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 Medications:
CAD h/o MI Aspirin
PVD Clopidogrel
Atorvastatin
AAA s/p elective
Atenolol
repair 3 years ago
Lisinopril
HTN
Hypercholesterole
mia
Lumbago
 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
Gastroesophageal varices commo
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
Diverticulosis diagnosis

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 re-
equilibration occurs)
Correct coagulopathy
 Resuscitation
IV access: large bore peripheral IVs best
(alt: cordis catheter)
Use crystalloids
bleed
first Time

Anticipate need for bloodIVFstransfusion

40%
Threshold should be40%based on underlying
20% 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 re-
equilibration occurs)
Correct coagulopathy
 Transfusion Strategy

Randomized trial:
921 subjects with severe acute UGIB
Restrictive (tx when Hgb<7; target 7-
9) vs. Liberal (tx when Hgb<9; target 9-
11)
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 10% 16% 0.01
bleeding
Overall 40% 48% 0.02
complication
rate

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
1 U PRBC should raise Hgb by 1 (HCT
Vitamin K by 3%)
slow acting,
long-lived
Remember that initial Hct can be misleading (Hct
remains the same with loss of whole blood, until re-
equilibration occurs) FFP fast acting, short
lived
Correct coagulopathy - 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

Am J Gastroenterol 2004;99:619
(groups are essentially the same)
 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
Patients
Bleeding
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 non-
bleeding 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 0 1 2 3
Age <60 60-79 80
Shock No Tachy- Hypotensio
SBP 100 SBP 100 n-
P<100 P>100 SBP <100

Comorbi No major Cardiac Renal

dity failure, failure,
CAD, other liver
major failure,
malignanc
Gut 1996;38:316
y
Clinical Rockall Score
Mortality Rates
 AIMS65

Simple risk score that predicts in-

hospital 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 High
Low risk
Has not been shown risk
to reduce rebleeding, Endoscopic treatment
surgery, or mortality required:
rates 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
Active bleeding 55-90%
majo
r Nonbleeding visible 40-50%
vessel
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
Kelsey, PB (Nov 08 2005). Stomach - Gastric Ulcer, Visible Vessel.
monotherapy
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
dose aspirin: restart rebleeding
than not 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 meta-
analysis
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
Layer, L. & Jaganmohan, S. & Raju, GS & DuPont, AW (Oct 28 2009).
preferred method 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) Fan, C. (Apr 25 2006). Vascular Interventions
in the Abdomen: New Devices and
Applications. The DAVE Project. Retrieved
Hepatology 2004;40:793 Aug, 2, 2010, from
Hepatology 2008;48:Suppl:373A http://daveproject.org/viewfilms.cfm?
N Engl J Med. 2010 Jun 24;362:2370 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:

00 factors:
factors: ~6%
~6%
HR>100 risk
risk
HR>100
SBP<115
SBP<115
Syncope 1-3
1-3 factors:
factors: ~40%
~40%
Syncope
nontender
nontender abdominal
abdominal examination
examination
bleeding during first 4 >3
>3
hoursfactors:
factors:
of ~80%
~80%
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, Arch Intern Med 2003;163:838
decline in HCT of 20+%) and/or recurrent bleeding after 24 hours of stability 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
Standard Management
Algorithm
Two RCTs
published to
date
Compared
urgent
colonoscopy
(within 8
hours) vs.
standard
management
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
Coordinate
Lacks therapeutic
with
with IR
IR so
so that
that positive
positive
capabilityscan
scan is is followed
followed closely
closely by
by
angiography
angiography
 Radiographic Studies

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

threatening 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 inacti
ve
Prep for
NG lavage
Colonoscopy

Positive Negative
No risk for
Risk for UGIB
UGIB
EGD

Treat negativ Hemodynamic

positiv e ally stable?
lesion
e
 Algorithmic Evaluation of
Patient with Hematochezia
Active Lower
GIB
Hemodynamic
ally stable?
No Yes

Angiography
(+/- Tagged Consider urgent
RBC scan) colonoscopy vs.
Or traditional
Surgery if life- approach
threatening
 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