When to be suspicious
- Visible hematemesis, hematochezia, or melena
- Unexplained anemia
- Acute: Normocytic
- Chronic: Microcytic (from iron deficiency)
- Elevated BUN (from reabsorption of RBC breakdown products in GI system)
Upper GI Bleed
- Proximal to ligament of Treitz (at duodenojejunal flexure)
- Hematemesis or melena, can potentially present with hematochezia if bleed is brisk enough (blood acts as an intestinal promotility agent)
- Esophageal varices, Mallory-Weiss or Boerhaave syndromes, gastritis, peptic ulcer disease, etc.
Lower GI Bleed
- Distal to ligament of Treitz
- Melena or hematochezia
- , Malignancy, diverticulosis, angiodysplasia, etc.
- Heyde’s Syndrome: Triad of aortic stenosis, acquired Von Willebrand Syndrome, and GI bleed from angiodysplasia (pathophysiology: Aortic valve induces shearing of Von Willebrand Factor, exposing cleavable sites at which ADAMTS-13 acts upon. This inhibits regulation of angiogenesis as well as the clotting cascade (1))
- Intubate if upper GI bleed with concern for airway protection
- Place 2 large-bore IVs for access
- Resuscitate as needed with IV fluid boluses
- Focused history and physical exam
- History of liver disease?
- Any NSAID or alcohol use?
- On antiplatelets or anticoagulation?
- How much blood lost? Is it dark black or bright red?
- Digital rectal exam (contraindicated only in neutropenia): assessing for melena vs bright red blood, also check for masses and/or hemorrhoids
- CBC (to check hemoglobin and platelet levels)
- CMP (to check for electrolyte/renal abnormalities as a result of fluid loss, also to evaluate for hepatic injury)
- Type and cross
- PT/INR, fibrinogen
- Lactic acid
- Supplement hemodynamics with IV fluid boluses as above
- Transfuse packed red blood cells to keep hemoglobin > 7
- Keep patient NPO
- If able, hold antiplatelets and anticoagulation (obviously, this must be weighed against risks of thrombosis/embolism, will vary patient-to-patient)
- Reverse anticoagulation if necessary/able
- Hold β-Blockers (Tachycardia is often first sign of GI bleed, β-Blockers blunt our ability to evaluate this)
- Start IV pantoprazole 80mg x1, then 40mg BID
- If suspicious of a variceal bleed (upper GI bleed in a patient with cirrhosis), start a continuous octreotide infusion (to divert blood from portal system)
- If an upper GI bleed in a patient with cirrhosis, start prophylactic antibiotics (generally IV Ceftriaxone, but can consider Fluoroquinolones if penicillin allergy) -> Has been shown to decrease infection and mortality rates (2)
- Consult GI for endoscopic evaluation and management
- Theis, S. (2020, July 10). Heyde syndrome. Retrieved March 15, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK551625/
- Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila F, et al. Meta-analysis: antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding – an updated Cochrane review. Aliment Pharmacol Ther. 2011;34(5):509–518.