An Approach To:

Gastrointestinal Bleeding

Amir SurmawalaPGY 2Bruyere Family Medicine

Upper vs. LowerObscure | Occult

ClassificationUpper gastrointestinal bleeding:Bleeding that originates from the gastrointestinal (GI) tract proximal to the ligament of Treitz (the junction of the duodenum and jejunum).

Lower gastrointestinal bleeding:Bleeding distal to the ligament of Treitz, and thus includes bleeding sources in the small bowel and colon. It is sometimes subcategorized as bleeding from the small bowel vs. bleeding from the colon.

Definitions

Hematochezia: passage of bright red blood per rectum

Melena: stools that appear black and tar-like (see picture)

Upper GI Bleeding - DDX Peptic Ulcer Disease (~50%): Gastric vs. Duodenal

Inflammatory: Esophagitis (CMV, Medication), Gastritis (10-20%), IBD (Crohn’s)

Varices: Esophagus (10-30%) vs. Stomach

Structural: Mallory-Weiss tear (10%); Boerhaave’s syndrome; Dieulafoy’s lesion; AVM; Aortoenteric fistula; Hemobilia

Tumor: Esophagus, Stomach, Duodenum

Other: Epistaxis, Hemoptysis, Coagulopathy

Duodenal ulcer with a visible vessel

Bleeding esophageal varix

Severe esophagitis

Lower GI Bleeding - DDX Upper GI Source with Brisk Bleeding (>1000mL)

Infectious: SECSY (Salmonella, E.coli - EHEC, EIEC, Campylobacter + C.diff, Shigella, Yersinia). Amoeba.

Inflammatory: Crohn’s and Ulcerative Colitis, Radiation Colitis

Ischemic: Ischemic colitis

Tumor: Colorectal, Small bowel, Polyp

Structural: Diverticulosis (R>L), Angiodysplasia, Intussusception, Meckel’s Diverticulum, Anorectal: Hemorrhoids, Anal Fissure

Blood vessel within a colonic diverticulum

Angiodysplasia of the colon

Ulcerative colitis

Ischemic colitis on colonoscopy

Immediate Resuscitation

1. ABC’s: 2 Large bore peripheral IVs, Crossmatch Blood, Start Transfusion if indicated

2. Immediate evaluation: NG, Postural changes, ECG, Trop, Urea

3. Reverse anticoagulation

4. Transfusion target: Start if Hgb <70 or hemodynamic instability. Target ~ 90

GI Bleed - History

Hematochezia > Hematemesis > Coffee ground emesis > Melena > Occult blood in stool

EtOH abuse, intoxication, emesis

Liver Disease

PMHx: PUD, H.pylori, Renal disease, Heart disease

Hematochezia, Occult Blood. Rarely Melena

Abd pain, fever, diarrhea

PMHx: IBD, cancer, diverticulosis

Meds: AC, NSAIDs

Last Meal

Constitutional symptoms

UPPER LOWER

GI Bleed - Physical

Signs of Cirrhosis

Bloody NG Aspirate (Occult Blood testing not validated)

Obvious signs of HEENT bleed

Mass, Hemorrhoid or fissure on rectal examination

ABC’s and Vitals

Signs of Hypovolemia: *Postural Changes (SBP >20, DBP>10, Pulse >30)

Abd. Exam, Rectal exam +ve for Occult Blood

UPPER LOWER

GI Bleed - Investigation

BUN/Creatinine ratio >20 OR Urea/Creatinine ratio >100

Due to degradation of blood cells and absorption of protein

Stool C&S, O&P, C.diff toxin

CBC, lytes, Cr, urea, type/crossmatch, PTT, INR, LFT’s, bilirubin, albumin

CXR, AXR, CT Scan

Upper and Lower Endoscopy

Angiography, RBC Scan

UPPER LOWER

Angiography vs. RBC Scan

If source not found via Endoscopy:

FASTER Bleed (>0.5ml/min): Angiography.

Embolization

SLOW Bleed (<0.5ml/min): 99Tc RBC Scan.

Detects 0.1ml/minhttp://www.wjgnet.com/1007-9327/full/v18/i11/WJG-18-1191-g004.jpg

Management As Per Etiology

UGIB Non-Variceal:

IV PPI (Pantoprazole 80mg bolus over 1h, then 8mg/hr infusion IV Erythromycin 250mg, 30min prior to Endoscopy (to facilitate gastric

emptying)

LGIB PEG Lavage to facilitate Endoscopy

Variceal: IV Octreotide (50mcg bolus, then 25-50mcg/hr infusion) If Cirrhosis - IV abx (Ceftriaxone OR Cipro x 10d.)

