EM@3AM: GI Bleed

Author: Katharine White, MD (EM Resident Physician, UTSW/Parkland Memorial Hospital) // Edited by: Brit Long, MD (@long_brit, EM Attending Physician, San Antonio, TX) and Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital)

Welcome to EM@3AM, an emDocs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.

With little notice, a patient walks into your ED with a shirt covered in blood. He’s actively vomiting. Your triage nurses quickly get him into a wheelchair and roll him back to one of your critical care booths. You have little time to act to stabilize this critically ill patient.

What’s the diagnosis, and what’s your next step in evaluation and treatment?

Answer: GI Bleed

Gastrointestinal Bleeding:^1,2,3

1. Upper GI bleeding etiologies include peptic ulcer disease (#1 cause), gastritis, esophagitis, esophageal varices, Mallory-Weiss tears, Dieulafoy lesions. Upper GI bleeding can present as either hematemesis or melena. In cases of brisk upper GI bleed, they can present as hematochezia.
   1. Hematochezia can originate from an upper GI source approximately 14% of the time.⁴
2. Lower GI bleeding etiologies include diverticular disease (#1 cause), AVM, colitis, polyps, malignancy. These typically present as hematochezia.

History, history, history when possible: ^1,2

• The importance of reviewing the medication list cannot be overstated: Aspirin, NSAIDs, anticoagulants, and glucocorticoids all increase the risk of bleeding. Medications such as beta-blockers can blunt a tachycardic response.
  • Pay particular attention to agents that can guide your resuscitation. Is the patient on anticoagulants? Is there a reversible agent you can use?
• Assess for risk factors:
  • Smoking History
  • Alcohol Use
• Review the medical history:
  • Does the patient have a history of liver disease? Could this bleeding be a result of esophageal varices?
    • In-hospital mortality rates for any type of GI bleed essentially double in cirrhotic patients.
  • Does the patient have a history of AAA repair? Should aortoenteric fistula be high on your differential?
  • Does the patient have a history of HTN? Is the “normotensive” blood pressure reading on your patient really a relative hypotension?
• Hematemesis vs. coffee-ground emesis. vs. melena
  • Presence of melena and age <50 years old more likely to be upper GI bleed vs. lower GI bleed even in patients without hematemesis.
• Be aware of mimics:
  • Taking iron or bismuth can simulate melena; liquid medications with red dye and different foods (beets) can simulate hematochezia.

Initial Evaluation:^1,2,3

• Initial management is focused on stabilization; As always, begin with your ABCs.
• Airway:
  • Consider endotracheal intubation for patients with ongoing massive hematemesis or signs of impending decompensation.
  • Intubations in this patient population can be complicated by a contaminated airway. Always have at least one (two if possible) suction catheters set up as well as multiple back-up airway modalities.
    • For further reading about the SALAD intubating technique: https://emcrit.org/emcrit/having-a-vomit-salad-with-ducanto/
• Breathing:
  • Provide oxygen support to maintain saturations >93%.
• Circulation:
  • Obtain two large bore IVs.
  • Begin fluid resuscitation with warmed LR/NS while obtaining blood.
  • Transfuse to Hgb 7.
  • Ensure a perfusing BP is reached. Cirrhotics may have a lower baseline BP. Aim for a MAP of 65 mm Hg.
• Don’t forget to expose the patient – look for signs of hepatic disease (spider angiomata, palmar erythema, jaundice, scleral icterus, etc.) and perform a rectal examination to evaluate for rectal bleeding or other obvious sources for hematochezia (hemorrhoids).
• Consult early: ^1,3
  • GI: Consult early for emergent endoscopy which can be both therapeutic and diagnostic.
  • Radiology: consult regarding angiography and radionuclide scans if the patient is stable enough for these modalities.
  • Surgery: consult regarding Emergent Procedures
    • Shunt operations: TIPS
    • Non-shunt operations: esophageal transection, GE junction devascularization
    • Non-variceal bleeding: percutaneous embolization or total gastrectomy
  • Colorectal surgery: consult regarding emergent procedures when suspecting massive lower GI bleed.

