Acute Gastrointestinal Bleeding: in the Clinic

Downloaded From: http://annals.org/ by McGill University, Teresa Rudkin on07/15/2016 Sankey Williams,MD Darren Taichman, MD,PhD Deborah Cotton,MD,MPH Section Editors Jeffrey L.Tokar, MD Meeta PrasadKerlin,MD,MSCE Physician Writers Information andEducationResource) resources ofthe The contentof CME Questions Patient Information Tool Kit Practice Improvement Treatment Presentation andDiagnosis Prevention Bleeding Gastrointestinal Acute In theClinic © 2013 American CollegeofPhysicians judgment. The informationcontainedhereinshould neverbeusedasasubstituteforclinical diagnosis, treatment,andpracticeimprovement ofacutegastrointestinalbleeding. CME Objective: mksap/15/?pr31, andotherresourcesreferencedineachissueof consult http://pier.acponline.org, http://www.acponline.org/products_services/ tent. Readerswhoareinterestedintheseprimaryresourcesformoredetail can ers. Editorialconsultantsfrom Publishing divisionsandwiththeassistanceofsciencewritersphysician writ- from theseprimarysourcesincollaborationwiththeACP’s MedicalEducationand Assessment Program). In theClinic To reviewcurrentevidencefortheprevention, presentationand American CollegeofPhysicians Annals ofInternalMedicine is drawnfromtheclinicalinformationandeducation PIER and MKSAP MKSAP provide expertreviewofthecon- (ACP), including (Medical KnowledgeandSelf- editors develop page ITC2-16 page ITC2-15 page ITC2-14 page ITC2-13 page ITC2-2 page ITC2-7 page ITC2-3 In theClinic PIER In theClinic (Physicians’ . In the Clinic cute gastrointestinal (GI) bleeding is common in both the outpatient setting and the emergency department. Annual U.S. incidence rates over Athe past decade are approximately 90–108 per 100 000 persons (1), lead- ing to approximately 300 000 hospitalizations annually. Most cases are due to nonvariceal sources of bleeding (e.g., peptic ulcers) and continue to be associated

1. Hreinsson JP, Kalaitza- with significant mortality (3–14%) and health economic burden (1–3). The inci- kis E, Gudmundsson dence of nonvariceal bleeding may be decreasing in the West largely because of S, Björnsson ES. Up- per gastrointestinal decreased incidence of Helicobacter pylori infection and increased awareness and bleeding: incidence, etiology and out- implementation of ulcer-prevention strategies in users of nonsteroidal anti- comes in a popula- inflammatory drugs (NSAIDs) (1). However, identifying patients with acute GI tion-based setting. Scand J Gastroen- bleeding who are in danger of serious adverse events and establishing evidence- terol. 2013;48:439-47. [PMID: 23356751] based treatment plans are essential in both primary and specialty care. 2. Yavorski RT, Wong RK, Maydonovitch C, et al. Analysis of 3,294 cases of upper gastrointestinal bleeding in mili- Prevention tary medical facilities. Am J Gastroenterol. Who is at risk for acute GI bleeding? with lower GI bleeding include in- 1995;90:568-73. [PMID: 7717312] Risk factors for acute GI bleeding flammatory bowel disease, infectious 3. Targownik LE, Nabal- vary according to the site and cause. amba A. Trends in colitis, neoplasia, angioectasias, and management and Upper GI bleeding most often re- benign anorectal disease (14). outcomes of acute nonvariceal upper sults from peptic ulcer disease (ap- gastrointestinal bleed- proximately one quarter of all cases), Approximately 10–20% of patients ing: 1993-2003. Clin Gastroenterol Hepatol. the primary risk factors for which with GI bleeding have “obscure” 2006;4:1459-1466. include NSAIDs and H. pylori infec- bleeding, defined as an unknown [PMID: 17101296] 4. McColl KE, el-Nujumi tion and, less commonly, increased cause despite evaluation with esopha- AM, Chittajallu RS, et gogastroduodenoscopy (EGD), al. A study of the gastric acid production (e.g., the pathogenesis of Heli- Zollinger-Ellison syndrome). Smok- colonoscopy, and radiographic small cobacter pylori negative chronic duode- ing (4–6), severe physiologic stress bowel imaging. Approximately half nal ulceration. Gut. (7), and various host factors (e.g., of these patients have recurrent or 1993;34:762-8. [PMID: 8314508] genetic polymorphisms affecting cy- persistent bleeding and are further 5. Kurata JH, Nogawa subclassified as obscure-overt (pas- AN. Meta-analysis of clooxygenase and prostaglandin pro- risk factors for peptic duction) (8, 9) may increase risk for sage of visible blood with melena or ulcer. Nonsteroidal antiinflammatory peptic ulcers even in persons without hematochezia) or obscure-occult drugs, Helicobacter concomitant H. pylori infection or (iron-deficiency anemia and/or posi- pylori, and smoking. J Clin Gastroenterol. NSAID exposure. Although spicy tive for fecal occult blood) (15). 1997;24:2-17. Many such patients have bleeding [PMID: 9013343] foods may cause GI symptoms, there 6. Talamini G, Zamboni are no convincing data that they in- sources in the small intestine, now G, Cavallini G. Antral mucosal Helicobacter crease the risk for peptic ulcers. Oth- sometimes referred to as “mid-GI pylori infection densi- er risk factors for acute upper GI bleeding” (between the ligament of ty as a risk factor of duodenal ulcer. Di- bleeding include varices, esophagitis, Treitz and the ileocecal valve). An- gestion. 1997;58:211- 7. [PMID: 9243115] vascular abnormalities (e.g., angioec- gioectasia is the most common cause 7. Barkun AN, Bardou M, tasias, arteriovenous malformations, of small-bowel bleeding in the West, Pham CQ, Martel M. Proton pump in- Dieulafoy lesions), Mallory–Weiss accounting for 70–80% of cases (16). hibitors vs. histamine tear from protracted vomiting, and 2 receptor antago- Can acute GI bleeding be prevented? nists for stress-related benign and malignant neoplasms mucosal bleeding Prevention of acute GI bleeding de- prophylaxis in critical- (10–13). ly ill patients: a meta- pends on the risk factors and causes. analysis. Am J Gas- Lower GI bleeding, historically de- For example, reducing use of troenterol. 2012;107:507-20. fined as bleeding from a source distal NSAIDs and administering antacid [PMID: 22290403] 8. Arisawa T, Tahara T, to the ligament of Treitz, also results treatment with H2-inhibitors or pro- Shibata T, et al. Asso- from several causes with distinct risk ton-pump inhibitors (PPIs) prevents ciation between genetic polymorphisms factors. Diverticulosis is the most peptic ulcer bleeding. Prophylactic in the cyclooxyge- common cause of hematochezia, ac- acid suppression should be considered nase-1 gene promot- er and peptic ulcers counting for up to half of all cases, in selected hospitalized patients who in Japan. Int J Mol Med. 2007;20:373-8. particularly in patients older than 65 are at increased risk for gastroduode- [PMID: 17671743] years. Other risk factors associated nal ulceration and bleeding, including

Downloaded From: http://annals.org/ by McGill University, Teresa Rudkin on 07/15/2016 patients who are mechanically venti- measures can prevent diverticular lated or who have coagulopathy or bleeding or bleeding related to an- thrombocytopenia, traumatic brain or gioectasias. Although high-fiber diets spinal cord injury, or a history of are often recommended, the role of burns (7, 17). In patients with chronic fiber in the pathogenesis or progres- liver disease, nonselective beta- sion of diverticulosis is debatable. Sur- blockers (such as propanolol or gical intervention for diverticulosis is nadolol) to reduce portal hypertension not routinely done for prevention, be- and endoscopic interventions, such as cause risk for diverticular bleeding is band ligation (18), can effectively pre- low relative to the morbidity of pro- vent variceal bleeding. No specific phylactic surgical resection (19).

Prevention... Risk factors for, and therefore prevention of, acute GI bleeding depends on the site and cause of bleeding. In general, minimizing use and appropriate prescribing of NSAIDs, antiplatelet agents, and anticoagulants, as well as judicious primary and secondary prophylactic acid suppression in selected patients, are effective measures for ulcer-related upper GI bleeding. Nonselective beta-blockers and endoscopic therapy for esophageal and gastric varices are effective for primary and secondary prevention of variceal bleeding. Few measures are helpful in preventing lower GI bleeding, except for reducing exposure to NSAIDS, anticoagulants, and antiplatelets.

