Gastrointestinal hemorrhage

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Gastrointestinal hemorrhage (GI bleeding) is defined as "bleeding in any segment of the gastrointestinal tract from esophagus to rectum."[1]

Diagnosis

Upper gastrointestinal tract bleeding

Summary

The diagnosis of upper GI bleeding is assumed when hematemesis is documented. In the absence of hematemesis, an upper source for GI bleeding is likely in the presence of at least two factors among: black stool, age < 50 years, and blood urea nitrogen/creatinine ratio 30 or more.[2] In the absence of these findings, consider a nasogastric aspirate to determine the source of bleeding. If the aspirate is positive, an upper GI bleed is greater than 50%, but not high enough to be certain. If the aspirate is negative, the source of a GI bleed is likely lower. The accuracy of the aspirate is improved by using a chemical occult blood test on stool.[3]

Clinical predictors

Several clinical prediction rules, the Glasgow-Blatchford bleeding score, the Rockall score, and the PNED Score can help identify patients at risk of complications.[4][5] A cohort of 325 patients reported that the odds ratios for the strongest predictors were: black stool, 16.6, age < 50 years, 8.4, and blood urea nitrogen/creatinine ratio 30 or more, 10.0.[2] Seven (5%) of 151 with none of these factors had an upper GI tract bleed, versus 63 (93%) of 68 with 2 or 3 factors. Ernst found similar results.[3]

Glasgow-Blatchford bleeding score

Low risk is 0 points.

Nasogastric aspirate

The nasogastric aspirate can help determine the location of bleeding and thus direct initial diagnostic and treatment plans; however, the sensitivity is low.[6] Witting found that nasogastric aspirate has sensitivity 42%, specificity 91%, negative predictive value 64%, positive predictive value 92% and overall accuracy of 66% in differentiating upper GI bleeding from bleeding distal to the ligament of Treitz.[7] Thus, in this study a positive aspirate is more helpful than a negative aspirate. In a smaller study, Cuellar found a sensitivity of 79% and specificity of 55%[8], somewhat opposite results from Witting. Cuellar also studied the appearance of the aspirate and the results are in the table.

Determining whether blood is in the gastric aspirate[8]
Finding Sensitivity Specificity Positive predictive value
(prevalence of 39%)		 Negative predictive value
(prevalence of 39%)
Gastroccult (occult blood) 95% 82% 77% 96%
Physician assessment 79% 55% 53% 20%

Determining whether blood is in gastric contents, either vomited or aspirated specimens, is surprisingly difficult. Slide tests are based on orthotolidine (Hematest reagent tablets and Bili-Labstix) or guaiac (Hemoccult and Gastroccult). Rosenthal found orthotolidine-based tests more sensitive than specific; the Hemoccult test's sensitivity reduced by the acidic environment; and the Gastroccult test be the most accurate.[9]

Holman used simulated gastric specimens and found the Hemoccult test to have significant problems with non-specificity and false-positive results, whereas the Gastroccult test was very accurate.[10] Holman found that by 120 seconds after the developer was applied, the Hemoccult test was positive on all control samples.[10]

Esophagogastroduodenoscopy

Esophagogastroduodenoscopy(EGD) can help determine the cause of the bleeding. Intravenous erythromycin prior to endoscopy can help clear the stomach of blood to improve the exam.[11]

Lower gastrointestinal tract bleeding

Treatment

Upper gastrointestinal tract bleeding

Clinical practice guidelines address the management of nonvariceal bleeding.[12] Most patients should receive esophagogastroduodenoscopy and some patients need a second look esophagogastroduodenoscopy.[12]

Some patients may be treated as outpatients.[13]

"In acute upper gastrointestinal bleeding, administration of intravenous erythromycin provides satisfactory endoscopic conditions, without the need for a nasogastric tube and gastric lavage.". [14]

Lower gastrointestinal tract bleeding

Prognosis

Upper gastrointestinal tract bleeding

The AIMS65 may be better a clinical prediction rule than the Glasgow-Blatchford system (GBS) in predicting mortality but the GBS may better predict the need for blood transfusion.[15] AIMS65 values of 2 are considered abnormal. The components of the AIMS65 are:

  • Albumin less than 3.0 g/dL
  • International normalized ratio greater than 1.5
  • Mental status abnormal
  • Systolic blood pressure 90 mm Hg or lower
  • Age older than 65 years

For patients with nonvariceal upper gastrointestinal tract bleeding, the Blatchford score is a clinical prediction rule for predicting patients that will require blood transfusion, endoscopic or surgical management for bleeding control.[16]

The Blatchford score is high risk if the patient has any of the following:

  • Blood urea nitrogen ≥18.2 (mg/dL)
  • Hemoglobin level
    • for men <13 (g/dL)
    • for women <12 (g/dL)
  • Systolic blood pressure <109(mm Hg)
  • Pulse rate ≥100 beats/min
  • Melena
  • Syncope
  • Hepatic disease
  • Heart failure

In a study in which 69.5% of the patients were had blood transfusion, endoscopic or surgical management, the accuracy of the score is:

which yielded:

The Blatchford score out performed Rockall score in one comparison.[16]