Labs and Adjuncts: ^{1, 3}

• If you only get one test, make it a type and screen.
• CBC, CMP, Type and Screen, Coags (PT/INR and PTT).
• Lactate: elevated lactate is a clear predictor of in-hospital mortality.
• BUN/Creatinine can help with diagnosis: BUN:Creatinine ratio >30 suggests UGI source of bleeding.
• EKG to evaluate for silent cardiac ischemia.
• Routine imaging is not needed; avoid studies with barium contrast as they may complicate obtaining angiography/endoscopy in the future.
• For brisk lower GI bleed, CTA can assist in localization and potential intervention for treatment (IR).
• NG-tube placement: can be both therapeutic and diagnostic; however, a negative aspirate does NOT reliably exclude an upper GI source.
  • Maintain NG tube on mild, intermittent suction.

Management:^1,3,5

• A PPI can be administered if gastritis or ulcer is the likely source – i.e. Protonix, 40mg IV.
• In cases of variceal bleedings, permissive hypotension with perfusing BP is advised (excessive transfusion can worsen portal HTN and therefore worsen variceal bleeding).
• Octreotide is recommended (though utility controversial): 50mcg IV bolus followed by 50mcg/hr IV gtt.
• Prophylactic antibiotics have been demonstrated to reduce mortality in the setting of cirrhosis: Ceftriaxone 1g/d IV vs. Ciprofloxacin 400mg IV BID.
• Prokinetics (erythromycin or metoclopramide) may be utilized prior to endoscopy to improve visualization.
• In most GI bleed patients, NPO status will be a given, but don’t forget to make ALL patients with GI-bleed NPO.
• For lower GI bleed with brisk bleeding, Interventional Radiology may assist.
• Balloon Tamponade:
  • A temporizing modality for patients who require transfer to an appropriate institution or who require stabilization prior to endoscopy.
  • Not routinely performed, a “hail-mary” to attempt to save a patient.
  • Multiple options:
    • Sengstaken-Blakemore tube

• • • • 250cc gastric baloon
      • Esophageal balloon
      • Single gastric suction port
    • Minnesota tube
      • As above with an added esophageal suction port

Re-bleeding: ³

• After stabilizing, be alert for re-bleeding. Continuous cardiopulmonary monitoring is essential in this patient population. Consider central venous catheter and arterial line placement in this patient population, as well as serial hemoglobins.

Disposition: ⁶

• Glasgow-Blatchford Bleeding Score (GBS)
  • Aids in determining which patients may be candidates for outpatient management.
    • Hemoglobin
    • BUN
    • Initial Systolic BP
    • Sex
    • HR >100
    • Melena Present
    • Recent Syncope
    • Hepatic Disease History
    • Cardiac Failure Present
  • Any score >0 indicates a need for inpatient management and further evaluation.

Pearls and Pitfalls:

• The GI bleed patient can rapidly decompensate: be vigilant! Establish two large bore IVs as quickly as possible and begin resuscitation early in these patients.
• Your history can aid in the diagnosis as well as therapeutic interventions in these patients- whenever possible, obtain a thorough history directly from the patient, or using family/medical records. This history MUST contain a review of the medication list.
• Secure the airway early- and be prepared for a difficult airway. Always have multiple airway tools at bedside as well as at one to two suction catheters.
• Do not practice on an island- involve your consults early on in the patient’s course.
• Be familiar with your institution’s form of balloon tamponade so you can act quickly in performing this life-saving intervention if necessary.

References:

1. Cline D, Meckler G, Ma OJ et al. Tintinalli’s Emergency Medicine Manual, Eighth Edition. McGraw-Hill Education / Medical; 2017.
2. Stone CK, Humphries R. CURRENT Diagnosis and Treatment Emergency Medicine, Seventh Edition. McGraw Hill Professional; 2011.
3. Parrillo JE, Dellinger RP. Critical Care Medicine, Principles of Diagnosis and Management in the Adult (Expert Consult – Online and Print). Elsevier Health Sciences; 2013.
4. Wilcox CM, Alexander LN, Cotsonis G. A prospective characterization of upper gastrointestinal hemorrhage presenting with hematochezia. Am J Gastroenterol. 1997;92(2):231-5.
5. Winters ME. Emergency Department Resuscitation of the Critically Ill. American College Emergency Physicians; 2011.
6. Chen IC, Hung MS, Chiu TF, Chen JC, Hsiao CT. Risk scoring systems to predict need for clinical intervention for patients with nonvariceal upper gastrointestinal tract bleeding. Am J Emerg Med. 2007;25(7):774-9.