Practical Approach to

Acute Gastrointestinal
Bleeding
Christopher S. Huang MD
Assistant Professor of Medicine
Boston University School of Medicine
Section of Gastroenterology
Boston Medical Center

Learning Objectives
UGIB
Nonvariceal (PUD) and variceal
Resuscitation, risk assessment, pre-endoscopy
management
Role of endoscopy
Post-endoscopy management

LGIB
Risk assessment
Role and timing of colonoscopy
Non-endoscopic diagnostic and treatment
options

Definitions
Upper GI bleed
arising from the
esophagus, stomach, or
proximal duodenum
Mid-intestinal bleed
arising from distal
duodenum to ileocecal
valve
Lower intestinal
bleed arising from
colon/rectum

Stool color and origin/pace of

bleeding
Guaiac positive stool
Occult blood in stool
Does not provide any localizing information
Indicates slow pace, usually low volume bleeding

Melena
Very dark, tarry, pungent stool
Usually suggestive of UGI origin (but can be small
intestinal, proximal colon origin if slow pace)

Hematochezia
Spectrum: bright red blood, dark red, maroon
Usually suggestive of colonic origin (but can be
UGI origin if brisk pace/large volume)

Case Vignette CC:

68 yo male presents with a chief
complaint of a large amount of
bleeding from the rectum

Case Vignette - HPI

Describes bleeding as large volume,
very dark maroon colored stool
Has occurred 4 times over past 3
hours
He felt light headed and nearly
passed out upon trying to get up to
go the bathroom

Case Vignette - HPI

Denies abdominal pain, nausea,
vomiting, antecedent retching
No history of heartburn, dysphagia,
weight loss
No history of diarrhea or
constipation/hard stools
No prior history of GIB
Screening colonoscopy 10 years ago
no polyps, (+) diverticulosis

Case Vignette PMHx, Meds

Hepatitis C
CAD h/o MI
PVD
AAA s/p elective
repair 3 years ago
HTN
Hypercholesterole
mia
Lumbago

Medications:

Aspirin
Clopidogrel
Atorvastatin
Atenolol
Lisinopril

Case Vignette Physical

Exam
Physical examination:
BP 105/70, Pulse 100, (+) orthostatic
changes
Alert and mentating, but anxious appearing
Anicteric
Mid line scar, benign abdomen, nontender
liver edge palpable in epigastrium, no
splenomegaly
Rectal examination no masses, dark
maroon blood

Case Vignette - Labs

Labs
Hct 21% (Baseline 33%)
Plt 110K
BUN 34, Cr 1.0
Alb 3.5
INR 1.6
ALT 51, AST 76

Initial Considerations
Differential diagnosis?
What is most likely source?
What diagnosis can you least afford to miss?

How sick is this patient? (risk

stratification)
Determines disposition
Guides resuscitation
Guides decision re: need for/timing of
endoscopy

Differential Diagnosis
Upper GIB

Peptic ulcer disease

Most
commo
Gastroesophageal varices
n
Erosive esophagitis/gastritis/duodenitis
Mallory Weiss tear
Vascular ectasia
Neoplasm
Dieulafoys lesion
Rare, but
cannot afford to
Aortoenteric fistula
miss
Hemobilia, hemosuccus pancreaticus

Differential Diagnosis
Lower GIB

Most common
diagnosis

Diverticulosis
Angioectasias
Hemorrhoids
Colitis (IBD, Infectious, Ischemic)
Neoplasm
Post-polypectomy bleed (up to 2
weeks after procedure)
Dieulafoys lesion

History and Physical

History

Physical Examination

Localizing symptoms
History of prior GIB
NSAID/aspirin use
Liver disease/cirrhosis
Vascular disease
Aortic valvular disease,
chronic renal failure
AAA repair
Radiation exposure
Family history of GIB

Vital signs, orthostatics

Abdominal tenderness
Skin, oral examination
Stigmata of liver disease
Rectal examination
Objective description of
stool/blood
Assess for mass,
hemorrhoids
No need for guaiac test

History and Physical

History

Physical Examination

Localizing symptoms
History of prior GIB
NSAID/aspirin use
Liver disease/cirrhosis
Vascular disease
Aortic valvular disease,
chronic renal failure
AAA repair
Radiation exposure
Family history of GIB

Vital signs, orthostatics

Abdominal tenderness
Skin, oral examination
Stigmata of liver disease
Rectal examination
Objective description of
stool/blood
Assess for mass,
hemorrhoids
No need for guaiac test