CLINICAL BOTTOM LINE

Presentation and What are the symptoms and signs it can occur with small-bowel bleed- Diagnosis of acute GI bleeding? Can they ing and even slowly bleeding right help localize the site of bleeding? colonic lesions. The source of hema- GI bleeding can present with myriad tochezia is usually the colon. Up to signs and symptoms (Table 1). The 10% of upper GI bleeding episodes most indolent forms may present as present with hematochezia, which is 9. Malaty HM, Graham DY, Isaksson I, En- severe anemia. Manifestations include often associated with signs and symp- gstrand L, Pedersen fatigue; dizziness; pallor; and rarely NL. Are genetic influ- toms of hemodynamic instability. ences on peptic ulcer end-organ complications, such as un- dependent or inde- What are the common causes of pendent of genetic stable angina. Brisk bleeding from the influences for Heli- upper or lower GI tract can present upper and lower GI bleeding? cobacter pylori infection? Arch Intern with more specific manifestations, Major causes of GI bleeding are Med. 2000;160:105-9. shown in the Box. Upper GI bleed- [PMID: 10632311] such as visualized blood, syncope, or 10. Boonpongmanee S, other symptoms of hypotension. ing is approximately 5 times as com- Fleischer DE, Pezzul- lo JC, et al. The fre- mon as lower GI bleeding, with quency of peptic ul- Distinguishing between upper and mortality rates of 10%. Upper GI cer as a cause of upper-GI bleeding is lower GI bleeding can help guide ini- bleeding can be classified as non- exaggerated. Gas- tial diagnosis and therapy. Upper GI trointest Endosc. variceal or variceal. 2004;59:788-94. bleeding is more likely to cause nau- [PMID: 15173790] 11. Enestvedt BK, Gral- sea and dyspepsia, whereas lower GI Methods allowing visualization and nek IM, Mattek N, bleeding is more likely to result in al- treatment of lesions deep in the Lieberman DA, Eisen G. An evaluation of tered bowel habits, lower abdominal small intestine have recently been endoscopic indica- tions and findings pain, or rectal discomfort. Hemate- developed. This has led to increasing related to nonva- mesis is exclusive to upper GI bleed- use of the term “mid-GI bleeding” riceal upper-GI hemorrhage in a large ing. Melena, which can be caused by (MGIB) (20). MGIB can present multicenter consor- tium. Gastrointest as little as 50 mL of blood, usually re- with occult bleeding (iron-deficiency Endosc. 2008;67:422- sults from upper GI bleeding; however, anemia and stools positive for occult 9. [PMID: 18206878]

Downloaded From: http://annals.org/ by McGill University, Teresa Rudkin on 07/15/2016 Table 1. History and Physical Examination Elements of Patients with Acute Upper Gastrointestinal Bleeding Category Physical Examination Finding Notes History Hematemesis Indicates bleeding proximal to the ligament of Treitz Melena Should not be confused with dark stool of another etiology (test with guaiac to confirm the presence of blood) Bloody diarrhea 10% of patients will have bleeding sources proximal to the ligament of Treitz Presyncope and/or syncope Indicates loss of significant blood volume Physical examination Hypotension (systolic blood pressure Indicates severe intravascular volume loss (≥50%), 90 mm Hg) assuming normal baseline systolic blood pressures Tachycardia (≥120 beats/min) Indicates severe intravascular volume loss (≥50%) Orthostatic changes in blood pressure Indicates loss of 20–25% of intravascular volume (≥10 mm Hg) or heart rate (≥30/min) Nasogastric aspirate shows blood or Indicates an upper gastrointestinal source of bleeding coffee ground–like material Pallor Subjective/poor indicator without corroborative evidence Perioral telangiectasias Suggestive of hereditary hemorrhagic telangiectasia syndrome Skin abnormalities Stigmata of cirrhosis, pigmented lip lesions, acanthosis nigricans, vascular anomalies

From Bjorkman DJ, Eisen GM. Gastrointestinal bleeding, non-variceal upper. http://pier.acponline.org/physicians/diseases/d184/tables/d184-thp.html. (Date accessed 26 May 2009). PIER. Philadelphia: American College of Physicians; 2009.

blood) or overt bleeding (melena, with acute GI bleeding (e.g., outpa- 12. Longstreth GF. Epi- demiology of hospi- hematochezia). More frequently tient vs. inpatient management) and talization for acute encountered sources of MGIB are upper gastrointesti- provide prognostic information. Pre- nal hemorrhage: a vascular lesions (e.g., angioectasias, dictors of rebleeding risk and mor- population-based study. Am J Gas- Dieulafoy lesions, arteriovenous tality in patients vary according to troenterol. malformations), ulcerating disorders 1995;90:206-10. the cause of bleeding; however, sev- [PMID: 7847286] (e.g., NSAID-enteropathy and in- eral factors portend a poorer prog- 13. Cook DJ, Fuller HD, Guyatt GH, et al. Risk flammatory bowel disease), and neo- nosis. Adverse outcomes have also factors for gastroin- plasms (e.g., neuroendocrine tumors, testinal bleeding in been associated with chronic alco- critically ill patients. GI stromal tumors, lymphoma, and holism and active cancer (22). Canadian Critical primary or metastatic carcinomas). Care Trials Group. N Engl J Med. The International Consensus Upper 1994;330:377-81. The most common source of lower [PMID: 8284001] Gastrointestinal Bleeding Confer- 14. Strate LL. Lower GI GI bleeding is diverticulosis, reflective ence Group advocates use of validat- bleeding: epidemiol- of the high prevalence of this condi- ogy and diagnosis. ed risk-stratification tools to facilitate Gastroenterol Clin tion in the adult population; however, North Am. triage of patients with acute upper 2005;34:643-64. only a few patients with diverticulosis GI bleeding by prognostication based [PMID: 16303575] have diverticular bleeding. Other 15. Rondonotti E, Mar- on risk for poor clinical outcomes mo R, Petracchini M, common causes of lower GI bleeding (e.g., rebleeding, need for emergent de Franchis R, Pen- include colonic polyps, cancer, colitis nazio M. The Ameri- surgery, or mortality) (22). The can Society for Gas- (due to inflammatory bowel disease, trointestinal Rockall scoring system (23) and the infection, or ischemia), vascular Endoscopy (ASGE) Glasgow–Blatchford Scale (24) diagnostic algorithm lesions (angioectasia, radiation procti- for obscure gastroin- (Table 2) are 2 commonly used risk- testinal bleeding: tis), and anorectal sources (hemor- eight burning ques- stratification systems that incorporate tions from everyday rhoids, anal fissures) (21). clinical practice. Dig clinical, laboratory, and/or endoscopic Liver Dis. Can risk for adverse outcomes be parameters. The Glasgow–Blatchford 2013;45:179-85. [PMID: 22921043] predicted in patients with acute and the “Clinical” Rockall stratifica- 16. Pennazio M. Tech- niques in Gastrotin- GI bleeding? Which patients may tion systems are preendoscopic testinal Endoscopy. be evaluated as outpatients, and scoring systems and use clinical and 2012;14:94-99. 17. Alain BB, Wang YJ. which require the emergency laboratory information to help pre- Cushing’s ulcer in traumatic brain in- department or hospitalization? dict the need for hospitalization or jury. Chin J Trauma- Risk stratification can help deter- endoscopic intervention. Additional tol. 2008;11:114-9. [PMID: 18377716] mine the disposition of a patient risk stratification by incorporating

