C H A P T E R 27 Gastrointestinal Bleeding David A. Meguerdichian | Eric Goralnick PERSPECTIVE most common source of massive UGIB and has a mortality rate of 30%. The latter is caused when an abdominal aortic aneurysm Upper and lower gastrointestinal bleeding (GIB) are defined based or, more commonly, an aortic graft adheres to and erodes through on their location relative to the ligament of Treitz in the terminal a bowel wall. Aortoenteric fistula is a rare but rapidly fatal cause duodenum, so esophagus, stomach, and duodenum origin bleeds of GIB, with the mortality of an untreated fistula of nearly 100%. are upper and all others are lower. Upper GIB (UGIB) mortality Aortoenteric fistula is a primary consideration in patients with rates have remained constant at about 15% over the past 2 decades GIB and known abdominal aortic aneurysms or aortic grafts despite advances in medical therapy, intensive care unit (ICU) until an alternative bleeding source is identified. Prompt surgical management, endoscopy, and surgery. This is most likely due to consultation is warranted when aortoenteric fistula is a likely the increasing proportion of older patients, who may die due diagnosis. to comorbid conditions, and increases in cirrhotic and variceal Finally, in the differential considerations, one must determine patients. The lower GIB (LGIB) mortality rate is approximately whether the blood is actually of GI origin. Epistaxis, dental bleed- 4%. Predictors include age older than 70 years, intestinal ischemia, ing, or red food coloring can mimic the appearance of hemateme- comorbid illness, coagulation defects, transfusion of packed red sis. Bismuth-containing medications and iron supplements can blood cells, and male gender. create melanotic-appearing (but guaiac-negative) stools. Vaginal bleeding, gross hematuria, and red foods (eg, beets) can all be DIAGNOSTIC APPROACH mistaken for hematochezia (Box 27.1). Unless an alternative diagnosis is clearly evident, the appropriate approach is to con- Differential Considerations tinue with the evaluation for GIB. The characteristics of the GIB, age of the patient, and social factors Pivotal Findings can all help determine the cause. UGIB can routinely manifest as bloody or coffee-ground–like vomit termed hematemesis or as The history centers on the GI tract and on the timing, quantity, dark, tarry stools termed melena. In older adults, peptic ulcer and appearance of the bleeding. Relevant comorbid conditions disease, esophagitis, and gastritis account for most cases. Younger should be reviewed as well (Box 27.2). The extent of the history patients typically present with Mallory-Weiss tears, GI varices, and will be dictated by the severity of the complaint and hemodynamic gastropathy (Table 27.1). As a whole, peptic ulcer disease makes stability of the patient on ED arrival. Reviewing the patient’s vital up more than 50% of all acute cases of UGIB seen in the emer- signs, appearance of the stool, and basic laboratory studies will gency department (ED).1 In pediatric patients, gastric and help identify the bleeding source and guide treatment. duodenal ulcers, esophagitis, gastritis, esophageal varices, and Mallory-Weiss tears account for most cases of UGIB, in descend- Symptoms ing order of frequency. LGIB usually produces bright red or maroon blood per rectum, A useful starting point for the emergency clinician is to determine termed hematochezia. LGIB may be classified according to patho- the time of onset, duration of symptoms, and relevant supporting physiologic cause—inflammatory, vascular, oncologic, traumatic, historical facts. Often, the degree of bleeding is better gauged by or iatrogenic. Anorectal sources, such as hemorrhoids, are the assessing symptoms associated with significant intravascular loss, most common causes of LGIB in all age groups. In adults, the such as weakness, shortness of breath, angina, orthostatic dizzi- most common sources of hematochezia are colonic diverticula ness, confusion, palpitations, and report of cool extremities. and angiodysplasia. Other noteworthy causes include colitis Blood loss more than 800 mL will usually result in the onset of caused by ischemia, infection, and inflammatory bowel disease. these complaints, with severe symptoms being described at a Among older patients with cardiovascular disease, ischemic colitis threshold greater than 1500 mL. Such symptoms indicate a as a cause for LGIB has been increasing. Although uncommon, a decreased oxygen-carrying capacity that often accompanies sig- brisk UGIB may present as hematochezia and be mistaken for a nificant blood loss and should prompt a thorough and expeditious bleed from a lower GI source. Up to 14% of bleeds characterized evaluation and resuscitation. as