Handle the gush of upper and lower GI bleeds with ease thanks to Dr. Tanvi Dhere (@DhereMdEmory)! Learn diagnosis, initial management as well as post-procedure management including when to resume anticoagulation and antithrombotic therapy.
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Patients can present with abdominal pain, light-headedness, dark, tarry stool, hematemesis (frank blood or coffee ground emesis). However, dark stools can be misleading and history can help determine if a bleed is not the cause of dark stools. Iron, black licorice or bismuth subsalicylate are substances that can cause dark colored stools. While melena and hematemesis are clear symptoms of a GI bleed, a thorough history can also help narrow the differential for the etiology of the bleed (Wilkins, 2020).
Symptoms include epigastric pain, nausea/vomiting. Reflux symptoms can suggest reflux esophagitis. Weight loss, appetite loss, dysphagia can suggest underlying malignancy (Wilkins, 2020).
Risk factors for peptic ulcer disease (PUD) include NSAIDs, aspirin, OTC pain relievers with high dose aspirin. Variceal bleeds should also be considered–take a thorough history for cirrhosis risk factors (Wilkins, 2020).
Past medical history can reveal other less common causes of bleed. For example, renal disease or aortic stenosis can predispose patients to arteriovenous malformations (AVMs). Similarly, previous abdominal surgeries, specifically upper GI tract surgeries like gastric bypass may result in anastomotic ulcers. History of AAA repair can cause aortoenteric fistulas which can lead to life threatening bleeds. These may present with a self-limited minor GI bleed referred to as a herald bleed prior to presenting with a more catastrophic GI bleed (Jones, 2012).
Once a thorough history is obtained, this can be used to calculate a Glasgow Blatchford score , which is used to determine risk of adverse outcomes in a bleed. A score of zero means low risk for adverse outcomes and a patient with this score can be discharged directly from the emergency department (Laine, 2021). An example of this would be a patient with a clear viral gastroenteritis presentation who has had ongoing non-bloody emesis that eventually becomes bloody but is otherwise stable. This is consistent with a Mallory-Weiss tear. In cases when a patient is discharged home from the emergency department, they should have close follow up.
Guaiac stool tests are more appropriate in the outpatient setting in colon cancer screening in someone who is average risk and should not be used in the inpatient setting. False positives can occur in several instances–epistaxis, and can lead to inadvertent other invasive testing. False negatives may occur with slow bleeds or intermittent bleeds. Not really needed given history yields high positive predictive value in GI bleed (Lee, 2020).
Regarding H. pylori, biopsies are often taken during endoscopy when an ulcer is found. However in active bleeds and PPI use, there can be false negatives. Dr. Dhere recommends outpatient follow up, after the acute ulcer bleed, and consider repeat H.pylori testing if inpatient testing is negative. PPI must be held for at least 2 weeks before a repeat stool H.pylori antigen test. Serum antibody testing should also be avoided (Wang, 2015). If H.pylori testing is positive, documentation of eradication should be performed after completion of treatment to prevent recurrence of ulcer. This is further reviewed on the Curbsiders Episode #322: H. pylori Infection!
While a decreased hemoglobin can solidify concerns for GI bleed, much like history, other labs can help narrow the likely etiology of a bleed. A BUN/Cr ratio of greater than 36 is more suggestive of upper GI bleed than lower GI bleed (Wilkins, 2020). Thrombocytopenia, leukopenia and abnormal coagulation studies may suggest cirrhosis, which may change approach to work-up and initial management compared to PUD.
First step in management is to consider the ABCs. Ensure adequate access with 2 large bore IVs, type and screen, IV fluids if needed. Fluids are indicated in patients with hemodynamic instability. In addition to addressing instability, starting an IV PPI is key–these can help downgrade severity of ulcer bleed and need for intervention (Wilkins, 2020).
PPIs can also be beneficial in non-ulcer related upper GIB causes by increasing the pH and increase clotting ability as a result. Notably, there does not appear to be a difference in outcomes between continuous drip of PPI versus intermittent bolus dosing (BID) of 80mg (Laine, 2021).
