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Evidence-Based
Hospital Management Of
Gastrointestinal Bleeding
August 2014
Volume 2, Number 8
Authors
Abstract
Gastrointestinal bleeding is one of the most common causes of
hospitalization. Effective initial patient evaluation determines the
potential source of gastrointestinal bleeding (upper vs lower),
provides risk stratification, and guides further management. The
gastroenterologist, interventional radiologist, and surgeon can
offer different invasive therapeutic interventions, and the hospitalist is often involved in the crucial management before and after
these procedures. Hemodynamic resuscitation, pharmacological
interventions, and triage to the appropriate setting of care are
initial supportive measures. Timely consultation and knowledge
of therapeutic measures provides appropriate and cost-effective
care, including individualized transfusion strategies and correction of coagulopathy. This issue provides an evidence-based
review of management strategies for gastrointestinal bleeding in
the hospitalized patient to optimize the quality of care, facilitate
cost-effective treatment, and improve clinical outcomes.
Editor-in-Chief
Editorial Board
Sunil Dacha, MD
Gastroenterology Fellow, Emory University School of Medicine,
Atlanta, GA
Stephen H. Berger, MD
Gastroenterology Fellow, Emory University School of Medicine,
Atlanta, GA
Mehul Parikh, MD
Gastroenterology Fellow, Emory University School of Medicine,
Atlanta, GA
Mohammad Wehbi, MD
Associate Professor of Medicine, Emory University School of
Medicine, Atlanta, GA
Peer Reviewers
Abebe Abebe, MD, FACP
Assistant Professor, Department of Internal Medicine/Hospital
Medicine, Division of General and Geriatric Medicine, University
of Kansas Medical Center, Kansas City, KS
Ivan Pavlov, MD
Hospitalist and Emergency Physician, Departments of General
and Emergency Medicine, Hpital de Verdun, Montral, Qubec,
Canada
Prior to beginning this activity, see Physician CME Information
on the back page.
Solomon Liao, MD
Director of Palliative Care Services,
Associate Clinical Professor, Hospitalist
Program, University of California Irvine,
Irvine, CA
www.hmpractice.com
Clinical Pearls
Coagulopathy
Treat high INR with fresh-frozen plasma or
4-factor prothrombin complex concentrate; use
vitamin K when bleeding is due to warfarin.
Transfuse platelets when platelets < 50,000/mm3.
Withold antiplatelet agents until hemostasis is
established.
Therapeutic Measures
Discharge from the emergency department
without endoscopy is appropriate for patients
with BUN < 18.2; Hb > 13 for men, 12 g/dL for
women; systolic blood pressure > 110 mm Hg;
pulse rate < 100; and absence of melena, syncope,
cardiac failure, and liver disease (2012 American
College of Gastroenterology practice guidelines).
Arrange endoscopy within 12 hours of admission
for high-risk patients (tachycardia, hypotension,
bloody emesis, or bloody nasogastric aspirate)
Arrange endoscopy within 24 hours for low-risk
patients (this reduces transfusion requirements,
ICU stay, and hospital stay).
Upper endoscopy (esophagogastroduodenoscopy) is the diagnostic modality of choice for UGIB;
lower endoscopy (colonoscopy) is the diagnostic
modality of choice for LGIB.
History (Page 6)
Presentation:
UGIB: hematochezia, hematemesis, melena.
LGIB: hematochezia, occult bleeding, and
systemic symptoms of blood loss or anemia.
Current medications should be reviewed for
etiology.
UGIB
Whenever feasible, arrange early endoscopic
evaluation of UGIB to identify high-risk lesions.
Discharge from the emergency department or
hospital day 1: patients with low-risk endoscopic
features, low-risk clinical features (stable vital
signs, stable Hb, no serious comorbidities), and
good social support. Provide oral PPI therapy
and appropriate follow-up.
Admit to the ICU: patients with high-risk endoscopic features and/or ongoing bleeding, unstable vital signs, or unstable comorbidities.
Treat high-risk stigmata for at least 3 days
to receive IV PPI therapy and to monitor for
rebleeding.
Do not obtain second-look endoscopy; this is
usually performed 24 hours after the initial
therapeutic endoscopy.
LGIB
Endoscopic risk stratification does not exist for
LGIB.
Patients can be discharged with resolution of
bleeding, stable vital signs, and stable Hb.