Downloaded From: http://annals.org/ by McGill University, Teresa Rudkin on 07/15/2016 some endoscopic information to the Table 2. Risk Stratification Tools for Major Causes of Clinical Rockall scale leads to the Gastrointestinal Bleeding Full Rockall scale, which helps pre- Upper Gastrointestinal Bleeding dict risk for adverse outcomes from Scoring System Points Inflammatory Peptic ulcer disease acute upper GI bleeding. Additional Rockall Risk: Total score = sum of all category scores; risk category: high (>5), intermediate Esophagitis or esophageal ulceration stratification schemes for upper and (3–4), low (0–2) Diaphragmatic hernia (Cameron lower GI bleeding have been pro- Age, y erosions) posed (25–28). Outpatient manage- >80 2 Inflammatory bowel disease ment may be appropriate for persons 60–79 1 Benign and malignant neoplasms with low risk scores (Rockall score of <60 0 Primary gastrointestinal tract 0–2 or Glasgow–Blatchford score of Shock neoplasms, at any site 0), whereas those with high risk Metastatic deposits in the SBP <100 mm Hg 2 gastrointestinal tract, at any site scores require inpatient care (24, SBP >100 mm Hg 1 Vascular anomalies 29–34). Admission to an intensive No shock 0 Gastroesophageal varices care unit (ICU) should be considered Comorbid conditions Angioectasias for patients with evidence of brisk, Renal failure, liver failure, 2 Dieulafoy lesion active bleeding, such as hemodynam- widespread cancer Gastric antral vascular ectasia (GAVE, ic instability (systolic blood pressure Cardiac failure, ischemic 1 also known as watermelon stomach) [BP] <100 or pulse >100, orthostatic heart disease Radiation proctopathy hypotension, evidence of shock), or No other comorbid conditions 0 Drug-induced other clinical parameters associated Diagnosis on EGD Aspirin with high risk for rebleeding and Upper gastrointestinal cancer 2 Nonsteroidal anti-inflammatory drugs mortality. To date, there are no wide- All other diagnoses 1 Miscellaneous ly accepted validated scoring systems No lesion on EGD 0 Colonic diverticulosis Postpolypectomy specific to acute lower GI bleeding. Stigmata of recent hemorrhage Blood in upper gastrointestinal 2 Mallory–Weiss tear What should the initial diagnostic tract, adherent clot, visible vessel Meckel diverticulum evaluation for possible acute GI No stigmata 0 From Rajan E, Ahlquist D. Gastro- bleeding include? Glasgow–Blatchford: Total score = sum of all intestinal bleeding. In: Dale DC, category scores; a score of zero suggests low risk Federman DD, eds. ACP Medicine, 3rd ed. The initial evaluation of a patient and the safety of outpatient care New York: WebMD; 2007:863. with acute GI bleeding should in- Blood urea nitrogen (mmol/L) clude a focused history and physical >25 6 examination. The history should in- 10–<25 4 clude associated signs and symptoms; 8–<10 3 use of NSAIDs, antiplatelet agents, 6.5–<8 2 18. Garcia-Tsao G, Sanyal AJ, Grace ND, anticoagulants, selective serotonin re- <6.5 0 Carey W; Practice uptake inhibitors, and beta-blockers Hemoglobin (g/dL) Guidelines Commit- tee of the American (because of issues of risk assessment <10 in men and women 6 Association for the Study of Liver Dis- with tachycardia and resuscitation im- 10–<12 in men 3 eases. Prevention and management of plications); prior GI bleeding epi- 10–<12 in women/12–<13 in men 1 gastroesophageal sodes; and comorbid conditions. Vital ≥12 in women or ≥13 in men 0 varices and variceal signs on postural changes should be hemorrhage in cir- SBP (mm Hg) rhosis. Hepatology. assessed, and stool should be exam- <90 3 2007;46:922-38. [PMID: 17879356] ined. Resting hypotension (systolic 90–99 2 19. McGuire HH Jr. Bleed- BP ≤90 mm Hg) or tachycardia ing colonic diverticu- 100–109 1 la. A reappraisal of ≥ ( 120 bpm) indicates severe intravas- >110 0 natural history and ≥ management. Ann cular volume loss ( 50%). An increase Other markers Surg. 1994;220:653-6. of ≥30/min in the pulse or severe [PMID: 7979613] Cardiac failure 2 20. Okazaki H, Fujiwara lightheadedness when rising from a Hepatic disease 2 Y, Sugimori S, et al. Prevalence of mid- supine position also indicates signifi- Presentation with syncope 2 gastrointestinal cant volume loss (35, 36). bleeding in patients Presentation with melena 1 with acute overt Pulse >100/min 1 gastrointestinal Immediate laboratory tests should bleeding: multi-cen- ter experience with include a complete blood count, pro- EGD = esophagogastroduodenoscopy; SBP = 1,044 consecutive thrombin and partial thromboplastin systolic blood pressure. patients. J Gastroen- terol. 2009;44:550-5. times, platelet count, blood type and [PMID: 19360374]

Downloaded From: http://annals.org/ by McGill University, Teresa Rudkin on 07/15/2016 crossmatch in anticipation of blood requirements, rescue surgery, or transfusion, and a routine chemistry mortality (41–43), urgent endoscopy panel. An increased ratio of blood (<12 hours) is indicated in patients urea nitrogen to creatinine (>25:1 if with suspected variceal bleeding (39, in mg/dL) suggests an upper GI 44, 45). It also provides valuable in- source of bleeding (35, 36). formation for appropriate patient 21. Zuckerman GR, Prakash C. Acute triage (see “Can risk for adverse out- lower intestinal Nasogastric or orogastric aspiration comes be predicted in patients with bleeding. Part II: etiology, therapy, and may confirm an upper GI source of acute GI bleeding?”). outcomes. Gastroin- bleeding and provide prognostic test Endosc. 1999;49:228-38. information on bleeding activity and What is the role of prokinetic [PMID: 9925703] medications before upper 22. Barkun AN, Bardou severity. However, the procedure is M, Kuipers EJ, et al. uncomfortable; yields false-negative endoscopy in patients with acute International consensus recommen- results in approximately 15% of GI bleeding? dations on the management of patients patients with active bleeding; and Prokinetic medications (such as with nonvariceal up- although it may lead to earlier per- erythromycin and, to a lesser extent, per gastrointestinal bleeding. Ann Intern formance of endoscopy, it has not metoclopramide) administered Med. 2010;152:101- been proven to improve clinical out- intravenously 20 to 120 minutes be- 13. [PMID: 20083829] 23. Rockall TA, Logan RF, comes (30, 37). Some expert panels fore upper endoscopy has the poten- Devlin HB, Northfield TC. Selection of pa- recommend it in selected patients tial to facilitate clearance of blood tients for early dis- but do not provide selection criteria and clots from the stomach, thus charge or outpatient care after acute up- (22, 38). Others state that it is not improving visualization in patients per gastrointestinal haemorrhage. Na- required in patients with suspected with upper GI bleeding. However, tional Audit of Acute upper GI bleeding for diagnosis, they do not seem to alter important Upper Gastrointesti- nal Haemorrhage. prognosis, visualization, or therapeu- clinical outcomes, including diag- Lancet. 1996;347:1138-40. tic effect (39). As a result, use of gas- nostic rates, need for transfusions or [PMID: 8609747] tric aspiration should be dictated by surgery, or hospital length of stay. 24. Blatchford O, Murray WR, Blatchford M. A institutional preference and practice. Routine use before upper endoscopy risk score to predict is not advocated and should be re- need for treatment for upper-gastroin- When should a gastroenterologist served for patients with red blood testinal haemor- be consulted in the evaluation of rhage. Lancet. hematemesis or blood in the naso- 2000;356:1318-21. acute GI bleeding? gastric aspirate (22, 39, 46). [PMID: 11073021] 25. Saltzman JR, Tabak A gastroenterologist should be con- YP, Hyett BH, et al. A sulted early to consider prompt en- What adjunctive tests can help simple risk score ac- curately predicts in- doscopy for patients with GI bleeding evaluate (and/or treat) patients hospital mortality, with acute GI bleeding without an length of stay, and and to facilitate patient triage. EGD cost in acute upper or colonoscopy or both are the initial identified source on EGD or GI bleeding. Gas- trointest Endosc. diagnostic tests of choice for identifi- colonoscopy? 2011;74:1215-24. Patients without a demonstrable [PMID: 21907980] cation and treatment of specific 26. Strate LL, Orav EJ, bleeding lesions. Clinical presentation bleeding source on good-quality up- Syngal S. Early pre- dictors of severity in dictates which procedures are done. per endoscopy or colonoscopy have acute lower intestin- “obscure” GI bleeding. Small-bowel al tract bleeding. EGD is appropriate for patients with Arch Intern Med. melena and hematemesis and a subset barium radiography, “push” enterog- 2003;163:838-43. [PMID: 12695275] of patients with hematochezia result- raphy, technetium-labeled red blood 27. Strate LL, Saltzman cell scan, and angiography have his- JR, Ookubo R, Mutin- ing from an upper GI source. ga ML, Syngal S. Vali- torically been considered as subse- dation of a clinical In upper GI bleeding, early en- prediction rule for quent diagnostic tests, however with severe acute lower doscopy (within 24 hours of admis- low diagnostic yield. Wireless video intestinal bleeding. Am J Gastroenterol. sion) has a greater impact than capsule endoscopy (VCE) has be- 2005;100:1821-7. delayed endoscopy on some clinical come most gastroenterologists’ test of [PMID: 16086720] 28. Das A, Wong RC. outcomes, such as blood transfusion choice for patients with obscure GI Prediction of outcome of acute GI requirements and hospital length of bleeding. The diagnostic yield ranges hemorrhage: a re- stay (40). Although emergent en- from 30–50% (7); however, no VCE view of risk scores and predictive mod- doscopy (<6–8 hours) does not systems can provide hemostatic inter- els. Gastrointest En- dosc. 2004;60:85-93. seem to further reduce rebleeding, ventions, and many institutions are [PMID: 15229431] hospital length of stay, transfusion unable to perform urgent inpatient