In patients who have a suspected bleeding peptic ulcer, endoscopy is recommended within 24 hours of presentation. If the patient is hemodynamically unstable, endoscopy should take place sooner once the patient is stabilized.
Consideration for administering IV erythromycin prior to the procedure should be made. Erythromycin is a pro motility agent and can help empty the stomach of blood debris/clot to improve endoscopic visualization (Laine, 2021).
Patients with cirrhosis who present with suspected variceal bleeds, initial management should include octreotide and prophylactic antibiotics. Mortality in such cases is as high as 20%. For this reason, Dr. Dhere recommends endoscopy within 12 hours after adequate resuscitation.
In the Villanueva study in 2013, outcomes in patients with more restrictive strategies had better outcomes than those with liberal transfusion thresholds. Specifically, the target hemoglobin is a hemoglobin of 7 g/dL. This study did not include patients with massive hemorrhage or patients with cardiovascular events within 90 days of the bleed (Villanueva, et al 2013).
Patients with underlying cardiovascular disease, the threshold is more liberal to a hemoglobin of 8g/dL (Laine, 2021). While the Villanueva study excluded active coronary disease only, Dr. Dhere recommends a higher threshold in any patient with significant coronary history.
Management following endoscopy depends on if there was an intervention during the endoscopy. Interventions are performed when there is an active bleed or exposed blood vessel. The interventions can include injection of epinephrine followed by cautery. In cases where intervention is performed, it is recommended that the patient remain on IV PPI twice a day for another 72 hours. If a patient has a clean-based ulcer, PPI can be switched from IV to oral. (Laine, 2021)
The duration of PPI course depends on the location of ulcers. Dr. Dhere recommends 8-12 weeks for patients with gastric ulcers and 4-8 weeks for duodenal ulcers. She also says this may change if a patient has other risk factors for peptic ulcers. For instance, if they are unable to stop using NSAIDs or require aspirin or anticoagulation, PPI should be used indefinitely. Similarly, if no clear risk factor or etiology is identified, PPI is also recommended indefinitely.
According to Dr. Dhere, the need for repeat endoscopy depends on the kind of ulcer. Gastric ulcers in particular should have repeat EGD as they can be malignant. In duodenal ulcers, malignancy is less likely so repeat scope is only indicated in patients with ongoing symptoms.
It can be difficult to determine when to resume anticoagulation and/or antithrombotic therapy in patients with upper GI bleed as there is limited data. Expert opinion suggests that for patients on AC for atrial fibrillation, it should be resumed 7 days after bleed if possible. For higher risk conditions, it should be done sooner. For patients with CAD, aspirin should be resumed immediately after endoscopic intervention. (Wilkins, 2020)
Listeners will develop a framework to approach evaluation and management of GI bleeds.
After listening to this episode listeners will…
Dr. Dhere reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
Dhere T, Trubitt ME, Amin M. “355 GI Bleed”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list September 19, 2022.
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Outstanding review! Is there any role for adding sucralfate to PPI for gastric or duodenal ulcer? At my hospital, general surgeons perform the bulk of our endoscopy and typically add sucralfate to the PPI. Although I'm familiar with head to head comparisons favoring PPI over sucralfate, I'm not aware of trials comparing combination to PPI only. I usually end up stopping the sucralfate since my patients don't like the frequency or, depending on the preparation, the cost.
Pre-endoscopic PPI therapy was not recommended in the ACG guideline from 2021 on upper GI bleeding. They report a paucity of evidence supporting it and the evidence was poorly designed. Not sure how to handle this as its seems pretty much SOC to do this. https://journals.lww.com/ajg/Fulltext/2021/05000/ACG_Clinical_Guideline__Upper_Gastrointestinal_and.14.aspx?context=LatestArticles
What is the mortality rate of patients that come to the Ed with an Acute Gi bleed and are hospitalized?
Hi! Great question. The number varies as underlying cause of the bleed is elucidated. For example, variceal bleed being higher mortality than gastritis. Additionally, mortality goes up with increasing co-morbidities. For UGIB, they have asked the question using observational studies, so not very robust data, but that rate is ~10%. For LGIB, similar data but rate is lower at < 4%.