Case Presentations
You are called to the ED for admission of a 45-year-old
man with no known past medical history other than
significant alcohol use after he presented to the ED with
complaints of episodes of bloody vomitus and dizziness
and weakness. The initial assessment reveals a blood pressure of 100/50 mm Hg, a pulse rate of 120 beats/min, and
an oxygen saturation of 99% on room air. His physical
examination is remarkable for mild icterus, spider angiomas on the chest, and dullness to percussion in the flank
areas. His labs are significant for a hemoglobin of 9 g/dL,
a platelet count of 45,000/mm3, an INR of 1.8, a total bilirubin of 2 mg/dL, a BUN of 68 mg/dL, and a creatinine of
1.2 mg/dL. What is the most likely cause of this patient's
bloody vomitus, and how should he be managed?
A 47-year-old woman, apparently healthy, presents to the ED with the chief complaint of dizziness and
generalized weakness of 1 days duration. On further
questioning, she mentions that she has passed black stools
on multiple occasions for the last 2 days. She reports
taking headache powders and ibuprofen tablets daily for
headaches. On physical examination, there is evidence of
conjunctival pallor and epigastric tenderness. Her vital
signs are within normal limits. Her hemoglobin is 6.5 g/
dL, BUN is 36 mg/dL, and creatinine is 1.2 mg/dL. Her
platelet count and INR are within the normal range.
When you review her chart for admission, you observe
that she is anemic, but what should the transfusion strategy be and how can you manage her bleeding?
A 76-year-old man with a history of coronary artery
disease and atrial fibrillation on warfarin presents to ED
with a chief complaint of bright red blood per rectum
for 3 days. He is currently on 325 mg aspirin daily. His
vital signs are within normal limits and he is, otherwise,
asymptomatic. He had a colonoscopy 2 years ago, which
showed extensive diverticulosis. His INR is 4, his hemoglobin is 12.3 g/dL, and his laboratory workup is otherwise unrevealing. As you prepare him for admission, you
consider what the guidelines say about managing bleeding
in an anticoagulated patient...
The paramedics bring in a 39-year-old man in an
unconscious state, and you are called in to manage his admission. He has a history of alcoholic cirrhosis, and there
is a report of him vomiting blood prior to passing out. On
initial assessment, he is responding to commands. On
presentation, his vital signs include a blood pressure of
80/50 mm Hg, a pulse rate of 140 beats/ min, and an oxygen saturation of 99% on room air. His physical exam is
significant for spider angiomas and ascites. His labs show
hemoglobin of 9 g/dL, a platelet count of 60,000/mm3 and
INR of 1.4. What would be the appropriate transfusion
strategy for this patient and timing for endoscopy?
Introduction
Gastrointestinal bleeding (GIB) is the most common
cause of gastrointestinal (GI) emergencies. UpAugust 2014 www.hmpractice.com
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Incidence
Risk Factors
Comments
40%-50%
Esophageal/gastric varices
20%-30%
Mallory-Weiss tear
5%-15%
Erosive esophagitis
10%
Vascular malformations
(angiodysplasia, Dieulafoy
lesion, GAVE, portal gastropathy, telangiectasia)
< 5%
Neoplasm
1%
Rare
Abbreviations: GAVE, gastric antral vascular ectasia; GERD, gastroesophageal reflux disease; H pylori, Helicobacter pylori; ICU, intensive care unit;
NSAID, nonsteroidal anti-inflammatory drug; UGIB, upper gastrointestinal bleed.
Differential Diagnosis
For information on the diagnosis of GIB, including
incidence and risk factors, see Tables 1, 2, and 3.
Differential diagnosis varies, based on the clinical
Incidence
Risk Factors
Comments
Diverticular
disease
15%-55%
Angiodysplasia
3%-37%
Neoplasms
15%
UGIB
13%
N/A
Colitis
10%
Ischemia, IBD, radiation, infections (bacterial: Salmonella, Shigella, E coli O157: H7; viral: CMV, etc)
Hemorrhoids
10%
Constipation
Abbreviations: CMV, cytomegalovirus; Escherichia coli, E coli; HNPCC, hereditary nonpolyposis colorectal cancer; IBD, inflammatory bowel disease;
LGIB, lower gastrointestinal bleeding; N/A, not applicable; UGIB, upper gastrointestinal bleeding.
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scenario. It is important to be thinking of all potential causes, especially in the setting where a patient's
past medical history is unobtainable.