Lower gastrointestinal tract bleeding

References

  1. ↑ National Library of Medicine. Gastrointestinal Hemorrhage. Retrieved on 2007-11-09.
  2. ↑ 2.0 2.1 Witting MD, Magder L, Heins AE, Mattu A, Granja CA, Baumgarten M (2006). "ED predictors of upper gastrointestinal tract bleeding in patients without hematemesis". Am J Emerg Med 24 (3): 280–5. DOI:10.1016/j.ajem.2005.11.005. PMID 16635697. Research Blogging.
  3. ↑ 3.0 3.1 Ernst AA, Haynes ML, Nick TG, Weiss SJ (1999). "Usefulness of the blood urea nitrogen/creatinine ratio in gastrointestinal bleeding". Am J Emerg Med 17 (1): 70–2. PMID 9928705. [e]
  4. ↑ Stanley AJ, Ashley D, Dalton HR, Mowat C, Gaya DR, Thompson E et al. (2009). "Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation.". Lancet 373 (9657): 42-7. DOI:10.1016/S0140-6736(08)61769-9. PMID 19091393. Research Blogging. Review in: Ann Intern Med. 2009 May 19;150(10):JC5-14
  5. ↑ Marmo R, Koch M, Cipolletta L, Capurso L, Grossi E, Cestari R et al. (2010). "Predicting mortality in non-variceal upper gastrointestinal bleeders: validation of the Italian PNED Score and Prospective Comparison with the Rockall Score.". Am J Gastroenterol 105 (6): 1284-91. DOI:10.1038/ajg.2009.687. PMID 20051943. Research Blogging.
  6. ↑ Palamidessi N, Sinert R, Falzon L, Zehtabchi S (2010). "Nasogastric aspiration and lavage in emergency department patients with hematochezia or melena without hematemesis.". Acad Emerg Med 17 (2): 126-32. DOI:10.1111/j.1553-2712.2009.00609.x. PMID 20370741. Research Blogging.
  7. ↑ Witting MD, Magder L, Heins AE, Mattu A, Granja CA, Baumgarten M (2004). "Usefulness and validity of diagnostic nasogastric aspiration in patients without hematemesis". Ann Emerg Med 43 (4): 525–32. DOI:10.1016/S0196064403009417. PMID 15039700. Research Blogging.
  8. ↑ 8.0 8.1 Cuellar RE, Gavaler JS, Alexander JA, et al (1990). "Gastrointestinal tract hemorrhage. The value of a nasogastric aspirate". Arch. Intern. Med. 150 (7): 1381–4. PMID 2196022. [e] summary of these results is available at the Evidence-Based On-Call database and through the Wayback Archive Cite error: Invalid <ref> tag; name "pmid2196022" defined multiple times with different content
  9. ↑ Rosenthal P, Thompson J, Singh M (1984). "Detection of occult blood in gastric juice". J. Clin. Gastroenterol. 6 (2): 119–21. PMID 6715849. [e]
  10. ↑ 10.0 10.1 Holman JS, Shwed JA (1992). "Influence of sucralfate on the detection of occult blood in simulated gastric fluid by two screening tests". Clin Pharm 11 (7): 625–7. PMID 1617913. [e]
  11. ↑ Winstead NS, Wilcox CM (2007). "Erythromycin prior to endoscopy for acute upper gastrointestinal haemorrhage: a cost-effectiveness analysis". Aliment. Pharmacol. Ther. 26 (10): 1371–7. DOI:10.1111/j.1365-2036.2007.03516.x. PMID 17848180. Research Blogging.
  12. ↑ 12.0 12.1 Barkun AN, Bardou M, Kuipers EJ, Sung J, Hunt RH, Martel M et al. (2010). "International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding.". Ann Intern Med 152 (2): 101-13. DOI:10.1059/0003-4819-152-2-201001190-00009. PMID 20083829. Research Blogging.
  13. ↑ Cooper GS, Kou TD, Wong RC (January 2009). "Outpatient management of nonvariceal upper gastrointestinal hemorrhage: unexpected mortality in Medicare beneficiaries". Gastroenterology 136 (1): 108–14. DOI:10.1053/j.gastro.2008.09.030. PMID 19010328. Research Blogging.
  14. ↑ Pateron D, Vicaut E, Debuc E, Sahraoui K, Carbonell N, Bobbia X et al. (2011). "Erythromycin infusion or gastric lavage for upper gastrointestinal bleeding: a multicenter randomized controlled trial.". Ann Emerg Med 57 (6): 582-9. DOI:10.1016/j.annemergmed.2011.01.001. PMID 21333385. Research Blogging.
  15. ↑ Hyett BH et al. The AIMS65 score compared with the Glasgow-Blatchford score in predicting outcomes in upper GI bleeding. Gastrointest Endosc 2013. DOI:10.1016/j.gie.2012.11.022
  16. ↑ 16.0 16.1 Chen IC, Hung MS, Chiu TF, Chen JC, Hsiao CT (2007). "Risk scoring systems to predict need for clinical intervention for patients with nonvariceal upper gastrointestinal tract bleeding". The American journal of emergency medicine 25 (7): 774–9. DOI:10.1016/j.ajem.2006.12.024. PMID 17870480. Research Blogging.
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