Take Home Point # 1

Always get objective

description of stool
Avoid noninformative terms such
as grossly guaiac positive

Take Home Point #2

If you need a card to tell you

whether theres blood in the
stool, its NOT an acute GIB

Narrowing the DDx: Upper or Lower

Source?
Predictors of UGI source:
Age <50
Melenic stool
BUN/Creatinine ratio
If ratio 30, think upper GIB

J Clin Gastroenterol 1990;12:500

Am J Gastroenterol 1997;92:1796
Am J Emerg Med 2006;24:280

Utility of NG Tube
Most useful situation: patients with severe
hematochezia, and unsure if UGIB vs. LGIB
Positive aspirate (blood/coffee grounds) indicates
UGIB

Can provide prognostic info:

Red blood per NGT predictive of high risk
endoscopic lesion
Coffee grounds less severe/inactive bleeding

Negative aspirate not as helpful; 15-20% of

patients with UGIB have negative NG aspirate
Ann Emerg Med 2004;43:525
Arch Intern Med 1990;150:1381
Gastrointest Endosc 2004;59:172

Take Home Point #3

Upper GI bleed must still be
considered in patients with
severe hematochezia, even
if NG aspirate negative

Initial Assessment
Always remember to assess A,B,Cs
Assess degree of hypovolemic shock

Resuscitation
IV access: large bore peripheral IVs best
(alt: cordis catheter)
Use crystalloids first
Anticipate need for blood transfusion
Threshold should be based on underlying condition,
hemodynamic status, markers of tissue hypoxia
Should be administered if Hgb 7 g/dL
1 U PRBC should raise Hgb by 1 (HCT by 3%)
Remember that initial Hct can be misleading (Hct
remains the same with loss of whole blood, until reequilibration occurs)

Correct coagulopathy

Resuscitation
IV access: large bore peripheral IVs best
(alt: cordis catheter)
bleed
Time
Use crystalloids
first
Anticipate need for bloodIVFs
transfusion
40%

20%
Threshold should be40%
based on underlying
condition,
hemodynamic status, markers of tissue hypoxia
Should be administered if Hgb 7 g/dL
1 U PRBC should raise Hgb by 1 (HCT by 3%)
Remember that initial Hct can be misleading (Hct
remains the same with loss of whole blood, until reequilibration occurs)

Correct coagulopathy

Transfusion Strategy
Randomized trial:
921 subjects with severe acute UGIB
Restrictive (tx when Hgb<7; target 79) vs. Liberal (tx when Hgb<9; target 911)
Primary outcome: all cause mortality
rate within 45 days

NEJM 2013;368;11-21

Restrictive Strategy
Superior
Restrictive

Liberal

P value

Mortality rate

5%

9%

0.02

Rate of further
bleeding

10%

16%

0.01

Overall
complication
rate

40%

48%

0.02

Benefit seen
primarily in Child
A/B cirrhotics

NEJM 2013;368;11-21

Resuscitation
IV access: large bore peripheral IVs best
(alt: cordis catheter)
Weigh risks and
Use crystalloids first
benefits of reversing
Anticipate need for bloodanticoagulation
transfusion
Threshold should be based on
underlying
Assess
degreecondition,
of
hemodynamic status, markers
of tissue hypoxia
coagulopathy
Should be administered if Hgb 7 g/dL
Vitamin
K by
slow
acting,
1 U PRBC should raise Hgb by
1 (HCT
3%)
long-lived
Remember that initial Hct can
be misleading (Hct
remains the same with loss of whole blood, until reFFP fast acting, short
equilibration occurs)

Correct coagulopathy

lived
- Give 1 U FFP for
every 4 U
PRBCs

Resuscitation
Early intensive resuscitation
reduces mortality
Consecutive series of patients with
hemodynamically significant UGIB
First 36 subjects = Observation Group (no
intervention)
Second 36 subjects = Intensive
Resuscitation Group (intense guidance
provided) goal was to decrease time to
correction of hemodynamics, Hct and
coagulopathy
Am J Gastroenterol 2004;99:619

Early Intensive
Resuscitation Reduces UGIB
Mortality

Intervention: Faster correction of

hemodynamics, Hct and coags.
Time to endoscopy similar

(groups are essentially the same)

Am J Gastroenterol 2004;99:619

Early Intensive
Resuscitation Reduces UGIB
Mortality

Observation
group
5 MI
4 deaths

Intense
group
2 MI
1 death
(sepsis)
Am J Gastroenterol 2004;99:619

Causes of Mortality in
Patients with Peptic Ulcer
Bleeding
Patients

rarely bleed
to death
Prospective
cohort study
>10,000 cases
of peptic ulcer
bleed
Mortality rate
6.2%
80% of
deaths not
related to
bleeding