History
Initial Evaluation
There are 5 types of GIB presentations: (1) hematemesis, (2) melena, (3) hematochezia, (4) obscure
bleeding, and (5) systemic symptoms of blood loss
or anemia. (See Table 4, page 7.)
The clinical presentation can help in the appropriate localization of the bleeding as upper or
lower. Hematemesis and melena are usually associated with UGIB, while hematochezia is usually
associated with LGIB. Melena can be a presenting manifestation of small intestinal bleeding and
right-sided colonic lesions. Up to 13% of patients
presenting with hematochezia have a primary upper
GI source.31 Bleeding from the left colon presents as
bright red blood, whereas bleeding from the right
colon presents as maroon-colored blood that is
intermixed with stool. The combination of accurate
history taking and the presenting symptomatology
can aid physicians in significantly narrowing down
the differential diagnosis.
Past medical history plays a major role in determining the triage and management strategies. Prior
GIB is an essential risk factor for GIB, with up to
60% of patients having a history of UGIB from the
same lesion.32 History of liver disease should raise
the suspicion for a portal hypertensive etiology.
History of NSAID use or potential H pylori infection
should raise the suspicion for peptic ulcer disease.
Retching and vomiting should raise the suspicion
for a Mallory-Weiss tear. History of weight loss
should raise the suspicion for a malignancy. History
of aortic stenosis, renal disease, or hereditary hemorrhagic telangiectasia should raise the suspicion of
angiodysplasia.
Comorbidities such as coronary artery disease,
heart failure, pulmonary disease, coagulopathies,
and end-stage renal disease significantly affect
morbidity and mortality in patients with GIB. Patients with a history of coronary artery disease have
a higher threshold for target hemoglobin with or
without evidence of ongoing ischemia. Patients with
heart failure and end-stage renal disease require
closer monitoring in an intensive care setting, as the
potential for volume overload and subsequent respiratory failure is high. Patients with coagulopathies
need closer hematologic monitoring and administration of blood products. Poor mental status may
necessitate intubation.6,14,33
Current medication history should be obtained.
Antiplatelet and anticoagulation therapy result in
bleeding that is difficult to control. The intake of bismuth or iron may alter the clinical presentation, as it
is associated with darkening in the color of stools.
Initial evaluation determines management in patients who present to the hospital with suspected
GIB. A 2012 study described a retrospective data
analysis of 1776 patients admitted for a suspected
Risk Factors
Peptic ulcers
Angioectasias
Dieulafoy lesions
Hemosuccus pancreaticus
Hemobilia
Aortoenteric fistula
Sources
Risk Factors
NSAID use
IBD
Multifactorial
Congenital
Dieulafoy lesions
Disease-specific history
(ICU) admission.
Given the limitations and the lack of routine
clinical use of the Glasgow-Blatchford and Rockall
scoring systems, The AIMS65 score was introduced
in 2013 as a pre-endoscopic risk stratification tool
to assess mortality. The 5 factors that are scored
in the AIMS65 score include: Albumin level < 3;
International normalized ratio (INR) > 1.5; altered
Mental status; Systolic blood pressure 90 mm
Hg; and age > 65 years.37 The AIMS65 score is better
at predicting inpatient mortality, length of hospital
stay (from 3.4 days for 0 risk factors to 8.1 days for 5
risk factors), and hospitalization cost (average cost
of $5647 USD with 0 risk factors to $15,776 USD with
5 risk factors). However, it could not predict risk of
the rebleeding after endoscopy.37
Physical Examination
Diagnostic Studies
A summary of the various types of diagnostic studies for GI bleeding can be seen in Table 6 (page 9).
Scoring Systems
Laboratory Testing
Description
Comments
Hematemesis
Melena
Hematochezia
Obscure bleeding
May present by presence of iron deficiency or fecal occult blood test previously worked up without a known
source
Abbreviations: GI, gastrointestinal; NSAID, nonsteroidal anti-inflammatory drug; UGIB, upper gastrointestinal bleeding.
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Nasogastric Lavage
Imaging Studies
Score
Blood Urea
6.5 to < 8
8 to < 10
10 to < 25
25
6
Hemoglobin (g/L) for men
12 to < 13
10 to < 12
< 10
6
Hemoglobin (g/L) for women
10 to < 12
< 10
6
Systolic Blood Pressure (mm Hg)
100-109
90-99
< 90
3
Other Markers
Hepatic disease
Cardiac failure
A total score > 8 carries high risk, justifying intensive care unit admission.
