gastrointestinal disorders
Overview of Gastrointestinal Bleeding
Treatment of GI Bleeding
Secure airway if needed IV fluid resuscitation Blood transfusion if needed Sometimes medications In some, endoscopic or angiographic hemostasis (See also the American College of Gastroenterology–Canadian Association of Gastroenterology’s2022 Clinical Practice Guideline: Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period, the American Journal of Gastroenterology's2023 Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline, the American Journal of Gastroenterology's2021 ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding, and the American Journal of Gastroenterology's2015 ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding.) Hematemesis, hematochezia, or melena should be considered an emergency. Admission to an intensive care unit or other monitored setting, with consultation by both a gastroenterologist and a surgeon, is recommended for all patients with severe GI bleeding. General treatment is directed at maintenance of the airway and restoration of circulating volume. Hemostasis and other treatment depend on the cause of the bleeding. A major cause of morbidity and mortality in patients with active upper GI bleeding is aspiration of blood with subsequent respiratory compromise. To prevent these problems, endotracheal intubation should be considered in patients who have inadequate gag reflexes or are obtunded or unconscious—particularly if they will be undergoing upper endoscopy. Intravenous access should be obtained immediately. Short, large-bore (eg, 14- to 16-gauge) IV catheters in the antecubital veins are preferable to a central venous catheter unless a large (8.5 French) sheath is used. IV fluids are initiated immediately, as for any patient with hypovolemia or hemorrhagic shock (see Intravenous Fluid Resuscitation ). Healthy adults are given normal saline IV in 500- to 1000-mL aliquots until signs of hypovolemia remit—up to a maximum of 2 L (for children, 20 mL/kg, that may be repeated once). Patients requiring further resuscitation should receive transfusion with packed RBCs. Transfusions continue until intravascular volume is restored and then are given as needed to replace ongoing blood loss. Transfusions in older adults or those with coronary artery disease may be stopped when hemoglobin is stable at 8 unless the patient is symptomatic. Younger patients or those with chronic bleeding are usually not transfused unless hemoglobin is<7 or they have symptoms such as dyspnea or coronary ischemia. Platelet count should be monitored closely; platelet transfusion may be required with severe bleeding. Patients who are taking antiplatelet medications (eg,clopidogrel,aspirin) have platelet dysfunction, often resulting in increased bleeding. Platelet transfusion should be considered when patients taking these medications have severe ongoing bleeding, although a residual circulating medication (particularlyclopidogrel) may inactivate transfused platelets. If patients are taking an antiplatelet medication or an anticoagulant for a recent cardiovascular indication, a cardiologist should be consulted, if possible, prior to stopping the medication, reversing the medication, or giving a platelet transfusion. If a significant blood transfusion is required, fresh frozen plasma and platelets also should be transfused along with packed RBCs according to the institution's massive transfusion protocols. If the patient has a coagulopathy, correction with fresh frozen plasma orprothrombin complex concentrateshould be considered. The decision to reverse a patient's anticoagulation or antiplatelet therapy should be made based on the assessed bleeding risk counterbalanced with the patient's thrombotic risk. The currently published guidelines are unable to provide guidelines for treatment with fresh frozen plasma, prothrombin complex concentrates, or other reversal agents because of a paucity of evidence in the literature (see also the American College of Gastroenterology–Canadian Association of Gastroenterology’s2022 Clinical Practice Guideline: Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period). An IV proton pump inhibitor (PPI) may be started in cases of possible upper GI bleeding and should be used if a gastroduodenal ulcer is confirmed as the source of bleeding. Octreotide(a synthetic analog of somatostatin) is used in patients with suspected variceal bleeding.Octreotideis given as a 50-mcg IV bolus, followed by continuous infusion of 50 mcg/hour. GI bleeding stops spontaneously in about 80% of patients. The remaining patients require some type of intervention. Specific therapy depends on the bleeding site. Early intervention to control bleeding is important to minimize mortality, particularly in older adults. Peptic Ulcer Disease , Treatment None caused by Colonic Diverticulosis or Polyps can be removed by snare or cautery. Surgerymay be done in patients with continued lower GI bleeding (requiring>6 units transfusion), but localization of the bleeding site is very important. If the bleeding site cannot be localized, subtotal colectomy is recommended. Blind hemicolectomy (with no preoperative identification of the bleeding site) carries a much higher mortality risk than does directed segmental resection and may not remove the bleeding site; the rebleeding rate is 40%. However, assessment must be expeditious so that surgery is not unnecessarily delayed. In patients who have received > 10 units of packed RBCs, the mortality rate is about 30%. Acute or chronic bleeding of internal hemorrhoids stops spontaneously in most cases. Patients with Treatment are treated via anoscopy with rubber band ligation, injection, coagulation, or surgery. 1.Hwang JH, Shergill AK, Acosta RD, et al: The role of endoscopy in the management of variceal hemorrhage.Gastrointest Endosc80(2):221–227, 2014. doi: 10.1016/j.gie.2013.07.023 