Am J Gastroenterol 2010;105:84

Causes of Mortality in
Patients with Peptic Ulcer
Bleeding
Most common
causes of nonbleeding mortality:
Terminal malignancy (34%)
Multiorgan failure (24%)
Pulmonary disease (24%)
Cardiac disease (14%)

Am J Gastroenterol 2010;105:84

Take Home Point #4

Early resuscitation and
supportive measures are
critical to reduce mortality
from UGIB

Risk Stratification
Identify patients at high risk for
adverse outcomes
Helps determine disposition (ICU vs.
floor vs. outpatient)
May help guide appropriate timing of
endoscopy

Rockall Scoring System

Validated predictor of mortality in patients
with UGIB
2 components: clinical + endoscopic
Variable

Age

<60

60-79

80

Shock

No
SBP 100
P<100

TachySBP 100
P>100

Hypotensio
nSBP <100

Comorbi
dity

No major

Cardiac
failure,
CAD, other
major

Renal
failure,
liver
failure,
malignanc
Gut 1996;38:316
y

Clinical Rockall Score

Mortality Rates

AIMS65
Simple risk score that predicts inhospital mortality, LOS, cost in
patients with acute UGIB

Gastrointest Endosc
2011;74:1215

AIMS65

Gastrointest Endosc
2011;74:1215

Blatchford Score
Predicts need
for endoscopic
therapy
Based on
readily
available
clinical and
lab data
Can use
UpToDate
calculator
Lancet
2000;356:1318

Blatchford Score

Gastrointest Endosc
2010;71:1134

Blatchford Score
Most useful for safely discriminating low
risk UGIB patients who will likely NOT
require endoscopic hemostasis
Fast track Blatchford patient at low risk
if:

BUN < 18 mg/dL

Hgb > 13 (men), 12 (women)
SBP >100
HR < 100

Pre-endoscopic
Pharmacotherapy
For Non-Variceal UGIB
IV PPI: 80 mg bolus, 8 mg/hr drip
Rationale: suppress acid, facilitate clot
formation and stabilization
Duration: at least until EGD, then based
on findings

Pre-endoscopy PPI
Reduces the
proportion of patients
with high risk
endoscopic stigmata
(downstages
lesion)
Decreases need for
endoscopic therapy
Has not been shown
to reduce rebleeding,
surgery, or mortality
rates

High
risk

Low risk

Endoscopic treatment
required:
Omeprazole 19% (23% of
PUD)
Placebo 28%
(37% of PUD)
N Engl J Med
2007;356:1631

Endoscopy - Nonvariceal
UGIB
Early endoscopy (within 24 hours) is
recommended for most patients with
acute UGIB
Achieves prompt diagnosis, provides
risk stratification and hemostasis
therapy in high-risk patients

J Clin Gastroenterol
1996;22:267
Gastrointest Endosc
1999;49:145

When is Endoscopic
Therapy Required?
~80% bleeds spontaneously resolve
Endoscopic stigmata of recent
hemorrhage
Stigmata
Continued/rebleeding
rate
majo
r

Active bleeding

55-90%

Nonbleeding visible
vessel

40-50%

Adherent clot

Variable, depending on
underlying lesion: 0-35%

Flat pigmented spot

7-10%

Clean base

< 5%

Major Stigmata Active

Spurting

Kelsey, PB (Dec 04 2003). Duodenum - Ulcer, Arterial Spurting,

Treated with Injection and Clip. The DAVE Project. Retrieved Aug, 1,
2010, from http://daveproject.org/viewfilms.cfm?film_id=39

Major Stigmata - NBVV

Adherent Clot
Role of endoscopic
therapy of ulcers
with adherent clot
is controversial
Clot removal
usually attempted
Underlying lesion
can then be
assessed, treated if
necessary

Minor Stigmata
Flat pigmented spot

Clean base

Low rebleeding risk no endoscopic

therapy needed

Endoscopic Hemostasis
Therapy
Epinephrine injection
Thermal
electrocoagulation
Mechanical
(hemoclips)
Combination therapy
superior to
monotherapy

Kelsey, PB (Nov 08 2005). Stomach - Gastric Ulcer, Visible Vessel.

