Gastrointestinal Bleeding – From Causes to Treatment

Gastrointestinal Bleeding – From Causes to Treatment

Gastrointestinal bleeding (GIB) is a condition where blood leaks from blood vessels in the gastrointestinal tract, manifesting as vomiting blood or passing blood in stools. It’s a medical/surgical emergency that requires prompt management.

# Classification of Gastrointestinal Bleeding

GIB is classified based on the location of bleeding:

• Upper GIB: From the angle of Treitz to the duodenal bulb.

• Small bowel GIB: Occult bleeding, difficult to detect.

• Lower GIB: Bleeding in the colon.

# Assessment of Gastrointestinal Bleeding Severity

The severity of GIB is assessed based on the following factors:

• Pulse: Heart rate.

• Blood pressure: Blood pressure.

• Blood loss: Amount of blood lost due to bleeding.

• Systemic symptoms: Dizziness, oliguria, cyanosis, pallor…

• Hematocrit (Hct): The percentage of red blood cells in the blood.

• Hemoglobin (Hb): The concentration of hemoglobin in the blood.

Moderate GIB:

• Pulse: 100-120 beats/minute.

• Blood pressure: 80-90 mmHg.

• Blood loss: 10%-30% (500-1500 ml).

• Systemic symptoms: Dizziness, oliguria, cyanosis, pallor.

• Hct: 20-30%.

• Hb: 2-3 million/mm3.

Early assessment within the first few hours based on:

• Pulse: Heart rate.

• Blood pressure: Blood pressure.

• Level of consciousness: Reflects blood loss, depending on the individual’s constitution.

• Volume of vomitus and stool: Rarely reflects the actual blood loss accurately, unless vomiting or passing blood is witnessed.

# Principles of Gastrointestinal Bleeding Treatment

• Medical resuscitation: General measures (head-down position, oxygen therapy, fasting), fluid resuscitation, medication.

• Diagnostic and therapeutic endoscopy: To determine the cause and control bleeding.

• Indication: Angiography + surgery, depending on the severity and location of bleeding.

Fluid Resuscitation in Gastrointestinal Bleeding

• Basic measure: Establish an IV line as soon as possible, administer LR, 0.9% NaCl, 5% glucose.

• Avoid using hypertonic solutions: 10-30% glucose.

• Blood transfusion: In case of severe GIB.

Purpose of fluid resuscitation:

• Ensure vital signs, avoid tachycardia, hypotension, and drop in blood pressure.

• Don’t raise blood pressure above 140 mmHg (risk of rebleeding).

• Caution: Heart failure, kidney failure, hypertension, chronic anemia.

Blood Transfusion

• Transfuse deficient components: Prioritize packed red blood cells > whole blood.

• In case of severe GIB: Don’t wait for hematological test results, proceed with blood transfusion immediately.

• High-risk patients: >65 years old, coronary artery disease, transfuse blood when Hb < 9g/dl, but not more than 10 g/dl.

• Low-risk patients: Hb < 7g/dl.

Fresh Frozen Plasma Transfusion

• Fibrinogen <1g/L or INR> 1.5: Transfuse 10-15 ml/kg.

• Consider overload: In patients with pre-existing heart disease, elderly individuals.

Platelet Transfusion

• Platelets below 50,000/mm3 AND progressing bleeding.

One platelet concentrate (kit) increases: 30,000-50,000/mm3.

# Gastrointestinal Bleeding Due to Portal Hypertension

• Leading cause of death in patients with cirrhosis: Rupture of esophageal varices (EV).

• Some EV rupture before cirrhosis: 30% of EV will bleed.

• Will bleed < 1 year after diagnosis: High risk of rebleeding.

• Bleeding due to esophageal varices: Mortality rate after 6 weeks is approximately 20%.

• Patients with GIB due to EV: The risk of rebleeding within 1 year is 80%.

# Classification of Esophageal Varices Severity

• Grade I: <5mm, straight, only seen in the distal esophagus.

• Grade II: 5-10mm, tortuous, extending to the middle segment of the esophagus.

• Grade III: > 10mm, occupying almost the entire esophageal lumen.

# Classification of Gastric Varices Severity

• Grade I: <5 mm, looks like gastric mucosa.

• Grade II: 5-10mm, including solitary pseudopolyp.

• Grade III: >10mm, multiple pseudopolyps.

# Management of Gastrointestinal Bleeding Due to Esophageal Varices

• Ensure ABC: Maintain airway, breathing, and circulation.