Reprinted from The Lancet, Volume 356, Issue 9238. Oliver Blatchford,
William R. Murray, Mary Blatchford. "A Risk Score to Predict Need for
Treatment for Uppergastrointestinal Haemorrhage." Pages 13181321, Copyright 2000, with permission from Elsevier.
To view the Rockall numerical risk scoring system, scan the QR code
with a smartphone or go to http://www.ncbi.nlm.nih.gov/pmc/articles/
PMC1383057/?page=3
Pharmacologic Interventions
Diagnostic studies for OGIB include wireless capsule endoscopy, push enteroscopy, and deep smallbowel enteroscopy with either a single or double
balloon. In the setting of an overt OGIB, testing with
bleeding scans and angiography is recommended.9
If examinations are negative, pursuing a capsule
endoscopy is the next best step. If occult obscure GI
blood loss and iron deficiency anemia are present,
the AGA recommends capsule endoscopy.9 This
is important (especially in younger patients), as
small-bowel tumors are the most common cause of
obscure bleeding in patients aged < 50 years. ASGE
has moderate evidence to recommend iron therapy
for occult OGIB with negative capsule studies.7
Treatment
Clinical Indication
Comments
Nasogastric lavage
Radiographic imaging
Abbreviations: ECG, electrocardiogram; GIB, gastrointestinal bleeding; INR, international normalized ratio; PT, prothrombin time.
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Therapeutic Measures
Upper Endoscopy
In addition to its use as the diagnostic modality of
choice for UGIB, upper endoscopy has the added
benefit of use as a therapeutic intervention. The
Forrest Classifications (see Table 7) describe endoscopic findings in patients with peptic ulcer disease,
guide management decisions, and predict the risk
of further bleeding.6,63,64 Treatment modalities for
Prevalence
(%)
Risk of Rebleed on
Medical Management (%)
10
90
10
10-20
25
50
10
25-30
10
7-10
35
3-5
Special Circumstances
Gastrointestinal Bleeding In The Setting Of
Mandatory Antiplatelet And Anticoagulant
Therapy
Antiplatelet and anticoagulation therapy can contribute to clinically significant GIB. In a prospective
study involving 18,820 hospital admissions, 376
were related to aspirin, clopidogrel (Plavix), or
warfarin.78 The majority of those admissions were
related to GIB. A meta-analysis that included 14 randomized controlled trials (including 57,000 patients)
showed a relative risk of 2.07 (95% CI, 1.61-2.66)
for aspirin versus placebo. There was no difference
whether the aspirin dose was 76 to 162.5 mg/day or
162.5 to 325 mg/day. The absolute annual increases
attributable to aspirin risk for major GIB was 0.12%
(95% CI, 0.07-0.19).79 Factors that increased the risk
of GIB in aspirin users included a history of GI
bleeding (OR, 6.5; 95% CI, 2.0-21.2),80 prior history
of peptic ulcer disease (OR 2.1; 95% CI, 91.0-4.10),80
concomitant corticosteroid or anticoagulant use, and
the concomitant use of nonaspirin NSAIDs.81 In a
multivariate analysis from case-controlled studies,
older age did not show an increased relative risk for
GIB.80,81 However, the absolute risk of GIB, regardless of aspirin use, remains higher in older age.81,82
The data for clopidogrel in GIB are limited.
Combination therapy increases the risk of GIB. This
was evident in the Clopidogrel in Unstable Angina
to Prevent Recurrent Events (CURE) study.81 The
risk of bleeding with dual antiplatelet therapy is
1.3% in the first 30 days; however, it increases to 12%
with a history of GIB.82
The management of antiplatelet agents in
patients with acute coronary syndromes or recent
coronary stents in the setting of GIB is difficult.
The ASGE guidelines recommend withholding
antiplatelet agents until hemostasis is achieved.
