GI Bleed

When to be suspicious

• Visible hematemesis, hematochezia, or melena
• Hypotension
• Tachycardia
• 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₎)

Approach

• ABCs
  • 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

• Labs
  • 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

• Management
  • 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

References:

1. Theis, S. (2020, July 10). Heyde syndrome. Retrieved March 15, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK551625/
2. 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.