Downloaded From: http://annals.org/ by McGill University, Teresa Rudkin on 07/15/2016 VCE. Another option is angiogra- approximately 50–70% and 25–70% phy, which allows for therapeutic in- of cases, respectively (16). Some cen- tervention (embolization) if a lesion ters offer advanced deep enteroscopic is localized; however, it requires ac- procedures, which are low-risk and tive bleeding to be diagnostic. Com- enable visualization and therapeutics puted tomography angiography or deep within the small intestine, es- 29. Chen IC, Hung MS, computed tomography/magnetic sentially eliminating the need for Chiu TF, Chen JC, resonance enterography are alterna- high-risk intraoperative enteroscopy Hsiao CT. Risk scoring systems to pre- tive diagnostic options that identify for patients with suspected small dict need for clinical intervention for pa- sources of obscure bleeding in bowel pathology. tients with nonvariceal upper gastrointestinal tract bleeding. Am J Presentation and Diagnosis... GI bleeding can present with myriad signs and Emerg Med. 2007;25:774-9. symptoms, ranging from asymptomatic to overt hematemesis or hematochezia, [PMID: 17870480] and can be due to a number of causes virtually anywhere along the GI tract. Ini- 30. Hwang JH, Fisher DA, Ben-Menachem tial evaluation, including history and physical examination and routine laboratory T, et al. The role of tests, can help to narrow the differential diagnosis. endoscopy in the management of acute non-variceal upper GI bleeding. CLINICAL BOTTOM LINE Gastrointest Endosc. 2012;75:1132-8. [PMID: 22624808] 31. Masaoka T, Suzuki H, Hori S, Aikawa N, Hibi T. Blatchford scoring system is a Treatment useful scoring system for detecting patients with upper What interventions should be cardiovascular function, with the goal gastrointestinal started immediately in patients bleeding who do of normal, stable vital signs. not need endoscop- with acute GI bleeding? ic intervention. J Gastroenterol Hepa- Regardless of the source, initial man- Observational studies and small con- tol. 2007;22:1404-8. trolled trials have suggested that blood [PMID: 17716345] agement of a patient with acute GI 32. Srirajaskanthan R, bleeding involves rapid diagnostic as- transfusion to a target helmoglobin Conn R, Bulwer C, Irving P. The Glas- sessment and aggressive resuscitation level of 9–10 mg/dL might actually gow Blatchford scor- be detrimental for some patients with ing system enables with isotonic fluids via 2 large-bore accurate risk stratifi- (18-gauge or larger) peripheral IV hypovolemic anemia, including those cation of patients with upper gastroin- catheters. Early intensive resuscita- with GI bleeding. testinal haemor- tion has been associated with de- rhage. Int J Clin A recent randomized controlled trial (49) Pract. 2010;64:868- creased mortality from GI bleeding 74. [PMID: 20337750] compared a “restrictive” vs. a “liberal” transfu- 33. Stanley AJ. Update (48). The goal of resuscitation is to on risk scoring sys- sion strategy in patients with acute upper GI tems for patients maintain tissue perfusion until bleed- bleeding. The threshold for transfusion of red with upper gastroin- ing resolves spontaneously or is con- testinal haemor- blood cells was a hemoglobin value <7 g/dL rhage [Editorial]. trolled by more definitive therapy. in the restrictive transfusion group (target World J Gastroen- terol. 2012;18:2739- Smaller catheters (e.g., 20- or 22- range, 7–9 g/dL) and 9 g/dL in the liberal 44. [PMID: 22719181] gauge) do not allow rapid fluid ad- transfusion group (target range, 9–11 g/dL). 34. Stanley AJ, Ashley D, Dalton HR, et al. Out- ministration. Longer central venous Overall, the restrictive transfusion strategy patient manage- was associated with a significantly greater ment of patients catheters increase resistance to fluid with low-risk upper- flow, thereby slowing the rate at probability of survival at 6 weeks, lower inci- gastrointestinal dence of further bleeding, fewer adverse haemorrhage: multi- which fluids may be given. Patients centre validation with emesis who are unable to pro- events, fewer total units of blood transfused, and prospective and less need for rescue therapy. Subgroup evaluation. Lancet. tect the airway from aspiration 2009;373:42-7. analysis revealed that the survival advan- [PMID: 19091393] should be intubated. Isotonic IV flu- 35. Cappell MS, Friedel tage of the restrictive strategy was limited to D. Initial manage- ids, such as normal saline or lactated Child–Pugh class A and B cirrhosis (not class ment of acute upper gastrointestinal Ringer solution, should be given im- C). Patients with “massive exsanguinating bleeding: from initial mediately, with the goal of replenish- evaluation up to bleeding,” the acute coronary syndrome, gastrointestinal en- ing intravascular volume as quickly as symptomatic peripheral vasculopathy, doscopy. Med Clin North Am. blood has been lost and as rapidly as stroke, transient ischemic attack, and lower 2008;92:491-509. is tolerated by the patient’s underlying GI bleeding were excluded from the trial, and [PMID: 18387374]

Downloaded From: http://annals.org/ by McGill University, Teresa Rudkin on 07/15/2016 a restrictive transfusion strategy may not be vessels, or active bleeding are associ- applicable to every patient. ated with a high-risk for continued or recurrent bleeding and warrant Although coagulopathy has been pharmacologic treatment and such 36. Zuccaro G Jr. Man- shown to be a risk factor for non- endoscopic interventions as thermal agement of the adult variceal upper GI bleeding, data are patient with acute methods; injection with vasoconstric- lower gastrointestinal limited and conflicting (48, 50, 51). bleeding. American tive agents, such as epinephrine; and College of Gastroen- Acknowledging the paucity of pub- mechanical hemostasis with various terology. Practice Pa- lished data on the topic, the recently rameters Committee. clips or sealants; or some combina- Am J Gastroenterol. published International Consensus tion (53, 54). Strong evidence 1998;93:1202-8. Recommendations advise that [PMID: 9707037] indicates that monotherapy with 37. Huang ES, Karsan S, coagulopathy in patients receiving Kanwal F, et al. Im- epinephrine injection alone is less pact of nasogastric anticoagulants be treated, but that effective than combination therapy lavage on outcomes management should not delay thera- in acute GI bleeding. (injection plus thermal therapy, or Gastrointest Endosc. peutic endoscopy unless the INR is 2011;74:971-80. clips followed by injection) (53, 54). [PMID: 21737077] supratherapeutic (>2.5). Furthermore, 38. Barkun A, Bardou M, Marshall JK; Nonva- this approach should not be general- In patients with peptic ulcer bleed- riceal Upper GI ized to patients with cirrhosis being, PPI therapy (bolus followed by Bleeding Consensus Conference Group. cause the INR, at any threshold, infusion) before endoscopy has been Consensus recom- cannot predict bleeding risk in these mendations for shown to decrease the likelihood of managing patients patients (22). In addition, a systemat- high-risk stigmata on subsequent with nonvariceal upper gastrointestinal ic review of published studies report- endoscopy and to reduce the likeli- bleeding. Ann Intern ed a lack of data on which to Med. 2003;139:843- hood of requiring an intervention 57. [PMID: 14623622] recommend optimal platelet counts during endoscopy. It may also be as- 39. Laine L, Jensen DM. Management of pa- for patients with GI bleeding. Based sociated with shorter length of stay tients with ulcer on expert opinion, they recommend- in the hospital. However, preendo- bleeding. Am J Gas- troenterol. ed targeting values of 50 000/µL in scopic PPI therapy has not been 2012;107:345-60; quiz 361. the absence of platelet dysfunction, shown to reduce mortality or the [PMID: 22310222] or 100 000/µL if functional platelet need for rescue surgery or rebleeding 40. Lin HJ, Wang K, Perng CL, et al. Early dysfunction is suspected (52). rates when endoscopic therapy is or delayed en- consistently delivered (55, 56) (Ap- doscopy for patients How should acute upper GI with peptic ulcer pendix Figure, available at www.an- bleeding. A prospec- bleeding due to peptic ulcer tive randomized nals.org). Thus, preendoscopic PPIs study. J Clin Gas- disease be managed? troenterol. should be considered but should not 1996;22:267-71. The initial diagnostic approach to delay early endoscopy (within the [PMID: 8771420] bleeding peptic ulcers is the same as 41. Sarin N, Monga N, first 24 h) or replace resuscitation Adams PC. Time to for other causes of GI bleeding. En- endoscopy and out- because its effect on outcomes is comes in upper gas- doscopy is nearly 100% specific and minor at best (57). After endoscopy, trointestinal bleed- >90% sensitive; can be done at the ing. Can J hemodynamically stable patients Gastroenterol. bedside in the emergency depart- without serious comorbid conditions 2009;23:489-93. ment, endoscopy unit, or ICU; and [PMID: 19623332] who are found to have low-risk ul- 42. Tai CM, Huang SP, allows biopsy to assess the cause of Wang HP, et al. High- H. pylori cers (e.g., clean-based, flat pigment- risk ED patients with the ulcer (e.g., infection or ed spot) can generally be discharged nonvariceal upper an ulcer within an adenocarcinoma). gastrointestinal early on once-daily oral PPIs (58). hemorrhage under- Endoscopists use the Forrest classifi- going emergency or urgent endoscopy: a cation to describe peptic ulcers and A meta-analysis of randomized trials of retrospective analy- to predict rebleeding risk associated high-dose IV PPI therapy (80 mg bolus then 8 sis. Am J Emerg Med. 2007;25:273-8. with different ulcer appearances. mg/h infusion for 72 h after endoscopic ther- [PMID: 17349900] Approximately 50% of ulcers have an apy) after successful endoscopic therapy for 43. Targownik LE, ulcers in patients with high-risk stigmata (i.e., Murthy S, Keyvani L, appearance associated with a low Leeson S. The role of active bleeding, nonbleeding visible vessel or rapid endoscopy for probability of rebleeding (i.e., clean high-risk patients adherent clot, or Forrest classification IA, IB, with acute nonva- ulcer base or flat pigmented spot in IIa, or IIb) (54, 59) concluded that mortality, riceal upper gas- the ulcer base). Patients with these trointestinal bleed- need for surgery, and rebleeding is reduced ing. Can J ulcers require only pharmacologic (relative risk 0.41, 0.43, and 0.40, respectively) Gastroenterol. 2007;21:425-9. treatment. By contrast, ulcers with compared with endoscopy alone. Another [PMID: 17637943] adherent clots, nonbleeding visible meta-analysis also concluded that for