The DAVE Project. Retrieved Aug, 1, 2010, from
http://daveproject.org/viewfilms.cfm?film_id=306
Baron, TH (May 01 2007). Duodenum - Bleeding Ulcer Treated with
Thermal Therapy, Perforation Closed with Hemoclips. The DAVE
Project. Retrieved Aug, 1, 2010, from
http://daveproject.org/viewfilms.cfm?film_id=620

Nonvariceal UGIB
Post-endoscopy
management

Patients with low risk ulcers can be fed

promptly, put on oral PPI therapy.
Patients with ulcers requiring endoscopic
therapy should receive PPI gtt x 72
hours
Significantly reduces 30 day rebleeding rate
vs placebo (6.7% vs. 22.5%)
Note: there may not be major advantage
with high dose over non-high dose PPI
therapy
N Engl J Med 2000;343:310
Arch Intern Med
2010;170:751

Nonvariceal UGIB
Post-endoscopy
management

Determine H. pylori status in all ulcer patients

Discharge patients on PPI (once to twice
daily), duration dictated by underlying
etiology and need for NSAIDs/aspirin
In patients with cardiovascular disease on low
dose aspirin: restart as soon as bleeding
has resolved
RCT demonstrates increased risk of rebleeding
(10% v 5%) but decreased 30 day mortality (1.3%
v 13%)
Ann Intern Med 2010;152:1

Nonvariceal UGIB
Post-endoscopy
management

Determine H. pylori status in all ulcer patients

Discharge patients on PPI (once to twice
daily), duration dictated by underlying
etiology and need for NSAIDs/aspirin
Not
Not dying
dying is
is more
more important
important
In patients with cardiovascular disease on low
than
not
rebleeding
than
not
dose aspirin: restart rebleeding
as soon as bleeding
has resolved
RCT demonstrates increased risk of rebleeding
(10% v 5%) but decreased 30 day mortality (1.3%
v 13%)
Ann Intern Med 2010;152:1

Variceal Bleeding
Occurs in 1/3 of patients with
cirrhosis
1/3 initial bleeding episodes are fatal
Among survivors, 1/3 will rebleed
within 6 weeks
Only 1/3 will survive
1 year or more

Predictors of large esophageal

varices

Severity of liver disease (Child Pugh)

Platelet count < 88K
Palpable spleen
Platelet count/spleen diameter (mm)
ratio <909

Gut 2003;52:1200
J Clin Gastroenterol 2010;44:146
J Gastroenterol Hepatol
2007;22:1909
Arch Intern Med 2001;161:2564
Am J Gastroenterol 1999;94:3103

 Goal: Reduce splanchnic blood flow

Terlipressin only agent shown to improve control
of bleeding and survival in RCTs and metaanalysis
Not available in US

Vasopressin + nitroglycerine too many adverse

effects
Somatostatin not available in US
Octreotide (somatostatin analogue)
Decreases splanchnic blood flow (variably)
Efficacy is controversial; no proven mortality benefit
Standard dose: 50 mcg bolus, then 50 mcg/hr drip for 3-5
days
Gastroenterology 2001;120:946
Cochrane Database Syst Rev
2008;16:CD000193
N Engl J Med 1995;333:555
Am J Gastroenterol 2009;104:617

 Bacterial infection occurs in up to 66% of

patients with cirrhosis and variceal bleed
Negative impact on hemostasis
(endogenous heparinoids)
Prophylactic antibiotics reduces
incidence of bacterial infection,
significantly reduces early
rebleeding
Ceftriaxone 1 g IV QD x 5-7 days
Alt: Norfloxacin 400 mg po BID
Hepatology 2004;39:746
J Korean Med Sci 2006;21:883
Hepatogastroenterology 2004;51:541

 Promptly but with caution

Goal = maintain hemodynamic
stability, Hgb ~7-8, CVP 4-8 mmHg
Avoid excessively rapid
overexpansion of volume; may
increase portal pressure, greater
bleeding

 Should be
performed as soon
as possible after
resuscitation
(within 12 hours)
Endotracheal
intubation
frequently needed
Band ligation is
preferred method

Layer, L. & Jaganmohan, S. & Raju, GS & DuPont, AW (Oct 28 2009).