Platelet transfusions may be needed in life-threatening GIB due to dysfunctional platelets, and
urgent cardiology consults should be obtained to
aid in the management.83-87
Anticoagulants increase the risk of major GIB. In
randomized controlled trials, the frequency of major
11
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Quality Improvement
Transfusion Strategies
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Active bleeding
Inactive bleeding
Video
capsule
enteroscopy,
deep endoscopy, push
enteroscopy,
and/or
colonoscopy
Suspected
upper GI
bleeding
Repeat EGD
or PE
Consider
deep enteroscopy*
NEGATIVE
Consider CT
enterography or CT
angiography
Other GI
bleeding
Consider CT
enterography or CT
angiography
NEGATIVE
Angiography
and/or
colonoscopy
Recurrent
bleeding
Consider
provocative
testing
NEGATIVE
No recurrent
bleeding
Consider interoperative
endoscopy
See Clinical
Pathway
for Occult
Obscure GI
Bleeding,
page 15
14
Consider trial of
empiric iron therapy
NO RESPONSE
Consider multiphase CT
enterography or
CT angiography
Small-bowel evaluation
NEGATIVE
Consider deep
enteroscopy*
NEGATIVE
Stable
Continued bleeding
Deep enteroscopy
15
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severe colonic bleeding, a rapid purge prior to urgent colonoscopy can be considered. Four to 8 liters
of polyethylene glycol orally or via nasogastric tube
over 2 to 3 hours is given until the rectal effluent is
clear. Rapid purge is not always well tolerated, however. Metoclopramide (10 mg) or erythromycin (250
mg) may be given intravenously before the purge
to facilitate gastric emptying. Risks of rapid purge
include aspiration and fluid overload.113
It is unclear whether or not urgent colonoscopy
with rapid purge changes outcomes. Jensen et al
reported that urgent colonoscopy may provide high
rates of endoscopic hemostasis and may reduce the
need for future surgery.114 A randomized trial of
72 patients did not show that urgent colonoscopy
improved clinical outcomes or lowered hospital
charges compared to elective colonoscopy. A major
limitation was that the study was terminated early,
so the small sample size may not have allowed for
statistical significance.31
Additional Considerations
Bowel Preparation Strategies
16
associated with more oxygen desaturation as compared to endoscopy within 12 to 24 hours.123 Another study, by Yavorski et al, showed that mortality
rates were higher for high-risk patients who did not
undergo an early endoscopic intervention than for
patients who did undergo the intervention early
(within 13 hours of clinical presentation) (11.1% vs
5.2%, respectively).124
Routine second-look endoscopy (usually performed 24 hours after the initial therapeutic endoscopy) is not recommended by any major society.
However, in patients with clinical evidence of recurrent bleeding, a repeat endoscopy with the intention to treat is warranted. This is especially true in
patients with high-risk stigmata for hemorrhage on
index endoscopy. Recurrent bleeding after a second
therapeutic endoscopic session should prompt a
surgical consultation or an interventional radiology
consultation, with consideration for transcatheter
artery embolization.67,122
Stress ulcerations are the major cause of GIB in critically ill patients in the ICU. A prospective multicenter cohort study identified 2 main risk factors for
bleeding: coagulopathy (OR, 4.3) and mechanical
ventilation longer than 48 hours (OR, 15.6). The frequency of clinically significant GIB to either or both
of these risk factors was 3.7%, compared with 0.1%
when neither risk factor was present. The mortality
rate was 48.5% in the group with bleeding and 9.1%
in the group without bleeding (P < .001).116 Other
proposed risk factors include history of GIB, sepsis,
ICU admission > 1 week, occult GIB lasting > 6
days, and glucocorticoid therapy.117
Prophylaxis of stress ulcerations is indicated in
high-risk groups. Pharmacological options include
H2 blocker, PPI, and sucralfate (Carafate). A metaanalysis of 13 randomized trials compared stress
ulcer prophylaxis with a PPI to prophylaxis with an
H2 blocker. Less GIB was seen among those who
received PPI (1.3 vs 6.6 %; OR, 0.30; CI, 0.17-0.54).
There was no difference in mortality or the incidence
of nosocomial pneumonia.118
Potential harms of prophylaxis include increasing gastric pH and increasing incidence of nosocomial pneumonia. However, only a trend (and not
statistical significance) has been reached in studies.
Stress ulcer prophylaxis should be discontinued
when the patient is no longer at risk.118
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compared urgent colonoscopy toexpectant or electivecolonoscopy alone or with radiographic interventions. It showed improved detection of the bleeding etiology; however, it did not significantly reduce
mortality, hospital stay, transfusion requirements,
or the need for surgery.128 On the other hand, other
studies have suggested that a therapeutic urgent
colonoscopy (< 12 hours from admission) can reduce
the risk of rebleeding and surgery in patients with
severe diverticular hemorrhage when compared to
patients treated conservatively.5,31,114,128-135
Summary
For patients with any GI bleeding, hemodynamic resuscitation is the initial management,
and appropriate transfusion strategies should be
followed. These include packed red blood cell
transfusions, correction of coagulopathy with
FFP if the INR is > 1.5; monitoring for hypothermia and electrolyte abnormalities; and correction of thrombocytopenia if the platelet count is
< 50,000/mm3. Thrombotic thrombocytopenic
purpura should be ruled out by checking a
peripheral smear (although this is not always
possible).