Downloaded From: http://annals.org/ by McGill University, Teresa Rudkin on 07/15/2016 patients with ulcer bleeding, PPIs reduce re- monitored closely for adverse effects bleeding and need for surgery or repeated of volume replacement, including endoscopic procedures and improve mortal- pulmonary edema. Targeting a ity in the highest–risk patients (59). hemoglobin level between 7–8 g/dL 44. Hearnshaw SA, Lo- might prevent excessive restitution of gan RF, Lowe D, et al. The optimal dose and route of acute Use of endoscopy for blood volume and subsequent in- management of PPI administration remain unclear, acute upper gastroin- but patients with high-risk lesions creases in portal pressure (62). testinal bleeding in the UK: results of a having endoscopic therapy should re- There are no definitive guidelines for nationwide audit. ceive in-hospital therapy (IV, high- Gut. 2010;59:1022-9. management of coagulopathy and [PMID: 20357318] dose therapy remains the regimen 45. Lim CH, Ahmed MM. thrombocytopenia in patients with The optimal timing with the best evidence [22]) for 3 acute variceal hemorrhage. Reversal for urgent en- days, mirroring the period during doscopy in nonva- of coagulopathy requires administra- riceal upper gas- which risk for rebleeding is greatest trointestinal tion of fresh frozen plasma, although bleeding [Letter]. En- (60, 61). In the absence of compara- the volume necessary may be prohibi- doscopy. tive data, a once-daily oral PPI is rec- 2011;43:1018. tive. Recombinant factor VIIa as an [PMID: 22057771] ommended after completion of 72 46. Barkun AN, Bardou alternative means of normalizing the hours of IV therapy (22, 30, 39). M, Martel M, Gralnek prothrombin time has been proposed, IM, Sung JJ. Prokinet- H-receptor blockers are not as effec- ics in acute upper GI but randomized, controlled trials have bleeding: a meta- tive and should not replace PPIs for analysis. Gastrointest not shown a consistent advantage acute management of bleeding ulcers. Endosc. (62). Because prothrombin time–INR 2010;72:1138-45. [PMID: 20970794] How should acute esophageal is not a reliable indicator of the 47. Pasha SF. Diagnostic yield of deep en- variceal bleeding be treated? coagulation status in patients with teroscopy tech- cirrhosis, recommendations regarding niques for small- Acute bleeding from esophageal bowel bleeding and varices is frequently life-threatening management of coagulopathy/throm- tumors. Tech Gastro Endosc. 2012;14:100- because it can be severe, difficult to bocytopenia cannot be made on the 105. basis of available data (63). 48. Baradarian R, Ramd- control, and rarely resolves sponta- haney S, Chapala- neously. It usually occurs in patients madugu R, et al. Ear- Antibiotic prophylaxis reduces infec- ly intensive with end-stage liver disease. Eso- resuscitation of pa- phageal varices are caused by signifi- tious complications and decreases tients with upper rebleeding with acute variceal bleed- gastrointestinal cant portal hypertension; therefore, bleeding decreases ing. A short-term quinolone course mortality. Am J Gas- bleeding occurs under high pressure troenterol. and is often brisk. In addition, pa- (e.g., up to 7 days of norfloxacin or 2004;99:619-22. ciprofloxacin) is recommended. Data [PMID: 15089891] tients have synthetic liver dysfunc- 49. Villanueva C, Colo- from a few studies suggest that cef- mo A, Bosch A, et al. tion and coagulopathy. Under these Transfusion strate- circumstances, acute management triaxione may prevent bacterial infec- gies for acute upper tions better than norfloxacin, and IV gastrointestinal requires rapid and aggressive inter- bleeding. N Engl J ventions, including fluid resuscita- ceftriaxone (1 g/day) may be prefer- Med. 2013;368:11- 21. [PMID: 23281973] tion, bleeding control, and efforts able in patients with advanced cir- 50. Wolf AT, Wasan SK, rhosis and/or in regions with high Saltzman JR. Impact aimed at reducing portal pressures. of anticoagulation prevalence of quinolone-resistant on rebleeding following endoscopic Intravascular volume replacement organisms (62, 64). therapy for nonva- should occur as with any patient riceal upper gas- Variceal bleeding can often be con- trointestinal hemor- with acute GI hemorrhage. Resusci- rhage. Am J tation of patients with end-stage trolled by both medical and endo- Gastroenterol. 2007;102:290-6. liver disease is often difficult due to scopic means. Medical therapy [PMID: 17100959] primarily involves infusion of 51. Shingina A, Barkun hypoalbuminemia and extravasation AN, Razzaghi A, Mar- of fluid from the intravascular space. octreotide, a somatostatin analogue tel M, Bardou M, Gralnek I; RUGBE In- Some experts advocate preferential that causes splanchnic vasoconstric- vestigators. System- use of blood products and albumin tion and reduced portal pressure. atic review: the pre- senting international for intravascular volume resuscita- Numerous trials of octreotide have normalised ratio (INR) as a predictor tion, because crystalloid fluids deliver yielded equivocal results, but it is of outcome in pa- a sodium load to patients who are recommended in combination with tients with upper nonvariceal gastroin- typically already total-body sodium endoscopic therapies to control testinal bleeding. Ali- ment Pharmacol overloaded and tend to eventually variceal bleeding and reduce risk for Ther. 2011;33:1010-8. exacerbate ascites. Patients should be recurrence (18). Octreotide should [PMID: 21385193]