Esophagus - Band Ligation of Actively Bleeding Gastroesophageal
Varices. The DAVE Project. Retrieved Aug, 2, 2010, from
http://daveproject.org/viewfilms.cfm?film_id=715

 TIPS Transjugular
Intrahepatic Portosystemic
Shunt
Early placement of shunt
(within 24-72hrs)
associated with improved
survival among high-risk
patients
Preferred treatment for
gastric variceal bleeding
(rule out splenic vein
thrombosis first)
Hepatology 2004;40:793
Hepatology 2008;48:Suppl:373A
N Engl J Med. 2010 Jun 24;362:2370

Fan, C. (Apr 25 2006). Vascular Interventions

in the Abdomen: New Devices and
Applications. The DAVE Project. Retrieved
Aug, 2, 2010, from
http://daveproject.org/viewfilms.cfm?
film_id=497

TIPS+embolization of gastric
varices

Sengstaken-Blakemore Tube

Very effective for

immediate, temporary
control
High complication rate
aspiration, migration,
necrosis + perforation
of esophagus
Use as bridge to TIPS
within 24 hours
Airway protection
strongly recommended

Self-Expanding Metal Stent

Specially designed
covered metal stent
Tamponades distal
esophageal varices
Removable; does not
require airway
protection
Very limited data

Gastrointest Endosc 2010;71:71

 Reduces risk for recurrent variceal

hemorrhage
Use nonselective beta blocker (e.g.
Nadolol splanchnic vasoconstriction,
decrease cardiac output) and titrate up
to maximum tolerated dose, HR 50-60
Start as inpatient, once acute bleeding
has resolved and patient shows
hemodynamic stability

Lower GI Bleed
Bleeding arising from the colorectum
In patients with severe
hematochezia, first consider
possibility of UGIB
10-15% of patients with presumed LGIB
are found to have upper GIB

Lower GI Bleed
Differential Diagnosis
Large volume,
-- Diverticulosis
Diverticulosis (#
(# 1
1 cause)
cause)
painless
-- Angioectasias
Angioectasias
-- Hemorrhoids
Hemorrhoids
Smaller volume,
-- Colitis
(IBD,
Infectious,
Ischemic)
Colitis (IBD, Infectious, Ischemic)
pain, diarrhea
-- Neoplasm
Neoplasm
-- Post-polypectomy
Post-polypectomy
-- Dieulafoys
Dieulafoys lesion
lesion

LGIB Risk Stratification

Predictors of severe* LGIB:
0
0 factors:
factors: ~6%
~6%

risk
risk
HR>100
HR>100
SBP<115
SBP<115
1-3
factors:
~40%
1-3
factors:
~40%
Syncope
Syncope
nontender
nontender abdominal
abdominal examination
examination
>3
factors:
~80%
>3
factors:
~80%
bleeding
during
first
4
hours
of
bleeding during first 4 hours of
evaluation
evaluation
aspirin
aspirin use
use
>2
>2 active
active comorbid
comorbid conditions
conditions

* Defined as continued bleeding within first 24 hours (transfusion of 2+ Units,

decline in HCT of 20+%) and/or recurrent bleeding after 24 hours of stability

Arch Intern Med 2003;163:838

Am J Gastroenterol 2005;100:1821

LGIB Risk Factors for

Mortality
Age
Intestinal ischemia
Comorbid illnesses
Secondary bleeding (developed during
admission for a separate problem)
Coagulopathy
Hypovolemia
Transfusion requirement
Male gender
Clinical Gastro Hepatol 2008;6:1004

Role of Colonoscopy
Like UGIB, ~80% of LGIBs will resolve
spontaneously; of these, ~30% will
rebleed
Lack of standardized approach
Traditional approach:
elective colonoscopy after resolution of bleeding,
bowel prep low therapeutic benefit
Angiography for massive bleeding,
hemodynamically unstable patient

Urgent colonoscopy approach

Similar to UGIB identify stigmata of hemorrhage,
perform therapy

Urgent Colonoscopy
Within 6-12 hours of presentation
Requires rapid purge prep with 5-6 L
Golytely administered 1L every 30-45
minutes
Colonoscopy performed within 1 hour
after clearance of stool, blood and clots
Need for bowel prep and risks of
procedural sedation may be prohibitive
in unstable patient

Endoscopic Therapy

Srinivasan, R. & Luthra, G. & Raju, GS (Jul 17 2007). Colon - Endoscopic

Hemostasis of Diverticular Bleed. The DAVE Project. Retrieved Aug, 3, 2010,
from http://daveproject.org/viewfilms.cfm?film_id=63

Urgent Colonoscopy
Limited high quality evidence of benefit
Establishes diagnosis earlier, shorter length of
stay
Landmark study supporting urgent
colonoscopy for diverticular bleed published in
2000
2 consecutive prospective, non-randomized studies
Group 1 (n=73): urgent colonoscopy, surgical
therapy
Group 2 (n=48): urgent colonoscopy, endoscopic
therapy
N Engl J Med 2000;342:78

