Gastrointestinal bleeding: Difference between revisions
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==Prognosis== |
==Prognosis== |
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Despite treatment re-bleeding occurs in about 7-16% of those with upper GI bleeding.<ref name=Epi2008/> In those with esophageal varicies, bleeding occurs in about 5-15% a year and if they has bleed once there is an higher risk of further bleeding in the next six weeks.<ref name=N2010>{{cite journal|last=Cat|first=TB|coauthors=Liu-DeRyke, X|title=Medical management of variceal hemorrhage.|journal=Critical care nursing clinics of North America|date=2010 Sep|volume=22|issue=3|pages=381-93|pmid=20691388}}</ref> Testing and treating ''H. pylori'' if found can prevent re-bleeding in those with peptic ulcers.<ref name=Overall2011/> The benefits verses risks of restarting blood thinners such as [[aspirin]] or [[warfarin]] and [[Anti-inflammatory|anti-inflammatories]] such as [[NSAIDs]] need to be carefully considered.<ref name=Overall2011/> |
Despite treatment re-bleeding occurs in about 7-16% of those with upper GI bleeding.<ref name=Epi2008/> In those with esophageal varicies, bleeding occurs in about 5-15% a year and if they has bleed once there is an higher risk of further bleeding in the next six weeks.<ref name=N2010>{{cite journal|last=Cat|first=TB|coauthors=Liu-DeRyke, X|title=Medical management of variceal hemorrhage.|journal=Critical care nursing clinics of North America|date=2010 Sep|volume=22|issue=3|pages=381-93|pmid=20691388}}</ref> Testing and treating ''H. pylori'' if found can prevent re-bleeding in those with peptic ulcers.<ref name=Overall2011/> The benefits verses risks of restarting blood thinners such as [[aspirin]] or [[warfarin]] and [[Anti-inflammatory|anti-inflammatories]] such as [[NSAIDs]] need to be carefully considered.<ref name=Overall2011/> |
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==Epidemiology== |
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Gastrointestinal bleeding from the upper tract occurs in 50 to 150 per 100,000 adults per year.<ref name=Red210>{{cite journal|last=Jairath|first=V|coauthors=Hearnshaw, S, Brunskill, SJ, Doree, C, Hopewell, S, Hyde, C, Travis, S, Murphy, MF|title=Red cell transfusion for the management of upper gastrointestinal haemorrhage.|journal=Cochrane database of systematic reviews (Online)|date=2010 Sep 8|issue=9|pages=CD006613|pmid=20824851}}</ref> |
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==References== |
==References== |
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Revision as of 05:14, 20 April 2012
| Gastrointestinal bleeding | |
|---|---|
| Specialty | Gastroenterology  |
Gastrointestinal bleeding or gastrointestinal hemorrhage describes every form of hemorrhage (loss of blood) in the gastrointestinal tract, from the pharynx to the rectum. It has diverse causes, and a medical history, as well as physical examination, generally distinguishes between the main forms. The degree of bleeding can range from nearly undetectable to acute, massive, life-threatening bleeding.
Initial emphasis is on resuscitation by infusion of intravenous fluids and blood transfusion, treatment with proton pump inhibitors. Upper endoscopy or colonoscopy are generally considered appropriate to identify the source of bleeding and carry out therapeutic interventions.