Downloaded From: http://annals.org/ by McGill University, Teresa Rudkin on 07/15/2016 be given as a bolus dose of 50 µg For patients with bleeding gastric followed by continuous IV infusion varices, initial clinical and phar- of 50 µg/hour for a total of 3 to 5 macologic management is similar days, although many experts cur- to that for esophageal varices. rently prefer a 5-day regimen (63). However, decision making regarding definitive treatment options, Endoscopy should be done within particularly for isolated gastric 12 hours in patients with known or varices, is more complex. Band lig- suspected varices who present with ation, injection sclerotherapy, and upper GI bleeding. There are 2 pri- TIPS have been reported and are mary endoscopic interventions: sometimes used in clinical prac- sclerotherapy and band ligation. tice. More recent therapeutic Sclerotherapy involves injection of developments for treatment of a sclerosing agent (e.g., sodium gastric varices include endoscopic morrhuate or ethanolamine) into injection of biological glues and a varices. Band ligation involves radiologic procedure called bal- wrapping elastic bands over the loon-occlusion retrograde transve- varices in the distal esophagus. nous obliteration. Recently, Clinical trials have shown that self-expanding esophageal stents compared with sclerotherapy, band- have been used to staunch bleeding has more prolonged benefit; ing, particularly in refractory lower rates of rebleeding, mortality, cases; however, further studies are 52. Razzaghi A, Barkun and complications (such as needed (63). AN. Platelet transfu- esophageal stricture formation, sion threshold in patients with upper perforation, and mediastinitis); and How should patients with acute gastrointestinal lower GI bleeding from colonic bleeding: a system- reduced need for endoscopic treat- atic review. J Clin ments (65). Thus, band ligation has diverticulosis be treated? Gastroenterol. 2012;46:482-6. become the acute treatment of Initial management of colonic diver- [PMID: 22688143] choice in most institutions. ticular hemorrhage is the same as 53. Barkun AN, Martel M, Toubouti Y, that for other causes of GI bleeding, Rahme E, Bardou M. For patients with variceal bleeding Endoscopic hemo- including fluid resuscitation, blood stasis in peptic ulcer refractory to medical and endoscopic transfusion, and diagnostic testing. bleeding for patients with high-risk le- therapy, balloon tamponade (e.g., Colonoscopy should be done to try sions: a series of with a Sengstaken–Blakemore tube) meta-analyses. Gas- to localize the bleeding, although trointest Endosc. may be used as a temporizing meas- with brisk hemorrhage, localization 2009;69:786-99. ure. The balloons should be inflated [PMID: 19152905] can be difficult due to poor visuali- 54. Laine L, McQuaid KR. for no more than 12 hours. More Endoscopic therapy zation. The timing of the colonos- for bleeding ulcers: definitive treatments include trans- copy remains controversial; however, an evidence-based jugular intrahepatic portosystemic approach based on it is usually done within 12–24 meta-analyses of shunt (TIPS) placement with a hours of presentation with a rapid randomized controlled trials. Clin PTFE stent and surgical interven- colonic preparation that seems to be Gastroenterol Hepa- tions. In patients at high risk for tol. 2009;7:33-47. safe in this setting (66). The most [PMID: 18986845] treatment failure (e.g., Child–Pugh important contribution of colonos- 55. Lau JY, Leung WK, Wu JC, et al. class C score < 14 or class B with ac- copy is usually exclusion of other Omeprazole before tive bleeding), TIPS should be endoscopy in pa- causes. In rare cases, it can also be tients with gastroin- placed within 72 hours (63). Salvage therapeutic if a visible vessel or ad- testinal bleeding. N (rescue) TIPS placement is associat- Engl J Med. herent clot is noted. More typically, 2007;356:1631-40. ed with a high mortality rate. These [PMID: 17442905] however, bleeding occurs from mul- 56. Sreedharan A, Mar- therapies are effective and often tiple sites and may be intermittent, tin J, Leontiadis GI, render surgical interventions unnec- et al. Proton pump so the opportunity for intervention inhibitor treatment essary. Surgical options include por- is limited. Other studies that may initiated prior to endoscopic diagnosis tosystemic shunting, esophageal localize the bleeding include nuclear in upper gastroin- transaction, and liver transplantation. testinal bleeding. imaging and angiography (19). Cochrane Database Mortality approaches 80% for pa- Syst Rev. 2010:CD005415. tients with continued bleeding from Bleeding resolves spontaneously in [PMID: 20614440] esophageal varices. approximately 75% of patients with

Downloaded From: http://annals.org/ by McGill University, Teresa Rudkin on 07/15/2016 diverticular hemorrhage; recurrent How should therapy for acute GI bleeding occurs in 25–35% of pa- bleeding be monitored? tients. If bleeding does not resolve Continued monitoring is required to spontaneously or with angiographic assess whether bleeding has stopped. intervention, surgical resection is Tachycardia may be an early warning the remaining therapeutic option. of recurrent bleeding, followed soon Approximately 20% of patients by hypotension. Hemoglobin levels hospitalized for diverticular bleed- should be checked on a serial basis at ing require surgery. Segmental/ least every several hours initially to subtotal colectomy may be required assess for stability after blood trans- if bleeding can be localized and fusions; levels that do not increase by endscopic therapy is not feasible. It approximately 1 g/unit of transfused may also be necessary if lower GI packed red blood cells may indicate bleeding remains nonlocalizable, ongoing blood loss. Additional blood despite the risk for ongoing bleed- transfusions and diagnostic testing ing (due to failure to resect the ac- (e.g., repeated endoscopy) should be tual bleeding site) and may be considered if the patient has evidence associated with significant morbidi- of ongoing blood loss. Similarly, ty and mortality (67). platelet count and coagulation should be measured serially to assess the What is the role of angiography? need for repeated transfusions. Pa- 57. Barkun AN. Should Angiographic interventions include tients requiring multiple transfusions every patient with suspected upper GI local administration of vasopressin of red blood cells should be moni- bleeding receive a and embolization of the source. Va- proton pump in- tored for hypocalcemia. hibitor while await- sopressin is a potent vasoconstrictive ing endoscopy? [Edi- When should a surgeon be torial]. Gastrointest agent, and local instillation can con- Endosc. trol bleeding in up to 80% of pa- consulted for the management of 2008;67:1064-6. [PMID: 18513549] tients; however, rebleeding occurs on a patient with acute GI bleeding? 58. Gralnek IM, Barkun cessation of the infusion in up to Advances in medical and endoscopic AN, Bardou M. Man- agement of acute 50% of patients. Therefore, vaso- therapies have resulted in fewer pa- bleeding from a peptic ulcer. N Engl J pressin may be most useful as a tem- tients requiring surgery for acute GI Med. 2008;359:928- porizing measure. Although there are bleeding. However, surgical consulta- 37. [PMID: 18753649] 59. Leontiadis GI, Shar- no absolute contraindications, vaso- tion should be considered early in the ma VK, Howden CW. Proton pump in- pressin should be used with caution evaluation and management of pa- hibitor therapy for in patients with coronary artery dis- tients with severe bleeding. Surgery is peptic ulcer bleeding: Cochrane col- ease or peripheral vascular disease be- indicated when life-threatening laboration meta- analysis of cause of the risk for vasoconstriction bleeding continues, hemodynamic randomized con- at sites other than the target lesion. compromise continues despite initial trolled trials. Mayo Clin Proc. Vasopressin can also cause cardiac ar- aggressive resuscitation, or bleeding 2007;82:286-96. rhythmia and hyponatremia. cannot be stopped by endoscopic or [PMID: 17352364] 60. Sung JJ, Barkun A, angiographic means. The choice of Kuipers EJ, Mössner Embolization is a common inter- J, et al. Intravenous surgery depends on bleeding location esomeprazole for vention for control of active hemor- and comorbid conditions. Localiza- prevention of recurrent peptic ulcer rhaging. It involves injection of tion of the bleeding site is critical for bleeding: a random- sealant materials, such as gel foam ized trial. Ann Intern surgical planning. Med. 2009;150:455- or polyvinyl alcohol, or mechanical 64. [PMID: 19221370] What follow-up outpatient 61. Lau JY, Chung SC, devices, such as coils and temporary Leung JW, et al. The balloons. Embolization is effective in evaluations are required in evolution of stigmata of hemorrhage in up to 80% of cases. The primary patients who have experienced bleeding peptic ul- contraindication is poor collateral acute GI bleeding? cers: a sequential endoscopic study. blood supply. The major complica- Specific guidelines for management Endoscopy. 1998;30:513-8. tions are intestinal ischemia and me- of patients after discharge other than [PMID: 9746158] chanical complications of the arterial those addressing secondary prophy- 62. Bari K, Garcia-Tsao G. Treatment of portal cannulation (such as local laxis are lacking. In general, decisions hypertension. World J Gastroenterol. hematoma, arterial dissection, or regarding timing of postdischarge 2012;18:1166-75. pseudoaneurysm). outpatient visits and repeated blood [PMID: 22468079]

Downloaded From: http://annals.org/ by McGill University, Teresa Rudkin on 07/15/2016 work are based on risk-stratification. diverges on this topic, reporting in- Early outpatient evaluation is appro- adequate outcomes and cost- priate for patients with high-risk effectiveness to support use of this endoscopic findings, significant strategy for every patient. Society comorbid conditions, recent severe guidelines advocate an individualized bleeding episode, and those in need approach (68). Surveillance en- of decision-making pertaining to an- doscopy is most appropriate for pa- tiplatelet or anticoagulant medication tients with suspicious ulcers on initial use. Conversely, the remaining low- endoscopy in whom initial biopsies risk patients usually do not require were negative or were not done, per- early outpatient evaluation. Patients sistent symptoms despite a course of should be advised to report symp- antisecretory medications, absence of

