Gastrointestinal Bleeding

Lisa N. Flemmons, ACNP-BC

Vanderbilt University Medical Center
Medical Intensive Care Unit
 Objectives
Learn how to effectively evaluate and manage gastrointestinal
bleeding in the critically ill patient
Distinguish upper gastrointestinal bleeding from lower and
discuss possible etiologies
Understand diagnostic testing and therapeutic interventions
Review and discuss transfusion strategies in the
gastrointestinal bleeding patient
 Epidemiology
Common and potentially fatal diagnosis
accounting for ~30,000 admissions/year

Upper GIB accounts for 20,000 deaths/year

 Distinguishing upper vs lower
Upper GI bleed Lower GI bleed
History History
Previous NSAID use ulcer Previous colon cancer
Previous PUD Previous colon surgery
Alcoholism varices Known diverticulosis
Previous stomach surgery
Known hemorrhoids
Retching/vomiting Mallory Weiss
Symptoms
Weight loss cancer
Abdominal pain or can be
Medications such as anticoagulants,
antiplatelets
painless
Symptoms Hematochezia
Nausea/vomiting Melena (less common)
Hematemesis
Melena
Rarely hematochezia (massive bleed)
 Evaluation and Assessment
ABCs of GIB
1. Airway and Access
2. Blood products
3. Correct Coagulopathy and
Consultation
4. Drugs and Diagnostic testing
 Airway and Access
Ensure adequate airway
Hematemesis
Altered mental status
Shock
Needed for endoscopy
Adequate access
2 large bore PIV vs CVC
 Blood Products
Crystalloid infusion while waiting on
PRBC
Vasopressors are not a substitute for
volume resuscitation
Each PRBC should increase PCV by ~3%
per unit
Transfusion goal
 Randomized 921 patients to either liberal or restrictive
strategy
Liberal strategy transfusion trigger was Hgb <9 and restrictive
strategy was 7
The probability of survival at 6 weeks was higher in the
restrictive-strategy group than in the liberal-strategy group
(95% vs. 91%).
Further bleeding occurred in 10% of the patients in the
restrictive-strategy group as compared with 16% of the
patients in the liberal-strategy group and adverse events
occurred in 40% as compared with 48%.
6 week survival rate in the 2 groups
 Correction of Coagulopathy
FFP transfusion
Synthetic liver dysfunction
Warfarin
Consider Vitamin K
Dilutional coagulopathy
Goal INR <1.5

Platelet transfusion
in bleeding pt if less than 50K
Platelet dysfunction
Anti-platelet agents or uremia
Goal platelets >50, 000/mm
 Consultation
Urgent gastroenterology consult
Consider surgical consult
Massive transfusion
Abdominal pain associated with GIB
Recurrent bleeding
 Diagnostics
Upper GIBEGD
(esophagogastroduodenoscopy)
Definitive test for diagnosis and treatment
Safe to perform once the airway is secure and pt is
reasonably hemodynamically stable
Interventional options: epinephrine injection,
cauterization, clipping, or banding of varices
May give 1 time dose of erythromycin 250 mg IV or Reglan
10 mg IVP to promote gastric emptying prior to procedure
Large ulcer Status post cauterization
 Diagnostics continued
Lower GIBcolonoscopy
If slow bleed consider bowel prep overnight to
allow for maximum visualization
If brisk bleed consider STAT colonscopy, tagged
RBC scan, or angiography
Tagged RBC scan vs angiography
If upper and lower endoscopy fail to ID source
then can consider video capsule or push
enteroscopy
 Drugs
PPI twice a day

Am J Health-Syst PharmVol 62 Jun 1, 2005 1165

 Drugs
If hx of liver disease or ascites give SBP
prophylaxis (quinolone, CTX, or bactrim)
Octreotide gtt for hx of liver disease or known
varices
Hold beta blocker in the acute setting which
will prevent/block reflex tachycardia
 Minnesota/Blakemore Tube
A flexible tube consisting
of an esophageal and
gastric balloon that is
inflated and is used as a
temporizing measure to
tamponade gastric and/or
esophageal varices.
 Minnesota/Blakemore Tube
Uses
Should have experienced
personnel assist with insertion
Maximum amt of time 24-72
hrs
Must be to traction (usually a
football helmet)
KUB and CXR for confirmation
of placement (keep in mind
after transfer from OSH)
Cautions
Necrosis if inflated too much
or too long
Nasal insertion can cause nose
bleeds and sinusitis
Can migrate upwards and
compress trachea especially in
shorter stature patients
Perforate or tear esophagus
during insertion
Large esophageal varices with red wales
sign Status post banding
 Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Increased pressure in PV forces blood to

flow into smaller branches coming from
abdominal organs that normally drain into
the PV. These veins then enlarge and are
referred to as varices
 63 patients with cirrhosis and acute variceal bleeding
randomly assigned within 24 hours after admission
32 patients assigned to early TIPS group (within 72
hours)
31 patients assigned to continuation of vasoactive
drugs, NS- beta blockade, and long term EBL with
insertion of a TIPS as rescue therapy if needed.
 Results
rebleeding or failure to control bleeding occurred in 14
patients in the pharmacotherapyEBL group as compared
with 1 patient in the early-TIPS group (P=0.001).
The number of days in the intensive care unit and the
percentage of time in the hospital during follow-up were
significantly higher in the pharmacotherapyEBL group
than in the early-TIPS group.
The 1-year actuarial survival was 61% in the
pharmacotherapyEBL group versus 86% in the early-TIPS
group (P<0.001).
 Special Considerations
Obscure GI bleed
If and when do you restart anticoagulation?
How do you prevent GIB in the ICU?
 References
Garcia-Pagan et al, NEJM 2010; 362:2370-9
Lau JY, Sung JJ, Lee KKC, et al, NEJM 2000; 343: 310316
Marini, J.J., Wheeler, A.W. (2010). Critical care medicine: The
essentials (4th ed.). Philadelphia, PA: Lippincott Williams &
Wilkins.
Rivkins, K., Lyakhovetskiy, A AJHP 2005; 62: 1164-1165
Villaneuva, C et al NEJM 2013; 368:11-21