Signs and symptoms
Gastrointestinal bleeding can range from microscopic bleeding, where the amount of blood is such that it can only be detected by laboratory testing, to massive bleeding where bright red blood is passed and hypovolemia and shock may develop. Blood that is digested may appear black rather than red, resulting in "coffee ground" vomit or stool.[1]
Differential diagnosis
Gastrointestinal bleeding can be roughly divided into two clinical syndromes: upper gastrointestinal bleeding and lower gastrointestinal bleeding. Each has its separate list of causes. Types of causes include: infections, cancers, vascular disorders, adverse effects of medications, and blood clotting disorders.[1]
Upper gastrointestinal
Upper gastrointestinal bleeding is from a source between the pharynx and the ligament of Treitz. An upper source is characterised by hematemesis (vomiting up blood) and melena (tarry stool containing altered blood). About half of cases are due to peptic ulcer disease.[2] Esophagitis and erosive disease is the next most common causes.[2] In those with liver cirrhosis 50-60% of bleeding is due to esophageal varices .[2] Approximately half of those with peptic ulcers have an H. pylori infection.[2]
Lower gastrointestinal
Lower gastrointestinal bleeding may be indicated by red blood per rectum, especially in the absence of hematemesis. Isolated melena may originate from anywhere between the stomach and the proximal colon.
Diagnostic approach
Diagnosis is often based on direct observation of blood in the stool. This can be confirmed with a fecal occult blood test.
Laboratory testing
Recommended laboratory blood testing includes: cross matching blood, hemoglobin, hematocrit, platelets, coagulation time, and electrolytes.[3]
Risk stratification
The severity of an upper GI bleed can be judged based on the Blatchford score.[3]
Prevention
In those with significant varices or cirrhosis nonselective β-blockers reduce the risk of future bleeding.[4] With a target heart rate of 55 beats per minute they reduce the absolute risk of bleeding by 10%.[4] Endoscopic band ligation (EBL) is also effective at improving outcomes.[4] Either B-blockers or EBL are recommended as initial preventative measures.[4] In those who have had a previous varcial bleed both treatments are recommended.[4] With some evidence supporting the addition of isosorbide mononitrate.[5]
Treatment
The initial focus is on resuscitation beginning with airway management and fluid resuscitation using either intravenous fluids and or blood.[3] A number of medications may improve outcomes depending on the source of the bleeding.[3]
Peptic ulcers
Based on evidence from people with other health problems crystalloid and colloids are believed to be equivalent for peptic ulcer bleeding.[3] Proton pump inhibitors may reduce mortality in those with severe disease as well as the risk of re-bleeding and the need for surgery among this group.[6] In those with less severe disease and where endoscopy is rapidly available, they are of less immediate clinical importance.[7] The evidence for the inhibition of fibrinolysis with tranexamic acid is insufficient to recommend it use.[3][8] Somatostatin and octreotide while recommended for varicial bleeding have not been found to be of general use for non varicial bleeds.[3]
Variceal bleeding
For initial fluid replacement colloids or albumin is preferred in people with cirrhosis.[3] Medications typically includes octreotide or if not avaliable vasopression and nitroglycerin to reduce portal pressures.[4] This is typically in addition to endoscopic banding or sclerotherapy for the varicies.[4] If this is sufficient than beta blockers and nitrates may be used for the prevention of re-bleeding.[4] If bleeding continues than balloon tamponade with a Sengstaken-Blakemore tube or Minnesota tube may be used in an attempt to mechanically compress the varicies.[4] This may than be followed by a transjugular intrahepatic portosystemic shunt.[4] In those with cirrhosis antibiotics decrease the chance of re bleeding, shorten the length of time spent in hospital, and decrease the chance of death.[9]
Blood products
If large amounts of pack red blood cells are used additional platelets and fresh frozen plasma should be administered to prevent coagulopathies.[3] Some evidence supports holding off on blood transfusions in those who have a hemoglobin greater than 7 to 8 g/dL and only moderate bleeding.[3] If the INR is greater than 1.5 to 1.8 correction with fresh frozen plasma or prothrombin complex may decrease mortality.[3] Evidence of a harm or benefit of recombinant activated factor VII in those with liver diseases and gastrointestinal bleeding is not determined.[10]