63. de Franchis R; toms or signs of recurrent bleeding. a defined cause, or patients from Baveno V Faculty. Re- With the exception of select clinical demographic regions with high inci- vising consensus in portal hypertension: scenarios (see below), empirical re- dence of gastric carcinoma. If H. py- report of the Baveno lori V consensus work- peated or “surveillance” endoscopy is infection has not been assessed shop on methodolo- not required for most patients partic- via prior gastric mucosal biopsies, gy of diagnosis and therapy in portal hy- ularly if the bleeding source is associ- serology, or stool antigen evaluation, pertension. J Hepa- ated with a low-risk for recurrent gastric mucosal biopsies for H. pylori tol. 2010;53:762-8. [PMID: 20638742] bleeding (e.g., Mallory–Weiss tears, testing should be considered. Litera- 64. Fernández J, Ruiz del Arbol L, Gómez C, et postpolypectomy bleeding). ture pertaining to detailed manage- al. Norfloxacin vs ment of patients with H. pylori is ceftriaxone in the prophylaxis of infec- Patients with cirrhosis who survive available (69). Bleeding sources that tions in patients variceal hemorrhage but do not have with advanced cir- may require additional endoscopic rhosis and hemor- further therapy are at significant risk therapy include gastric antral vascular rhage. Gastroen- terology. for rebleeding (60%) and death (ap- ectasia (GAVE, or “watermelon 2006;131:1049-56; proximately 33%) within 1–2 years of quiz 1285. stomach”) and radiation proctopathy. [PMID: 17030175] the initial bleeding episode. These 65. Laine L, Cook D. En- outcomes are improved using com- How long should antisecretory doscopic ligation compared with scle- bined endoscopic variceal band liga- therapy be continued? rotherapy for treatment of esophageal tion and beta-blockers (which are Antisecretory therapy for patients variceal bleeding. A often given once there has been no with small (<1 cm), uncomplicated meta-analysis. Ann Intern Med. evidence of hemorrhage for at least ulcers can usually be discontinued 1995;123:280-7. [PMID: 7611595] 24 hours, barring any contraindica- after 4–6 weeks in the absence of on- 66. Jensen DM, Machi- tions). Patients who have shunt sur- going ulcer-related symptoms. Main- cado GA, Jutabha R, Kovacs TO. Urgent gery or TIPS do not require further tenance therapy should be considered colonoscopy for the diagnosis and treat- preventive measures.The American for higher-risk patients (complicated, ment of severe di- Association for the Study of Liver recurrent, or large ulcers). In patients verticular hemor- H. pylori rhage. N Engl J Med. Disease suggests repeating endoscopy with –associated ulcers, ther- 2000;342:78-82. at 7- to 14-day intervals until eradica- apy is often continued until eradica- [PMID: 10631275] 67. Stollman N, Raskin tion of esophageal varices has been tion of infection is confirmed, or JB. Diverticular dis- H. pylori ease of the colon. achieved (usually requires 2–4 ses- indefinitely if attempts at Lancet. sions); and once varices are eradicat- eradication have failed. Instructions 2004;363:631-9. [PMID: 14987890] ed, repeating endoscopy every 3–6 for patients with alternative causes of 68. Banerjee S, Cash BD, Dominitz JA, et al. months initially to evaluate for recur- bleeding are made on a case-by-case The role of en- rence and need for repeated band lig- basis. doscopy in the management of patients ation (18). Eventually, the interval can with peptic ulcer What instructions do patients disease. Gastrointest be increased to 6–12 months. Endosc. 2010;71:663- require after acute GI bleeding? 8. [PMID: 20363407] For patients that recover from gastric Specific guidelines for management 69. Malfertheiner P, Megraud F, O’Morain ulcer bleeding, surveillance en- of patients after discharge are lacking CA, et al. Manage- ment of Helicobacter doscopy 6 to 12 weeks after the last and should be individualized. Patients pylori infection—- bleeding episode to exclude a non- should be educated regarding the the Maastricht IV/ Florence Consensus healing ulcer (which raises concern signs and symptoms of recurrent Report. Gut. 2012;61:646-64. for cancer) is common in clinical bleeding and the anticipated benefit [PMID: 22491499] practice. However, the literature and duration of targeted therapies.

Downloaded From: http://annals.org/ by McGill University, Teresa Rudkin on 07/15/2016 Patients with bleeding ulcers associat- recommended (70). Similarly, patients ed with H. pylori infection should be with a bleeding ulcer while receiving encouraged to complete a full course low-dose aspirin therapy for second- of H. pylori therapy and to have test- ary prevention of established cardio- ing, such as a urea breath test or vascular disease should resume H. pylori stool antigen assay, to con- therapy as soon as possible after ces- firm successful eradication of the bac- sation of bleeding (within 1 week, teria. For patients suspected of having ideally as early as 3–5 days). Data are NSAID-related ulcer bleeding, dis- less robust for management of aspirin continuation is preferable but some- therapy after acute bleeding when as- times not feasible. If a patient must pirin is being used for primary pre- resume NSAIDs, a cyclooxygenase- vention of cardiovascular events, and 2–selective NSAID at the lowest ef- the risk and benefits must be weighed fective dose plus a daily PPI is on an individual basis.

Treatment... Treatment of GI bleeding is highly dependent on the cause and severity. Initial evaluation and management in all cases should include history and physical examination, with simultaneous stabilization interventions, such as placement of IV ac- cess and IV fluid resuscitation. Emergent endoscopy (e.g., within 6 hours) is rarely indicated, but urgent endoscopy (e.g., within 12 h) in selected circumstances can be considered, and is mandatory if variceal bleeding is suspected. Administering a PPI is warranted in patients with suspected peptic ulcer disease but should not delay endoscopy. Transfusion practices should target a hemoglobin threshold of 7–8 g/dL. Out- patient follow-up should be individualized based on the cause of bleeding and the es- timated risk for rebleeding.

CLINICAL BOTTOM LINE

Practice

What do professional organiz- colonoscopy have been unrevealing, Improvement ations recommend with regard the American Society of Gastroen- to the prevention, diagnosis and terology recommends early evalua- treatment of acute GI bleeding? tion of the small bowel by VCE or The International Consensus Upper angiography, with CT angiography, Gastrointestinal Bleeding Conference CT enteroscopy, and deep entero- Group recommends early risk stratifi- scopy as secondary considerations, cation and early diagnostic endoscopy depending on availability and ex- in most patients with upper GI pertise at the institution. bleeding. What measures do stakeholders The American Society of Gastroen- use to evaluate the quality of care terology recommends early for patients with acute GI colonoscopy for diagnosis of acute bleeding? lower GI bleeding, with angiogra- The Agency for Healthcare Re- phy and tagged red blood cell scan- search and Quality has identified ning in patients with active bleeding mortality rate as the primary quality 70. Kanwal F, Barkun A, indicator for care of patients with Gralnek IM, et al. and nondiagnostic colonoscopies. If Measuring quality of surgical intervention is contemplat- GI bleeding. An expert panel inde- care in patients with nonvariceal upper ed, preoperative localization of pendently developed a list of 26 gastrointestinal quality indicators for non-variceal hemorrhage: devel- bleeding is desirable. opment of an explic- upper GI bleeding, categorized as it quality indicator set. Am J Gastroen- In patients with obscure acute GI preendoscopic, endoscopic, and terol. 2010;105:1710- bleeding in whom EGD and postendoscopic factors (70). 8. [PMID: 20686458]

