Gastrointestinal Bleeding

Gastrointestinal bleeding is divided anatomically into:

UGIB makes up 80% of all gastrointestinal bleeding and is much more likely to require procedural intervention.

Upper GI Bleeding
Intraluminal bleeding proximal to the ligament of Treitz, from:
- Oesophagus
  - Varices
    Abnormally dilated veins at the junction of the portal and systemic venous systems.
    - Mallory-Weiss tears
      5-15% of cases.
  - Oesophagitis
- Stomach
  - Ulcers
    ~15% of cases. Acute stress ulceration may occur after gastric hypoxia or hypopefusion in the critically unwell.
  - Varices
  - Gastritis
  - Portal hypertensive gastropathy
- Duodenum
  - Ulcers
    ~60% of cases.
  - Duodenitis
Lower GI bleeding
Intraluminal bleeding occurring distal to the ligament of Trietz, from:
- Small bowel
  - Angiodysplasia
  - AVM
  - Meckel’s Diverticulum
- Colon
  - Diverticular bleeding
    Most common cause, resolves spontaneously in >75% of cases.
  - Ischaemic colitis
  - Post-polypectomy bleeding
  - Polyps
  - Carcinoma
  - Radiation enteropathy
  - IBD
- Rectum
  - Carcinoma
  - Haemorrhoids
  - Anal fissure

Epidemiology and Risk Factors

Risk factors include:

Critical illness
- Acute stress ulceration in 8-45% of ICU patients

Pathophysiology

Aetiology

Clinical Manifestations

Features due to:

Pain is less commonly a feature with ulcers in the elderly and NSAID users.

Melaena describes black tarry stools and suggests UGIB. Haematochezia describes bright red or maroon blood and suggests LGIB.

Bleeding
- Haematemesis
  Bright red haematemesis suggests active oesophageal, stomach, or upper duodenal bleeding.
- Pain
- Vomiting
  History of vigorous vomiting prior to onset of bleeding suggests a Mallory-Weiss tear of oesophageal varicies.
Hypovolaemia
- Tachycardia
- Tachypnoea
- Hypotension
- Impaired organ perfusion
  - Anxiety
  - Confusion
  - Oliguria

Severe UGIB indicated by:

SBP <100mmHg
Transfusion >4 PRBC in 12 hours
Frank haematemesis
Syncope

Diagnostic Approach and DDx

Investigations

Bloods:

FBE
Coagulation screen
LFTs

Radiology:

Angiography
Usually performed as part of interventional embolisation strategy, but can identify bleeding points for subsequent intervention.

Management

If intubation is required, ensure adequate volume resuscitation prior to induction due to the risk of profound haemodynamic instability.

Anaesthetic considerations and management is covered under Endoscopy.

Resuscitation:

Note that overresuscitation may lead to increased portal venous pressure and should be avoided.

A
- Definitive airway if airway compromised
  Very high aspiration risk.
C
- Wide-bore IV
- Volume resuscitation
  - MTP
H
- Urgent crossmatch

Specific therapy:

The majority of patients with UGIB will stop bleeding spontaneously and not require procedural intervention. The overwhelming majority of patients with LGIB will stop bleeding prior to any intervention.

Pharmacological
- Cease anticoagulation
- Cease NSAID
- Acid suppression
  Inadequate without endoscopic control in severe or persistent bleeding. No evidence to support use pre-endoscopy, but decreased rebleeding and repeated endoscopy when used post-bleeding.
  - PPI
  - H₂-antagonist
- For variceal bleeds:
  - ↓ Portal pressure
    - Vasopressin
      - May precipitate hypertension and cardiac ischaemia
    - Terlipressin
      Preferable to vasopressin due to ↓ cardiac side effects. Improves haemostasis and mortality in variceal bleeding.
    - Octreotide
      ↓ Portal blood flow, no demonstrated mortality improvement.
  - Propranolol
    Secondary prevention of variceal bleeding.
  - Antibiotics
    High risk of concomitant (or precipitating) infection in variceal bleeds. Consider:
  - Ceftriaxone 1g IV daily
  - Ciprofloxacin 500mg PO BD
Procedural
- Balloon tamponade
  Insertion of a gastric-oesopahgeal balloon which is placed to provide balloon tamponade feeding veins. Used only in extremis to provide control of bleeding.
- Endoscopy
  Gold standard of treatment for severe bleeding, or patients with rebleeding.
  - Early (<24 hours) associated with:
    - ↓ Transfusion
    - ↓ Rebleeding
    - ↓ Open surgical risk
    - ↓ Length of stay
  - Therapeutic options include:
    - Dilute adrenaline injection
    - Cauterisation
    - Stapling of ulcer
      ↓ Risk of perforation compared with cauterisation.
    - Variceal band ligation
      Rubber bands used to strangle varices, to decrease future risk of bleeding.
  - Repeat endoscopy should be performed if initial endoscopy suboptimal
- Embolisation
  - Effective at achieving immediate haemostasis
  - Small risk of gut ischaemia and rebleeding
  - Useful in patients at high surgical risk
- Surgical bowel resection
  Largely superseded by endoscopy but has a role in:
  - Massive transfusion with ongoing haemodynamic instability
  - Recurrent bleeding despite initial endoscopic success
  - Arterial bleeding not controlled by endoscopic haemostasis
  - GI perforation
- TIPS
  Indicated in variceal bleeding refractory to control by all other methods. Results in:
  - Significantly decreased portal venous pressure and variceal bleeding
  - Hepatic encephalopathy in 60%

Urgent endoscopy is preferable for suspected ulcer bleeding; haemodynamically stable suspected variceal bleeding is appropriate to defer until the next elective list.

Disposition:

Consider H. Pylori eradication
- More effective than acid suppression

Marginal and Ineffective Therapies

Complications

Death
4-10% of cases.
A
- Aspiration

Prognosis

Poor prognostic factors include:

Inpatient
Age >60
CLD
Portal hypertension increases size and bleeding rate of varices.
Known varices
Haemodynamic instability