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GI bleed

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Upper GI bleed
Lower GI bleed

Gastro-intestinal bleeding

Updated March 2017

  • Important site of occult bleeding. Significant blood loss may occur before bleeding is apparent.
  • Although relatively uncommon in the ICU population, chronic GI bleeding should always be considered as a cause of unexplained anaemia
  • Classified into:
    • Upper - bleeding proximal to ligament of Treitz
    • Middle - bleeding from small intestine distal to ligament of Treitz
    • Lower - bleeding from large intestine

Immediate management of overt GI bleeding

  • Assess severity of shock and start rapid fluid resuscitation with IV crystalloid
  • If blood transfusion of >3 units is expected, order platelets and fresh frozen plasma from the start. Ratio of blood:plasma:platelets is unclear. Trauma data suggest there is no advantage of 1:1:1 over 2:1:1
  • 1:1:1 ratio may not be appropriate in patients with cardiac failure or patients with variceal bleeding, in whom excessive transfusion may markedly raise portal venous pressure resulting in increased bleeding
  • A restrictive transfusion policy aiming for a Hb ≥7 g/dl is associated with a lower mortality in patients with upper GI bleeding(but note that this study excluded patients with immediately life threatening haemorrhage and patients with acute coronary syndrome). May not be appropriate in whom definitive treatment to stop the bleeding will be delayed.
  • Keep INR, APTT and PT 1.5 times upper limit of normal, fibrinogen >1.5 g/l and platelet count >50 x 109/l
  • The appropriate target blood pressure is unclear but a systolic pressure of 90 mmHg is probably satisfactory provided this results in adequate tissue perfusion AND early definitive treatment to stop the bleeding is planned
  • Determine whether the patient needs intubation for airway protection. This needs to be repeatedly assessed.
    • Recurrent haematemesis
    • Decreased consciousness
    • Requires sedation for endoscopy
  • Determine whether the bleeding is coming from the upper GI tract (proximal to the ligament of Treitz), middle (small bowel distal to ligament of Treitz) or the lower GI tract (large bowel) as this will determine the appropriate definitive management.
  Upper GI bleeding Lower GI bleeding Notes
Incidence Overall, 60-80% of GI bleeding but probably higher in patients presenting to ICU as upper GI bleeding more likely to be severe    
History Haematemesis
Coffee ground vomitus
Melaena
Previous upper GI bleed
Peptic ulcer disease
Liver disease
Alcoholism
Repeated vomiting
Critical illness
Fresh blood PR
Altered blood mixed with stool
Abdominal pain
Fresh blood PR in the presence of severe shock may be the result of massive upper GI bleeding with a rapid transit time through the gut.
Occasionally melaena may be due to colonic bleeding
Examination Active bowel sounds
Fresh blood or coffee grounds aspirated from nasogastric tube.
Quiet or absent bowel sounds The absence of coffee grounds or blood in the NG aspirate does not exclude upper GI bleeding, especially in the absence of bile in the aspirate. It may simply be the result of a closed pylorus preventing reflux of blood into the stomach.
Investigations Urea:creatinine ratio>100 (SI units)
BUN:creatinine ratio >30 (mg/dl)
   
  • Unless the bleeding is clearly lower GI, give IV bolus of proton pump inhibitor. This has been shown to reduce the need for repeated endoscopy (but does not reduce mortality, re-bleeding or need for surgery).

For details of further management see Upper GI bleeding and Lower GI bleeding

Further reading

Jairath V and Desborough MJR. Modern management of upper gastrointestinal haemorrhage. Transfusion Medicine, 2015; 351-7


©Charles Gomersall, March, 2017 unless otherwise stated. The author, editor and The Chinese University of Hong Kong take no responsibility for any adverse event resulting from the use of this webpage.
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