palpable spleen
Platelet count/spleen diameter (mm) ratio
<909
Gut 2003;52:1200
J Clin Gastroenterol 2010;44:146
J Gastroenterol Hepatol 2007;22:1909
Arch Intern Med 2001;161:2564
Am J Gastroenterol 1999;94:3103
leed
asoconstrictor therapy
ntibiotics
esuscitation
U level care
ndoscopy
ternative/Rescue therapies
eta blockade
asoconstrictor therapy
• Goal: Reduce splanchnic blood flow
• Terlipressin – only agent shown to improve control of
bleeding and survival in RCTs and meta-analysis
– Not available in US
• Vasopressin + nitroglycerine – too many adverse effects
• Somatostatin – not available in US
• Octreotide (somatostatin analogue)
• Decreases splanchnic blood flow (variably)
• Efficacy is controversial; no proven mortality benefit
• Standard dose: 50 mcg bolus, then 50 mcg/hr drip for 3-5 days
Gastroenterology 2001;120:946
Cochrane Database Syst Rev 2008;16:CD000193
N Engl J Med 1995;333:555
Am J Gastroenterol 2009;104:617
ntibiotics
• Bacterial infection occurs in up to 66% of
patients with cirrhosis and variceal bleed
• Negative impact on hemostasis (endogenous
heparinoids)
• Prophylactic antibiotics reduces incidence of
bacterial infection, significantly reduces early
rebleeding
– Ceftriaxone 1 g IV QD x 5-7 days
– Alt: Norfloxacin 400 mg po BID
Hepatology 2004;39:746
J Korean Med Sci 2006;21:883
Hepatogastroenterology 2004;51:541
esuscitation
• Promptly but with caution
• Goal = maintain hemodynamic stability, Hgb
~7-8, CVP 4-8 mmHg
• Avoid excessively rapid overexpansion of
volume; may increase portal pressure, greater
bleeding
ndoscopy
• Should be performed as
soon as possible after
resuscitation (within 12
hours)
• Endotracheal intubation
frequently needed
• Band ligation is
preferred method
Layer, L. & Jaganmohan, S. & Raju, GS & DuPont, AW (Oct 28 2009). Esophagus Band Ligation of Actively Bleeding Gastroesophageal Varices. The DAVE Project.
Retrieved Aug, 2, 2010, from http://daveproject.org/viewfilms.cfm?film_id=715
ternative/Rescue therapies
• TIPS – Transjugular
Intrahepatic Portosystemic
Shunt
• Early placement of shunt
(within 24-72hrs) associated
with improved survival among
high-risk patients
• Preferred treatment for gastric
variceal bleeding (rule out
splenic vein thrombosis first)
Hepatology 2004;40:793
Hepatology 2008;48:Suppl:373A
N Engl J Med. 2010 Jun 24;362:2370
Fan, C. (Apr 25 2006). Vascular Interventions in the
Abdomen: New Devices and Applications. The DAVE
Project. Retrieved Aug, 2, 2010, from
http://daveproject.org/viewfilms.cfm?film_id=497
TIPS+embolization of gastric varices
ternative/Rescue therapies
Sengstaken-Blakemore Tube
• Very effective for
immediate, temporary
control
• High complication rate –
aspiration, migration,
necrosis + perforation of
esophagus
• Use as bridge to TIPS within
24 hours
• Airway protection strongly
recommended
ternative/Rescue therapies
Self-Expanding Metal Stent
• Specially designed covered
metal stent
• Tamponades distal
esophageal varices
• Removable; does not
require airway protection
• Very limited data
Gastrointest Endosc 2010;71:71
eta blockade
• Reduces risk for recurrent variceal
hemorrhage
• Use nonselective beta blocker (e.g. Nadolol –
splanchnic vasoconstriction, decrease cardiac
output) and titrate up to maximum tolerated
dose, HR 50-60
– Start as inpatient, once acute bleeding has
resolved and patient shows hemodynamic stability
Lower GI Bleed
• Bleeding arising from the colorectum
• In patients with severe hematochezia, first
consider possibility of UGIB
– 10-15% of patients with presumed LGIB are found
to have upper GIB
Lower GI Bleed
• Differential Diagnosis
- Diverticulosis (# 1 cause)
Large volume, painless
- Angioectasias
- Hemorrhoids
volume, pain,
- Colitis (IBD, Infectious, Ischemic) Smallerdiarrhea
- Neoplasm
- Post-polypectomy
- Dieulafoy’s lesion
LGIB – Risk Stratification
• Predictors of severe* LGIB: 0 factors: ~6% risk
 HR>100
1-3 factors: ~40%
 SBP<115
 Syncope
>3 factors: ~80%
 nontender abdominal examination
 bleeding during first 4 hours of evaluation
 aspirin use
 >2 active comorbid conditions
* Defined as continued bleeding within first 24 hours (transfusion of 2+ Units, decline in HCT of
20+%) and/or recurrent bleeding after 24 hours of stability
Arch Intern Med 2003;163:838
Am J Gastroenterol 2005;100:1821
LGIB – Risk Factors for Mortality
• Age
• Intestinal ischemia
• Comorbid illnesses
• Secondary bleeding (developed during admission
for a separate problem)
• Coagulopathy
• Hypovolemia
• Transfusion requirement
• Male gender
Clinical Gastro Hepatol 2008;6:1004
Role of Colonoscopy
• Like UGIB, ~80% of LGIBs will resolve
spontaneously; of these, ~30% will rebleed
• Lack of standardized approach
– Traditional approach:
• elective colonoscopy after resolution of bleeding, bowel
prep – low therapeutic benefit