Urgent Colonoscopy
Group 1: 17 pts with
definite diverticular
bleed
9 had recurrent/persistent
bleeding
6 required emergency
surgery

Group 2: 10 pts with

definite diverticular
bleed
All 10 patients treated
endoscopically
0 had recurrent bleed,
complications, further
transfusions, or surgery
N Engl J Med 2000;342:78

Urgent Colonoscopy
Two RCTs
published to
date
Compared
urgent
colonoscopy
(within 8
hours) vs.
standard
management

Standard Management
Algorithm

Am J Gastroenterol
2005;100:2395

Urgent Colonoscopy
RCT#1
Definite bleeding source
identified more frequently
(42% vs 22%)

But no significant difference in

important outcomes (but
underpowered)
Am J Gastroenterol
2005;100:2395

Urgent Colonoscopy
RCT#2
85 patients with serious hematochezia
(hemodynamically significant, Hgb
drop > 1.5 g/dL, blood transfusion)
EGD performed within 6 hours
If EGD negative, randomized to urgent
(<12 hr) or elective (36-60 hr)
colonoscopy
Primary endpoint= further bleeding
Am J Gastroenterol
2010;105:2636

Urgent Colonoscopy
RCT#2
EGD positive in 15%

No evidence of improved clinical

outcomes with urgent colonoscopy but
prespecified sample size not reached
Am J Gastroenterol
2010;105:2636

Urgent Colonoscopy
In published series, endoscopic
therapy is applied in 10-40% of
patients undergoing colonoscopy for
LGIB
Taken together, evidence suggests
that colonoscopy should be performed
within 12-24 hours in stable patients
However, it is unclear how faster
timing affects major clinical outcomes

Radiographic Studies
Tagged RBC scan
Noninvasive, highly
sensitive (0.05-0.1
ml/min)
Ability to localize
bleeding source correctly
only ~66%
More accurate when
positive within 2 hours
(95-100%)
Coordinate
with
IR
so
that
positive
Coordinate
with
IR
so
that
positive
Lacks therapeutic
scan
capability
scan is
is followed
followed closely
closely by
by

angiography
angiography

Radiographic Studies
Angiography
Detects bleeding rates
Recommended
test
Recommended
test for
for patients
patients
of 0.5-1
ml/min
Therapeutic
with
capability
bleeding
with brisk
brisk
bleeding who
who cannot
cannot be
be
embolization
with
stabilized
or
prepped
for
stabilized
or
prepped
for
microcoils, polyvinyl
colonoscopy
alcohol, gelfoam colonoscopy
(or
had
(or have
havebowel
had colonoscopy
colonoscopy with
with
Complications:
infarction,
renal
failure
to
failure
to localize/treat
localize/treat bleeding
bleeding
failure, hematomas,
site)
thromboses, dissectionsite)

Radiographic Studies
Multi-Detector CT (CT angio)

Readily available, can be

performed in ER within 10
minutes
Can detect bleeding rate of 0.5
ml/min
Can localize site of bleeding
(must be active) and provide info
on etiology
Useful in the actively bleeding
but hemodynamically stable
patient
Gastrointest Endosc 2010;72:402

Role of Surgery
Reserved for patients with lifethreatening bleed who have failed
other options
General indications:
hypotension/shock despite
resuscitation, >6 U PRBCs transfused
Preoperative localization of bleeding
source important

Algorithmic Evaluation of
Patient with Hematochezia
Hematochez
ia
Assess
activity of
bleed

active
NG lavage
Positive
EGD
Treat
lesion

positiv
e

inacti
ve
Prep for
Colonoscopy

Negative
Risk for
UGIB
negativ
e

No risk for
UGIB
Hemodynamic
ally stable?

Algorithmic Evaluation of
Patient with Hematochezia
Active Lower
GIB

No

Hemodynamic
ally stable?

Angiography
(+/- Tagged
RBC scan)
Or
Surgery if lifethreatening

Yes

Consider urgent
colonoscopy vs.
traditional
approach

Take Home Points

Always get objective description of
stool color (best way examine it
yourself)
Dont order guaiac tests on inpatients
Severe hematochezia can be from
UGIB, even if NG lavage is negative

Take Home Points

All bleeding eventually stops (and
majority of nonvariceal bleeds will
stop spontaneously, with the patient
alive)
Early resuscitation and supportive
care are key to reducing morbidity
and mortality from GIB