Procedures
The benefits verses risks of placing a nasogastric tube in those with upper GI bleeding are not determined.[3] Endoscopy within 24 hours is recommended.[3] Prokinetic agents such as erythromycin before endocopy can decrease the amount of blood in the stomach and thus improve the operators view.[3] They also decrease the amount of blood transfusions required.[11] Early endoscopy decreases hospital and the amount of blood transfusions needed.[3] Proton pump inhibitors, if they have not been started earlier, are recommended in those in whom high risk signs for bleeding are found.[3] It is also recommended that people with high risk signs are kept in hospital for at least 72 hours.[3] Those at low risk of re-bleeding may begin eating typically 24 hours following endoscopy.[3]
Prognosis
Despite treatment re-bleeding occurs in about 7-16% of those with upper GI bleeding.[2] In those with esophageal varicies, bleeding occurs in about 5-15% a year and if they has bleed once there is an higher risk of further bleeding in the next six weeks.[4] Testing and treating H. pylori if found can prevent re-bleeding in those with peptic ulcers.[3] The benefits verses risks of restarting blood thinners such as aspirin or warfarin and anti-inflammatories such as NSAIDs need to be carefully considered.[3]
Epidemiology
Gastrointestinal bleeding from the upper tract occurs in 50 to 150 per 100,000 adults per year.[12]
References
- ^ a b Westhoff, John (2004). "Gastrointestinal Bleeding: An Evidence-Based ED Approach To Risk Stratification". Emergency Medicine Practice. 6 (3).
{{cite journal}}: Unknown parameter|month=ignored (help) - ^ a b c d e van Leerdam, ME (2008). "Epidemiology of acute upper gastrointestinal bleeding". Best practice & research. Clinical gastroenterology. 22 (2): 209–24. PMID 18346679.
- ^ a b c d e f g h i j k l m n o p q r s t Jairath, V (2011 Oct). "The overall approach to the management of upper gastrointestinal bleeding". Gastrointestinal endoscopy clinics of North America. 21 (4): 657–70. PMID 21944416.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ a b c d e f g h i j k Cat, TB (2010 Sep). "Medical management of variceal hemorrhage". Critical care nursing clinics of North America. 22 (3): 381–93. PMID 20691388.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ Li, L (2011 Mar). "Endoscopic band ligation versus pharmacological therapy for variceal bleeding in cirrhosis: a meta-analysis". Canadian journal of gastroenterology = Journal canadien de gastroenterologie. 25 (3): 147–55. PMID 21499579.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ Leontiadis, GI (2007 Dec). "Systematic reviews of the clinical effectiveness and cost-effectiveness of proton pump inhibitors in acute upper gastrointestinal bleeding". Health technology assessment (Winchester, England). 11 (51): iii–iv, 1–164. PMID 18021578.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ Sreedharan, A (2010 Jul 7). "Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding". Cochrane database of systematic reviews (Online) (7): CD005415. PMID 20614440.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ Gluud, LL (2012 Jan 18). "Tranexamic acid for upper gastrointestinal bleeding". Cochrane database of systematic reviews (Online). 1: CD006640. PMID 22258969.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ Chavez-Tapia, NC (2011 Sep). "Meta-analysis: antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding - an updated Cochrane review". Alimentary pharmacology & therapeutics. 34 (5): 509–18. PMID 21707680.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ Martí-Carvajal, AJ (2012 Mar 14). "Human recombinant activated factor VII for upper gastrointestinal bleeding in patients with liver diseases". Cochrane database of systematic reviews (Online). 3: CD004887. PMID 22419301.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ Bai, Y (2011 Jul). "Meta-analysis: erythromycin before endoscopy for acute upper gastrointestinal bleeding". Alimentary pharmacology & therapeutics. 34 (2): 166–71. PMID 21615438.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help) - ^ Jairath, V (2010 Sep 8). "Red cell transfusion for the management of upper gastrointestinal haemorrhage". Cochrane database of systematic reviews (Online) (9): CD006613. PMID 20824851.
{{cite journal}}: Check date values in:|date=(help); Unknown parameter|coauthors=ignored (|author=suggested) (help)