Downloaded From: http://annals.org/ by McGill University, Teresa Rudkin on 07/15/2016 Downloaded From: http://annals.org/ by McGill University, Teresa Rudkin on07/15/2016 © 2013 AmericanCollegeofPhysicians Bleeding Gastrointestinal Acute Tool Kit In theClinic Rockall scoring system for identifying patients at risk for patientsatrisk foridentifying system scoring Rockall http://pier.acponline.org/physicians/diseases/d184/tables/ Glasgow–Blatchford screening tooltoassessthelikelihood http://pier.acponline.org/physicians/diseases/d184/tables/ andotherstudiesforacuteupperGI List oflaboratory http://pier.acponline.org/physicians/diseases/d184/tables/ Diagnostic Tests andCriteria International consensusrecommendations formanaging http://annals.org/article.aspx?articleid=745521 Clinical Guidelines Patient brochure Collegeof from theAmerican www.gi.org/physician-resources/brochures/ Resources related toGI bleedingfrom theNational www.nlm.nih.gov/medlineplus/spanish/tutorials/ upper www.nlm.nih.gov/medlineplus/tutorials/uppergiendoscopy/ www.nlm.nih.gov/medlineplus/gastrointestinalbleeding.html Patient informationthatappearsonthenextpagefor http://pier.acponline.org/physicians/diseases/d184/d184-pi.html Patient Information PIER moduleongastrointestinal (GI)bleedingfrom the http://pier.acponline.org/physicians/diseases/d184/d184.html PIER Module Consensus documentonconcomitantuseofproton pump http://content.onlinejacc.org/article.aspx?articleid=1143980 of Consensus documentonreducing theGIrisks http://circ.ahajournals.org/content/118/18/1894.full guidelineonthemanagement ofacuteupperand Clinical www.sign.ac.uk/guidelines/fulltext/105/index.html adverse outcome after acute upperGIbleeding. adverse outcomeafter d184-t2.html intervention. medical that apatientwithanacuteupperGIbleedingwillneed d184-t1.html bleeding from PIER. d184-tlab.html published in upper gastrointestinal bleeding,patients withnonvariceal common painmedications, andGIBleeding. (ACG)Gastroenterology onunderstandingulcers, and Spanish. onupperGIendoscopy,interactive tutorial inEnglish Institutes ofHealth’s MedlinePLUS, an including giendoscopy/htm/index.htm htm/index.htm topatients. anddistribution duplication CollegeofPhysicians. American ACCF, ACG, andAHA in2010. inhibitors andthienopyridines, anupdatefrom the Association(AHA)in2008. Heart American FoundationCollege ofCardiology (ACCF), ACG, and antiplatelet therapyandNSAIDusefrom theAmerican NetworkGuidelines in2008. lower GIbleeding from theScottishIntercollegiate ITC2-14 Annals of Internal Medicine of Annals In theClinic in 2010. Annals ofInternal Medicine

6 August2013 In theClinic THINGS YOU SHOULD In the Clinic Annals of Internal Medicine KNOW ABOUT GASTROINTESTINAL BLEEDING

What is gastrointestinal (GI) bleeding? • Bleeding in the digestive tract. • The upper digestive tract includes the esophagus, stomach, and upper portion of the small intestine. • The lower digestive tract includes lower portion of the small intestine, large intestine (also called the colon), and anus. • Most causes of bleeding are curable or controllable, but some may be life-threatening if left untreated. What causes bleeding in the digestive tract? Causes of bleeding in the upper digestive tract include: • Peptic ulcers from Helicobacter pylori infections or long-term use of nonsteroidal anti-inflammatory drugs, such as aspirin and ibuprofen. • Varices (enlarged veins) in the lower esophagus that rupture and bleed. • Tears in the lining of the esophagus or inflammation in the lining of the stomach (gastritis) or esophagus (esophagitis). • Cancerous or noncancerous (benign) growths.

Causes of bleeding in the lower digestive tract include: • Diverticular disease (diverticula are irregular pouch- • Chronic bleeding (light bleeding that continues for a es that develop in the colon wall). long time or starts and stops) may lead to fatigue, • Colitis (inflammation of the colon) or angiodysplasia lethargy, and shortness of breath over time. • Acute bleeding (heavy bleeding) may lead to dizzi- (abnormalities in blood vessels of the intestine). ness or faintness, shortness of breath, abdominal • Hemorrhoids (ruptured veins in the anus or rectum) pain, and shock. or fissures (anal cuts or tears). • Cancerous or noncancerous (benign) growths. How is it treated? What are the signs and symptoms? • Medical imaging techniques, such as endoscopy or angiography, may be used to locate the source of the • Vomiting bright-red blood or vomit that looks like bleeding inside of the digestive tract and to stop the coffee grounds indicates bleeding in upper digestive bleeding. tract. • Surgery may be needed if these interventions do not • Black or tarry stool or stool that contains dark or work. bright red blood indicates bleeding in upper or lower • Your doctor will try to prevent future bleeding by digestive tract. treating the condition that is causing the bleeding. For More Information http://digestive.niddk.nih.gov/ddiseases/pubs/bleeding/ http://digestive.niddk.nih.gov/Spanish/pubs/bleeding/index.aspx Information on bleeding in the digestive tract from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), in English and Spanish.

http://digestive.niddk.nih.gov/ddiseases/pubs/lowergi/Lower_GI _Series_T_508.pdf Information on the lower GI x-rays ordered to help diagnose problems of the large intestine from the NIDDK. Patient Information Patient

Downloaded From: http://annals.org/ by McGill University, Teresa Rudkin on 07/15/2016 CME Questions

1. A 58-year-old man is evaluated in the Which of the following is the most 4. A 78-year-old woman is evaluated in the emergency department for painless appropriate management of this patient? hospital after being admitted 5 days ago bright-red blood per rectum that began A. Banding of hemorrhoids for a 2-week history of abdominal pain 3 hours ago. The bleeding was B. Colonoscopy and nausea. She has also had black, tarry accompanied by syncope. He has a stools for the past 36 hours. On day 1, C. Fiber supplementation without history of rheumatoid arthritis. His esophagogastroduodenoscopy showed a further evaluation current medications are adalimumab, clean-based bleeding gastric ulcer that D. Home fecal occult blood testing methotrexate, and ibuprofen. was positive for Helicobacter pylori On physical examination, temperature is 3. A 60-year-old man hospitalized for infection; the ulcer was treated with 37.2°C (99.0°F), blood pressure is advanced cirrhosis complicated by ascites injection therapy and coagulation 88/58 mm Hg, pulse rate is 132/min, and encephalopathy is evaluated for therapy with probe cautery, and proton- and respiration rate is 24/min. massive hematemesis and hypotension. pump inhibitor therapy was initiated. The Abdominal examination is normal. Rectal The patient’s medications are bleeding did not stop, and esophago- examination discloses bright-red blood in spironolactone, furosemide, and gastroduodenoscopy was repeated on day the rectal vault. Nasogastric tube lactulose. 3 with endoclip therapy. The bleeding aspirate shows no evidence of blood or continued, and the patient has received On physical examination, temperature eight 8 of packed erythrocytes. coffee-ground material. is 35.6°C (96°F), blood pressure is Laboratory studies reveal a hemoglobin 80/50 mm Hg, pulse rate is 146/min, and On physical examination on day 5, ° ° level of 7.3 g/dL (73 g/L). respiration rate is 20/min. The patient temperature is 37.2 C (99.0 F), blood has just vomited red blood and has pressure is 95/50 mm Hg, pulse rate is Emergency intravenous fluid 103/min, and respiratory rate is 16/min. resuscitation is begun. large-volume ascites; the stool is brown and positive for occult blood. Laboratory Rectal examination reveals melanotic Which of the following is the most studies show hemoglobin of 9 g/dL stool. Laboratory studies reveal appropriate diagnostic test to perform (90 g/L), platelet count of 60 000/µL hemoglobin of 10.8 g/dL (108 g/L); all next? (60 × 109/L), and INR of 3. other tests, including coagulation parameters, are normal. A. Colonoscopy In addition to rapid volume resuscitation, B. Tagged red blood cell scan which of the following is the most Which of the following is the most C. Upper endoscopy appropriate management of this patient? appropriate next step in the management D. Video capsule endoscopy of this patient? A. Arteriography A. Bleeding scan 2. A 46-year-old man is evaluated for a B. Esophagogastroduodenoscopy B. Helicobacter pylori eradication 3-week history of painless occasional C. Intravenous nadolol therapy bright-red rectal bleeding. He has no D. Mesocaval shunt C. Intravenous octreotide fatigue, lightheadedness, weight loss, or E. Transjugular intrahepatic D. Surgery abdominal pain. His stools are frequently portosystemic shunt firm, occasionally hard, and there is no change in the frequency or consistency of bowel movements. He has never been screened for colorectal cancer. On physical examination, temperature is 37.2°C (98.9°F), blood pressure is 132/78 mm Hg, and pulse rate is 84/min. Digital rectal examination yields a stool sample that is positive for occult blood; the examination is otherwise normal. Anoscopy reveals a few internal hemorrhoids without active bleeding. Laboratory studies show a blood hemoglobin level of 14 g/dL (140 g/L).

Questions are largely from the ACP’s Medical Knowledge Self-Assessment Program (MKSAP, accessed at http://www.acponline.org/products_services/mksap/15/?pr31). Go to www.annals.org/intheclinic/ to complete the quiz and earn up to 1.5 CME credits, or to purchase the complete MKSAP program.

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