• Bleeding control: Reduce portal hypertension (PH), endoscopic banding, balloon tamponade.

• Other treatments: Antibiotics to prevent infection, prevention of hepatic encephalopathy, PPI after endoscopic treatment.

Bleeding Control in Gastrointestinal Bleeding Due to Esophageal Varices

• Medical treatment: Reduce PH.

• Endoscopic treatment: Banding, sclerotherapy.

• Balloon tamponade: Temporary bleeding control.

Other Treatments in Gastrointestinal Bleeding Due to Esophageal Varices

• Antibiotics: Prevent infection.

• Prevention of hepatic encephalopathy: Lactulose.

• PPI: After endoscopic treatment.

Fluid Resuscitation in Gastrointestinal Bleeding Due to Esophageal Varices

• Establish 2 IV lines: One dedicated blood line if available.

• If GIB is severe: Request blood immediately.

Things to avoid:

• Transfusing too much blood, increasing PH, increasing the rate of rebleeding and mortality.

In Gastrointestinal Bleeding Due to Esophageal Varices Rupture

• When coagulation factors are present: Adjust coagulation factors, but don’t delay endoscopic procedure.

Bleeding Control Strategy in Gastrointestinal Bleeding Due to Pre-esophageal Varices

• Drugs to reduce PH: Terlipressin, Somatostatin, Ocreotide.

• Endoscopic banding of EV: Banding of esophageal varices.

• Endoscopic sclerotherapy: Sclerotherapy of esophageal varices.

• Balloon tamponade: Tamponade with a balloon for temporary bleeding control.

Drugs to Reduce Portal Hypertension

• Mechanism: Causes splanchnic vasoconstriction, reduces blood flow, reduces PH.

• First-line measure: Control bleeding and rebleeding.

Indication: As soon as GIB due to increased PH is suspected.

Effectiveness: Temporary bleeding control 80%, lasting 3-5 days after diagnosis.

• Terlipressin: 2 mg IV/4h, can be reduced to 1 mg/4h after bleeding control.

• Somatostatin: Bolus 250 ug IV, infusion 250 ug/h.

• Ocreotide: Bolus 50 ug, infusion 50 ug/h.

Note: Ocreotide has a shorter duration of effect compared to Terlipressin and Somatostatin. Ocreotide can be effective in supporting bleeding control after endoscopic treatment.

Endoscopic Bleeding Control in Gastrointestinal Bleeding Due to Esophageal Varices

• < 12h: As soon as possible, as soon as hemodynamic stability is achieved, ideally after blood transfusion.

• Don’t wait for coagulation factor adjustment: Perform endoscopy as soon as hemodynamic stability is achieved.

Evidence of ongoing bleeding:

• Seeing blood actively bleeding from varices.

• Seeing a blood clot attached to the wall of the varices.

• Seeing nipple sign (white nipple due to a clot attached to the vessel wall).

Treatment: EVL (Endoscopic Variceal Ligation) >>>> Sclerotherapy.

NS bleeding control in gastric varices:

• Inject cyanoacrylate glue.

• Especially GEV1: Glue > EVL.

GEV1: Gastric varices of the lesser curvature of the stomach.

GEV2: Gastric varices of the fundus of the stomach.

IGV 1: Solitary gastric varices.

Balloon Tamponade for Bleeding Control

• Temporary bleeding control: Effective in > 80% of cases.

• Multiple complications: Aspiration, displacement, esophageal rupture.

• Should only be used: In cases of massive bleeding, to achieve temporary bleeding control while awaiting other methods.

• No more than 24h.

Blakemore tube: Has 2 balloon tamponade: esophageal balloon 80ml, gastric balloon 140ml.

Linton tube: Has 1 balloon with a volume of 350ml.

Pressure applied to the balloon: P: 35-45 mmHg, monitor every 3h.

Absolute contraindication: Known esophageal stenosis, recent surgery in the cardia region.

Relative contraindication: Respiratory failure, heart failure, arrhythmia, hiatal hernia, uncertain whether bleeding is due to varices rupture, esophageal ulcer due to previous endoscopic treatment (use only the gastric balloon, not the esophageal balloon).

Monitoring: Check balloon pressure every 3h, deflate the esophageal balloon for 5 minutes every 6h.

Bleeding control 24h: Deflate the esophageal balloon, leave in place for 6-12h. If stable, deflate the gastric balloon, leave in place for 6-12h. If stable, remove the balloon. If rebleeding, continue tamponade for another 24h.