LGIB is more common than UGIB, but UGIB
events are more clinically significant.
In patients with suspected nonvariceal UGIB,
the pre-endoscopic institution of intravenous
PPI may alter the endoscopic detection of
high-risk lesions; however, it does not affect
outcomes. H pylori and NSAIDs should be considered as possible etiologies of peptic ulcers.
All gastric ulcers need a follow-up endoscopy to
ensure healing and to rule out malignancy.
Patients with nonvariceal UGIB and high-risk
lesions on endoscopy must be treated with intra-
18
Case Conclusions
Your 45-year-old patients clinical presentation of bloody
vomiting was suggestive of variceal bleeding. The initial
acute management included hemodynamic resuscitation
along with PPI drip, octreotide drip, IV ceftriaxone to
prevent spontaneous bacterial peritonitis, and appropriate PRBC transfusion for a target hemoglobin of 7 g/dL,
avoiding overtransfusion. He was managed in an ICU
setting and was intubated electively. An emergent EGD
revealed bleeding esophageal varices. Band ligation of
varices was performed, with control of bleeding, and the
octreotide drip was continued. Nadolol and PPI were
prescribed on discharge.
Your anemic female patient's clinical history was
suspicious for peptic ulcer related to significant NSAID
use. The degree of anemia suggested significant blood loss.
Initial management included appropriate hemodynamic
resuscitation with IV fluids, PRBC transfusion, and PPI
drip, along with close monitoring. Upper endoscopy revealed numerous large gastric ulcers with visible vessels.
Endoscopic treatment with epinephrine and cautery was
performed. IV PPI was continued for 72 hours. She was
discharged on PPI with a plan for repeat EGD in 8 weeks
to assess for healing of her gastric ulcers. H pylori testing
was negative.
For the elderly patient with coronary artery disease,
you noted that his clinical history was suspicious for
diverticular LGIB in the setting of supratherapeutic INR.
His acute management included appropriate hemodynamic resuscitation with IV fluids, PRBC transfusion as
needed, and close monitoring in the hospital setting. FFP
was administered to correct his INR. A colonoscopy was
performed after appropriate bowel preparation. Old blood
clots were seen on the left side of the colon, along with diverticula; the rest of the colon along with terminal ileum
was normal, suggestive of left-sided diverticular bleeding.
Aspirin was restarted immediately after the procedure
and warfarin was restarted in 2 days, as he was felt to be
at high risk for thromboembolic events.
19
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5. The patient had a recurrent episode of hematemesis requiring transfusion therapy, but I
discharged him, as his endoscopy was normal.
It is always possible for lesions to be missed
on endoscopy, so it is not appropriate to
discharge patients in these circumstances. This
is particularly true of Dieulafoy lesions and
arteriovenous malformations.
20
Diagnosis
Severity Index
G-LOS (days)
379
0.69
2.41
$4100
378
GI hemorrhage with CC
3.3
$6000
377
1.76
4.8
$10,600
384
0.85
$5100
380
1.92
5.5
$11,500
Abbreviations: CC, comorbid condition; GI, gastrointestinal; GIB, gastrointestinal bleeding; G-LOS, geometric mean length of stay; MCC, major
comorbid condition; MS-DRG, Medicare severity diagnosis-related group; NSAID, nonsteroidal anti-inflammatory drug; SI, severity index.
21
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The alcoholic cirrhotic patient's clinical history was
suspicious for variceal UGIB, and he was hemodynamically unstable. The acute GI bleeding and hemoconcentration made his initial hemoglobin unreliable. Due to
the clinical scenario, he was emergently intubated in the
ED, and the initial acute management included hemodynamic resuscitation along with PPI drip, octreotide drip,
prophylactic antibiotics in the form of IV ceftriaxone to
prevent spontaneous bacterial peritonitis, and appropriate PRBC transfusion, avoiding overtransfusion. Emergent EGD was performed after initial resuscitation, but
bleeding could not be controlled due to bleeding gastric
fundic varices. A Sengstaken-Blakemore tube was placed
for tamponade therapy. He subsequently underwent TIPS
procedure with control of his bleeding.