Definitive management is usually Endoscopic, Vascular or Surgical intervention

Tips on Occult GI Bleeding

Common foods and drugs that can cause the stool to appear bloody

Red coloration, similar to fresh blood

Certain antibiotics*

Beets

Flavored gelatin (red colored)

Kool­Aid or fruit punch (red colored)

Red licorice

Red­dyed snack foods (eg, spicy "red­hot" snacks)

Black coloration, similar to melena

Bismuth preparations (Pepto­Bismol, Maalox, Kaopectate)

Activated charcoal

Chocolate

Blueberries

Iron supplements

Large quantities of some dark green foods

False­positive results to fecal occult blood test

Rare red meat

Peroxidase­containing vegetables (turnips, horseradish, broccoli, cauliflower, and cantaloupe)

* Several reports have described cases of very red­appearing stools associated with cefdinir, apparently

¶

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The Tests FOBT

Guaiac based test (Guaiac changes color in the presence of pseudoperoxidase contained in Heme)

Detection: 10mg/gram of stool

iFOBT or FIT Antibody directed against human

hemoglobin

Detection: 0.3mg/gram of stool

More sensitive and specific for Lower GI blood loss; as well as for colon cancer screening

8/13/2015 Colorectal Cancer Association of Canada - CCAC

http://www.colorectal-cancer.ca/en/screening/fobt-and-fit/ 4/5

AutoFIT Personal Pack CollectionMaterials

Automated Analyzer OC­Auto Micro 80 used forAuto FIT Testing

Automation allows for standardization and quality control in the laboratory as well as a closed systemenvironment ensuring safety from biohazards for technologists running the test.

Supplies include a collection device/bottle, absorbent paper, biodegradable collection paper, and asample mailing envelope. This personal pack/ kit will provide detailed instructions on how to collect thespecimen and it will also provide an educational brochure on the benefits of screening. Themanufacturer advises that AutoFIT can pick up as little as 0.3 ml of blood and that it significantlyimproves sensitivity and specificity over traditional guaiac based methods.14 Testing requires only onesingle sample collection with no dietary or medicinal restrictions resulting in increased patientcompliance, a primary goal of colorectal cancer screening methods and programs. Both FOBT andiFOBT can help direct the “right” patients to colonoscopy thereby leading to the earlier detection ofpolyps and colorectal cancer.15

A summary of the differences between gFOBT (traditional guaiac) and AutoFit is shown below as wellprovided by Somagen (www.somagen.com).

Feature Auto­FIT Guaiac Test

Dietary Restrictions None Yes

Restriction on Medications None Yes

Number of Samples Required 1 3

Number of Days Required for SampleCollection 1 3

Specificity 99% 98%*

Sensitivity 100% 50%

Patient Compliance 91%** 23%

Methodology Automated Manual

Specimen Container Completely ClosedSystem

Open System, Risk ofExposure

Collection of Sample Easy, one step Subject to Patient Error

*Denotes strict adherence to sample collection regarding diet and medications** European J of Cancer Prevention 2006; 15: 384­390

Disclosure:

The contents of this section were made possible through an unrestricted educational grant fromSomagen Diagnostics Inc. The Colorectal Cancer Association of Canada is proud to partner withSomagen and Polymedco in their effort to promote widespread, population­based colorectal cancerscreening across all the provincial jurisdictions of Canada. Their mandate is to reduce colorectal cancermortality and incidence through the implementation of the most advanced immunoassay available todate. For more information on Somagen’s AutoFIT, please visit Somagen’s website atwww.somagen.com or www.fobt­tests.com.

References:

1. Leddin D, et al., Canadian Association of Gastroenterology and the Canadian Digestive Health Foundation: Guidelines oncolon cancer screening. Can J Gastroenterol 2004; 18: 93­99

2. Screening for colorectal cancer: U.S. preventive Services Task Force recommendation statement. Ann Intern Med 2008;149: 627­637

3. Levin, B, et al., Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: ajoint guideline from the American Cancer Society, the US Multi­Society Task Force On Colorectal Cancer, and theAmerican College of Radiology. CA Cancer J Clin 2008; 58: 130­160

*Applies to CRC Screening Only*

Occult Bleed - Important Considerations

Patients with Iron deficiency require more extensive investigation: Upper + Lower scope, as well as small bowel evaluation.

It should never be assumed that anticoagulant or anti platelet agents are responsible for occult bleeding in patients

Iron deficiency anemia without FOBT +ve stool should be investigated for GI causes based on patient risk factors

References

Toronto Notes 2014: Gastroenterology Section

David Hui: Approach to Internal Medicine

UptoDate

Colorectal Cancer Association of Canada: http://www.colorectal-cancer.ca/en/screening/fobt-and-fit/