Other Treatments in Esophageal Varices

• Antibiotic prophylaxis: Use for 7 days: moloxacine 400mg x2, ciprofloxacine 400mg x2, ceftriaxone 1g (if Child-Pugh B/C).

• Hepatic encephalopathy prevention: Lactulose: 10g/packet x3, adjust to achieve 2-3 bowel movements/day.

# Management of Gastrointestinal Bleeding Not Due to Esophageal Varices

• Ensure ABC: Maintain airway, breathing, and circulation.

• Fluid resuscitation: Fluid resuscitation, blood transfusion.

• Medical treatment: Acid suppression.

• Endoscopic treatment: Bleeding control.

Medical Treatment in Gastrointestinal Bleeding Not Due to Esophageal Varices

• Rationale: The influence of pH on platelet aggregation, the effect of gastric juice on the breakdown of clots.

Role of acid:

• Prevents clot formation.

• Promotes clot breakdown.

• Weaken the protective barrier of mucus/bicarbonate.

Use of acid suppression medications before endoscopy:

• PPI >>>> antiH2.

• Timing: Administer upon admission, if endoscopy is not required urgently.

• Type of medication: Eso, Panto, Ome.

• Route: IV >>> oral.

• Dosage: Bolus 80mg, SE 8mg/h.

• Reassess after endoscopy results.

Forrest

Classification of lesion severity:

• Forrest Ia: Blood spurting, risk of rebleeding is 55%.

• Forrest Ib: Blood oozing, risk of rebleeding.

• Forrest IIa: Visible vessel, risk of rebleeding is 43%.

• Forrest IIb: Attached blood clot, risk of rebleeding is 22%.

• Forrest IIc: Hematin accumulation on the ulcer base, risk of rebleeding is 10%.

• Forrest III: Lesion with no signs of recent bleeding, covered with pseudomembrane, risk of rebleeding is 5%.

Assessment of rebleeding risk:

• High risk: Ia, Ib, IIa, IIb.

• Low risk: IIc, III.

Use of PPI after endoscopy:

• High risk: Endoscopic treatment, high-dose IV PPI (bolus followed by maintenance for 72h).

• Low risk: No endoscopic treatment, and oral PPI.

Endoscopic Intervention Not Due to Esophageal Varices Rupture

• From 12-24h: Except for 2 cases:

• Patients with significant vomiting, hemodynamic instability -> need endoscopy as soon as possible when hemodynamically stable.

• Patients with cardiovascular or respiratory diseases -> can be delayed if pulse, temperature, blood pressure, and SaO2 are stable.

Endoscopic Techniques in Gastrointestinal Bleeding Not Due to Esophageal Varices Rupture

• Sclerotherapy: Local pressure (diluted adrenaline), sclerosis, thrombosis (polidocanol, Ethanolamine), tissue glue (cyanoacrylate, Thrombin, fibrin).

• Heat: Heat, APC, Laser.

• Mechanical: Clip, banding.

• New: Powder hemostatic spray.

Sclerotherapy alone: Doesn’t achieve optimal bleeding control, should be combined with mechanical or heat methods.

Monitoring for Rebleeding in Non-esophageal Varices Rupture

• Glasgow Blatchford score: Higher score, higher risk of rebleeding.

• High Forrest lesions: High risk of rebleeding.

• Endoscopic characteristics: Gastric ulcer along the lesser curvature of the stomach (near the left gastric artery), posterior duodenal ulcer (gastroduodenal artery), large ulcer 1-2 cm (the artery at the base of the ulcer is usually large).

Management of Rebleeding

• Continue medical resuscitation: Fluid resuscitation, fluid resuscitation, blood transfusion.

• Repeat endoscopy: Usually considered first.

If rebleeding occurs or recurs during the second endoscopy:

• Angiography: Less invasive, consider first.

• Surgery:

Absolute indication for surgery:

• Rebleeding with perforation of hollow organs.

• Rebleeding with shock that cannot be controlled with endoscopy and angiography.

• Angiographic failure.

Relative indication for surgery:

• Rare blood type.

• Elderly patients who cannot tolerate prolonged resuscitation.

• Large fluid resuscitation.

• Episodes of hypotension.

Angiography in Rebleeding Not Due to Esophageal Varices Rupture

• Successful bleeding control: 52-98%.

• Reduced rate of rebleeding: 12-20%.

Note: This article is for informational purposes only and should not be considered a substitute for professional medical advice. If you suspect you or a loved one may have gastrointestinal bleeding, please contact a doctor immediately for a timely diagnosis and treatment.