GI Bleed

Links:

Variceal:
Portal Hypertensive Bleeding in Cirrhosis: Risk Stratification, Diagnosis, and Management: 2016 Practice Guidance by the American Association for the Study of Liver Diseases (PDF)

The Role of Transjugular Intrahepatic Portosystemic Shunt (TIPS) in the Management of Portal Hypertension: Update 2009 (PDF)

Prevention and Management of Gastroesophageal Varices and Variceal Hemorrhage in Cirrhosis

Ulcer:
Management of Patients With Ulcer Bleeding

Small Bowel:
ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding

Lower:
ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding

(ESGE Guidelines)

◊ Upper= above Ligament of Treitzà hematemesis, melena

◊ PUD, varices, gastritis, Mallory-Weiss tear, AVM

◊ Lower= below Ligament of Treitzà hematochezia

◊ diverticular, neoplasm, colitis, angiodysplasia

MANAGEMENT

  • Access: 2 large bore (18g or larger) IVs OR cordis
  • Assess severity: tachycardia-> orthostatic hypotension-> hypotension
  • Resuscitate with crystalloid
  • Restrictive red blood cell transfusion strategy that aims for a target hemoglobin between 7 g/dL and 9 g/dL. A higher target hemoglobin should be considered in patients with significant co-morbidity (e. g., ischemic cardiovascular disease) UNLESS ACTIVELY HEMORRHAGING
  • Medications
    • Variceal bleed
      • Keep hemoglobin ~8 g/dL
      • Octreotide gtt (50 µg followed by a continuous infusion of 50 µg/hour)
        splanchnic vasoconstrictor, can consider vasopressin if pt unstable
      • Pantoprazole gtt (80mg then 8mg/hour)
      • SBP prophylaxis (norfloxacin administered orally at a dose of 400 mg BID for 7 days unless area with high resistance rates like ours: ceftriaxone 1g)
    • Other UGIB (e.g. PUD)
      • Pantoprazole gtt (80mg then 8mg/hour), can switch to BID dosing after scope depending on results
      • Erythromycin 250mg given 30–120 minutes prior to endoscopy in patients with clinically severe or ongoing active UGIH

DIAGNOSIS

UGIB: EGD

  • Following hemodynamic resuscitation, ESGE recommends early (≤24 hours) upper GI endoscopy. Very early (< 12 hours) upper GI endoscopy may be considered in patients with high risk clinical features, namely: hemodynamic instability (tachycardia, hypotension) that persists despite ongoing attempts at volume resuscitation; in-hospital bloody emesis/nasogastric aspirate; or contraindication to the interruption of anticoagulation. MOST VARCIEAL BLEEDS REQUIRE ENDOSCOPY ASAP.
  • PPI therapy for patients who receive endoscopic hemostasis and for patients with adherent clot not receiving endoscopic hemostasis. PPI therapy should be high dose and administered as an intravenous bolus followed by continuous infusion (80mg then 8mg/hour) for 72 hours post endoscopy
  • LGIB: Rule out UGIB. Then colonoscopy.
  • If recurrent bleeding and unable to localize source, repeat EGD with push enteroscopy. Then may try arteriography (bleeding rate >/= 0.5 cc/min) or tagged RBC scan (bleeding >/= 0.1 cc/min)

SPECIAL CONSIDERATIONS

  • ESGE recommends aspirin be resumed immediately following index endoscopy if the risk of rebleeding is low (e. g., FIIc, FIII).
  • In patients with high risk peptic ulcer (FIa, FIb, FIIa, FIIb), early reintroduction of aspirin by day 3 after index endoscopy is recommended, provided that adequate hemostasis has been established
  • In the case of failure of this second attempt at hemostasis, transcatheter angiographic embolization (TAE) or surgery should be considered
  • Rescue therapy for variceal hemorrhage should include Blakemore tamponade followed by emergent TIPS
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