hematochezia are due to such lesions and are associated with The context of the bleeding can help explain its cause. For higher transfusion rates, surgical interventions, and mortality. example, if a patient complains of bright red blood per rectum Major causes of LGIB in children include anorectal fissures and after several days of constipation and straining, that presentation infectious colitis. Bleeding can also be caused by intussusception suggests an anorectal source. Alternatively, a patient with and Meckel’s diverticulum in infants and toddlers. Despite diag- hematemesis after several earlier episodes of retching would lead nostic advances for all ages, the source of GIB is not identified in one to suspect an esophageal tear. Finally, a patient with easy nearly 15% of patients. bruising and recurrent gingival bleeding might suggest an under- Death from exsanguination resulting from GIB is rare. lying coagulopathy. However, there are two causes of GIB that may rapidly cause Efforts should be made to quantify the amount of blood lost death if not recognized and mitigated, esophageal varices and during the bleeding event. Patients may describe the passage of aortoenteric fistula. The former, which typically arises from portal large clots, blood changing the toilet bowl water red, or simply hypertension usually caused by alcoholic cirrhosis, is the single streaks of blood on the toilet paper. The patient’s recollection of 242 Downloaded for Angela Pugliese ([email protected]) at Hosp Henry Ford - Detroit - WE from ClinicalKey.com by Elsevier on July 26, 2017. For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved. CHAPTER 27 Gastrointestinal Bleeding 243 TABLE 27.1 BOX 27.3 Common Causes of Gastrointestinal (GI) Bleeding in Key Historical Information for Patients With Adults and Children Gastrointestinal Bleeds (GIBs) CAUSE ADULTS CHILDREN • Events prior to or leading up to the bleeding episode Common causes Peptic ulcers (gastric more Duodenal ulcers • Severity, frequency, and quantity of the bleeding episode of upper GI than duodenal) Gastric ulcers • Appearance and color of the bleed bleeds Gastric erosion Esophagitis • Medical history, including risk factors for GIB: Esophagogastric varices Gastric erosion • Prior bleeding episodes and any identified source Mallory-Weiss tears Esophageal varices • Medication use that may increase the risk of GIB Esophagitis Mallory-Weiss tears • Social factors that may increase the risk of GIB Gastric cancer • Symptoms patient is experiencing with the bleeding episode Common causes Diverticular disease Anorectal fissure of lower GI Angiodysplasia Infectious colitis bleeds Colitis (inflammatory, Inflammatory bowel infectious, ischemic) disease the bleed and its amount is usually poorly quantified and Anorectal sources Juvenile polyps inaccurate. Neoplasm Intussusception Classifying the blood as hematemesis, melena, or hematochezia Upper GI bleeding Meckel’s diverticulum provides the initial clue to the source of bleeding. Vomiting of fresh blood or blood with the appearance of coffee grounds strongly suggests a UGI source. The passage of melena, dark digested stools, also suggests likely UGIB. In contrast, the presence of hematochezia, bright red or maroon stools, usually signifies BOX 27.1 LGIB. There are exceptions, however. In a hemodynamically unstable patient, bright red blood per rectum can represent brisk Alternative Diagnoses or Mimics of UGIB. Hematemesis rarely can arise from a source in the LGI tract that is proximal to an obstruction. Although the definitive cause Gastrointestinal Bleeding and location of the bleed will usually be determined by the gas- troenterologist, the emergency clinician uses the history to make Melena a reasoned determination of the likely source and help guide the • Ingestion of bismuth medications initial diagnostic evaluation. • Ingestion of activated charcoal Hematemesis • Nasopharyngeal bleeding (eg, nosebleeds, dental bleeding) Relevant Medical History • Ingestion of red drinks or food A review of the patient’s relevant medical history and risk factors Hematochezia for bleeding should note whether a patient has had similar bleed- • Vaginal bleeding ing before and the location of the causative lesion (Box 27.3). This • Gross hematuria • Partially digested red food (eg, red beets, red grapes) is especially important with UGIB because most of these presenta- tions are caused by rebleeding of previously identified sources. Next, identification of relevant comorbid diseases helps risk- stratify these patients in the context of their bleed. Patients with GIB and a history of coronary artery disease, congestive heart failure, liver disease, or diabetes have a higher mortality and BOX 27.2 therefore may require