13. Boyer TD, Haskal ZJ. American Association for the Study
of Liver Diseases practice guidelines: the role of transjugular intrahepatic portosystemic shunt creation in the
management of portal hypertension. J Vasc Interv Radiol.
2005;16(5):615-629. (Guidelines)
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22
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88. Choudari CP, Rajgopal C, Palmer KR. Acute gastrointestinal haemorrhage in anticoagulated patients: diagnoses and
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87. Fox KA, Mehta SR, Peters R, et al. Benefits and risks of the
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73. Cho SK, Shin SW, Lee IH, et al. Balloon-occluded retrograde transvenous obliteration of gastric varices: outcomes
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77. Yazici C, Losurdo J, Brown MD, et al. Inpatient capsule endoscopy leads to frequent incomplete small bowel examinations. World J Gastroenterol. 2012;18(36):5051-5057. (Retrospective observational study; 355 patients)
93. Witt DM, Delate T, Garcia DA, et al. Risk of thromboembolism, recurrent hemorrhage, and death after warfarin
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24
110. Wysocki JD, Srivastav S, Winstead NS. A nationwide analysis of risk factors for mortality and time to endoscopy in
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94. Zaman A, Katon RM. Push enteroscopy for obscure gastrointestinal bleeding yields a high incidence of proximal lesions
within reach of a standard endoscope. Gastrointest Endosc.
1998;47(5):372-376. (Retrospective observational; 95 patients)
95. Triester SL, Leighton JA, Leontiadis GI, et al. A meta-analysis of the yield of capsule endoscopy compared to other
diagnostic modalities in patients with obscure gastrointestinal bleeding. Am J Gastroenterol. 2005;100(11):2407-2418.
(Meta-analysis)
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hemorrhage. N Engl J Med. 2000;342(2):78-82. (Prospective
study; 80 patients)
99. Strate LL, Ayanian JZ, Kotler G, et al. Risk factors for mortality in lower intestinal bleeding. Clin Gastroenterol Hepatol.
2008;6(9):1004-1010. (Healthcare cost and utilization project
nationwide inpatient sample; 227,022 patients)
116. Cook DJ, Fuller HD, Guyatt GH, et al. Risk factors for
gastrointestinal bleeding in critically ill patients. Canadian
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(Prospective multicenter cohort study; 2252 patients)
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patients)
118. Barkun AN, Bardou M, Pham CQ, et al. Proton pump inhibitors vs. histamine 2 receptor antagonists for stress-related
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meta-analysis. Am J Gastroenterol. 2012;107(4):507-520. (Metaanalysis; 1587 patients)
102. Pateron D, Vicaut E, Debuc E, et al. Erythromycin infusion or gastric lavage for upper gastrointestinal bleeding:
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2011;57(6):582-589. (Prospective randomized multicenter
study; 253 patients)
119. Spiegel BM, Vakil NB, Ofman JJ. Endoscopy for acute
nonvariceal upper gastrointestinal tract hemorrhage:
is sooner better? A systematic review. Arch Intern Med.
2001;161(11):1393-1404. (Review)
103. Mandell MS. Blood transfusion: friend or foe? Crit Care Med.
2013;41(3):928-929. (Comment)
120. Tsoi KK, Ma TK, Sung JJ. Endoscopy for upper gastrointestinal bleeding: how urgent is it? Nat Rev Gastroenterol Hepatol.
2009;6(8):463-469. (Systematic review; 23 studies)
104. Smith HM, Farrow SJ, Ackerman JD, et al. Cardiac arrests
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series; 16 patients)
121. Cooper GS, Chak A, Way LE, et al. Early endoscopy in upper
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1997;15(7):644-647. (Prospective study; 50 patients)
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CME Questions
128. Green BT, Rockey DC, Portwood G, et al. Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial. Am J
Gastroenterol. 2005;100(11):2395-2402. (Randomized trial; 100
patients)
129. Sreedharan A, Martin J, Leontiadis GI, et al. Proton pump
inhibitor treatment initiated prior to endoscopic diagnosis
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controlled trials; 2223 patients)
133. Chan FK, Chung SC, Suen BY, et al. Preventing recurrent
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patients)
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136. Pruitt RE, Truss CD. Endoscopy, gastric ulcer, and gastric
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139. Stolte M, Seitter V, Muller H. Improvement in the quality of
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2001;39(5):349-355. (Retrospective review; 1658 patients)
26
Coming Soon In
Hospital Medicine
Practice
AUTHORS:
TRUSHAR M. DUNGARANI, DO
Clinical Assistant Professor, Assistant Director of
Hospitalist Medicine, Department of Medicine,
North Shore LIJ Lenox Hill Hospital, New York, NY
RAJI SHAMEEM, MD
Department of Internal Medicine, Lenox Hill
Hospital, New York, NY
27
Reprints: www.hmpractice.com/hmpissues
Date of Original Release: August 1, 2014. Date of most recent review: July 15,
2014. Termination date: August 1, 2017.
Accreditation: EB Medicine is accredited by the Accreditation Council for
Continuing Medical Education (ACCME) to provide continuing medical
education for physicians. This activity has been planned and implemented in
accordance with the Essential Areas and Policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a
maximum of 4 AMA PRA Category 1 CreditsTM. Physicians should claim only
the credit commensurate with the extent of their participation in the activity.
AOA Accreditation: Hospital Medicine Practice is eligible for up to 48 American
Osteopathic Association Category 2A or 2B credit hours per year.
Needs Assessment: The need for this educational activity was determined
by a survey of medical staff, including the editorial board of this publication;
review of morbidity and mortality data from the CDC, AHA, and NCHS; and
evaluation of prior activities for hospital medicine physicians.
Target Audience: This enduring material is designed for hospital medicine
physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate
medical decision-making based on the strongest clinical evidence; (2) costeffectively diagnose and treat the most critical presentations; and (3) describe
the most common medicolegal pitfalls for each topic covered.
Objectives: Upon completion of this activity, you should be able to: (1)
identify various presentations of GI bleeding; (2) understand the etiology
of upper, lower and obscure GI bleeding; (3) identify high-risk patients for
ICU admission; and (4) determine appropriate management of various
medications with GI bleeding.
Volume
y 2014
2, Numb
er 1
Editorial Board
Alpesh N. Amin, MD, MBA, MACP, SFHM Amish A. Dangodara, MD, FACP
Thomas & Mary Cesario Endowed
Professor of Medicine, Director of
Chair of Medicine
Preoperative Clinic and General
Professor of Medicine, Business,
Internal Medicine Consultation,
Public Health, Nursing Science &
Hospitalist Program, University of
Biomedical Engineering
California Irvine, Irvine, CA
Executive Director, Hospitalist
Nancy Dawson, MD, FACP
Program
Assistant Professor, Hospital Practice
University of California Irvine,
Chair, Division of Hospital Medicine,
Irvine, CA
Mayo Clinic, Jacksonville, FL
Steven Deitelzweig, MD
System Chairman, Hospital Medicine,
Regional Vice President of Medical
Affairs, Ochsner Health System, New
Orleans, LA
Charting Contributor
January 2014
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Solomon Liao, MD
Director of Palliative Care Services,
Associate Clinical Professor, Hospitalist
Program, University of California
Irvine, Irvine, CA
David Likosky, MD, SFHM
Medical Director, Evergreen
Neuroscience Institute, Kirkland,
WA; Clinical Faculty, University of
Washington, Seattle, WA
Sylvia McKean, MD
Associate Professor of Medicine,
Harvard Medical School; Associate
Physician, Brigham and Womens
Hospital, Boston, MA
Geno J. Merli, MD
Clinical Professor, Jefferson Hospital;
Co-Director, Jefferson Vascular Center,
Philadelphia, PA
Franklin A. Michota, MD, FACP, FHM
Associate Professor of Medicine,
Director of Academic Affairs,
Department of Hospital Medicine,
Cleveland Clinic, Cleveland, OH
Daniel Robitshek, MD
Medical Director, Hospitalist Program,
Floyd Medical Center, Rome, GA
Mike Wang, MD
Director of Hospital Medicine,
Associate Professor of Clinical
Medicine, Keck Medical Center of USC,
Los Angeles, CA
David Wooldridge, MD, FACP
Program Director, Internal Medicine
Residency Program, Associate
Professor of Internal Medicine,
University of Missouri-Kansas City
School of Medicine, Kansas City, MO
Nejat Zeyneloglu, MD
Medical Director, Hospital Medicine
Program, New York Hospital Queens,
Weill-Cornell Medical College, New
York, NY
Pharmacology Contributor
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