• Angiography for massive bleeding, hemodynamically
unstable patient
– Urgent colonoscopy approach
• Similar to UGIB – identify stigmata of hemorrhage, perform
therapy
Urgent Colonoscopy
• Within 6-12 hours of presentation
• Requires rapid “purge” prep with 5-6 L
Golytely administered 1L every 30-45 minutes
• Colonoscopy performed within 1 hour after
clearance of stool, blood and clots
• Need for bowel prep and risks of procedural
sedation may be prohibitive in unstable
patient
Endoscopic Therapy
Srinivasan, R. & Luthra, G. & Raju, GS (Jul 17 2007). Colon - Endoscopic
Hemostasis of Diverticular Bleed. The DAVE Project. Retrieved Aug, 3, 2010,
from http://daveproject.org/viewfilms.cfm?film_id=63
Urgent Colonoscopy
• Limited high quality evidence of benefit
• Establishes diagnosis earlier, shorter length of
stay
• “Landmark” study supporting urgent colonoscopy
for diverticular bleed published in 2000
– 2 consecutive prospective, non-randomized studies
– Group 1 (n=73): urgent colonoscopy, surgical therapy
– Group 2 (n=48): urgent colonoscopy, endoscopic
therapy
N Engl J Med 2000;342:78
Urgent Colonoscopy
• Group 1: 17 pts with
definite diverticular bleed
– 9 had recurrent/persistent
bleeding
– 6 required emergency
surgery
• Group 2: 10 pts with
definite diverticular bleed
– All 10 patients treated
endoscopically
– 0 had recurrent bleed,
complications, further
transfusions, or surgery
N Engl J Med 2000;342:78
Urgent Colonoscopy
• Two RCTs
published to
date
• Compared
urgent
colonoscopy
(within 8 hours)
vs. standard
management
Standard Management Algorithm
Am J Gastroenterol 2005;100:2395
Urgent Colonoscopy – RCT#1
Definite bleeding source identified
more frequently (42% vs 22%)
But no significant difference in important
outcomes (but underpowered)
Am J Gastroenterol 2005;100:2395
Urgent Colonoscopy – RCT#2
• 85 patients with serious hematochezia
(hemodynamically significant, Hgb drop > 1.5
g/dL, blood transfusion)
• EGD performed within 6 hours
• If EGD negative, randomized to urgent (<12 hr)
or elective (36-60 hr) colonoscopy
• Primary endpoint= further bleeding
Am J Gastroenterol 2010;105:2636
Urgent Colonoscopy – RCT#2
• EGD positive in 15%
• No evidence of improved clinical outcomes
with urgent colonoscopy – but prespecified
sample size not reached
Am J Gastroenterol 2010;105:2636
Urgent Colonoscopy
• In published series, endoscopic therapy is
applied in 10-40% of patients undergoing
colonoscopy for LGIB
• Taken together, evidence suggests that
colonoscopy should be performed within 1224 hours in stable patients
• However, it is unclear how faster timing
affects major clinical outcomes
Radiographic Studies
Tagged RBC scan
• Noninvasive, highly
sensitive (0.05-0.1 ml/min)
• Ability to localize bleeding
source correctly only ~66%
• More accurate when
positive within 2 hours (95100%)
• Lacks therapeutic capability
Coordinate with IR so that positive scan is
followed closely by angiography
Radiographic Studies
Angiography
• Detects bleeding rates of
0.5-1 ml/min
Recommended
• Therapeutic
capability –test for patients with brisk
embolization
with who cannot be stabilized or
bleeding
microcoils, polyvinyl
prepped for colonoscopy
alcohol, gelfoam
(or have bowel
had colonoscopy with failure to
• Complications:
infarction, renal
failure,
localize/treat
bleeding site)
hematomas, thromboses,
dissection
Radiographic Studies
Multi-Detector CT (CT angio)
• Readily available, can be performed in
ER within 10 minutes
• Can detect bleeding rate of 0.5 ml/min
• Can localize site of bleeding (must be
active) and provide info on etiology
• Useful in the actively bleeding but
hemodynamically stable patient
Gastrointest Endosc 2010;72:402
Role of Surgery
• Reserved for patients with life-threatening
bleed who have failed other options
• General indications: hypotension/shock
despite resuscitation, >6 U PRBCs transfused
• Preoperative localization of bleeding source
important
Algorithmic Evaluation of Patient
with Hematochezia
Hematochezia
Assess activity
of bleed
active
inactive
Prep for
Colonoscopy
NG lavage
Positive
EGD
Negative
No risk for UGIB
Risk for
UGIB
negative
Treat lesion
positive
Hemodynamically
stable?
Algorithmic Evaluation of Patient
with Hematochezia
Active Lower GIB
Hemodynamically
stable?
No
Angiography
(+/- Tagged RBC
scan)
Or
Surgery if lifethreatening
Yes
Consider “urgent
colonoscopy” vs.
traditional approach
Take Home Points
• Always get objective description of stool color
(best way – examine it yourself)
• Don’t order guaiac tests on inpatients
• Severe hematochezia can be from UGIB, even
if NG lavage is negative
Take Home Points
• All bleeding eventually stops (and majority of
nonvariceal bleeds will stop spontaneously,
with the patient alive)
• Early resuscitation and supportive care are key
to reducing morbidity and mortality from GIB