Gastrointestinal Bleeding in the Critically ill Patient

Published on 07/03/2015 by admin

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Chapter 46 Gastrointestinal Bleeding in the Critically ill Patient

George Kasotakis, MD , George C. Velmahos, MD, PhD, MSEd

1 What are the anatomic definitions of upper versus lower gastrointestinal (GI) bleeding?

The GI tract is anatomically divided into upper and lower by the ligament of Treitz. Although this classification has little physiologic significance, it is important to bear in mind that bleeding originating distal to the ligament of Treitz cannot travel backward to the upper GI tract because of the acute angle of the small bowel at this site. Bleeding from the upper GI tract is far more common than in the lower, and this is particularly true in the critically ill.

2 What are hematemesis, coffee-ground emesis, hematochezia, and melena? Are these features helpful in determining the site and rate of bleeding?

image Hematemesis is vomiting of fresh, red blood and indicates bleeding in the upper GI tract. Approximately 50% of patients with upper GI bleeding (UGIB) will present with hematemesis.

image If the blood is older, it can appear like coffee grounds. The return of bright red blood or coffee grounds through a nasogastric tube (NGT) is highly specific for hemorrhage proximal to the ligament of Treitz.

image Hematochezia is used to describe passage of bright red or maroon-colored blood through the rectum and typically indicates a lower tract source. Less commonly (< 15%) it may indicate the rapid transit of torrential hemorrhage from the upper tract.

image Melena is the passage of black, tarry, and usually foul-smelling stool because of degradation of blood components as they traverse the GI tract. It typically signifies upper GI tract bleeding (70%) or, less often, hemorrhage from the proximal lower tract (30%).

3 Do all patients with GI bleeding need to be monitored in the intensive care unit (ICU)?

No, but patients with evidence of active bleeding (ongoing transfusion requirement, hemodynamic instability) or other significant comorbidities should be closely monitored in a high-acuity setting, such as an ICU.

4 What are the most common causes of upper and lower GI bleeding?

See Tables 46-1 and 46-2.

Table 46-1 Causes of Upper Gastrointestinal Bleeding

Cause Prevalence (%)
Peptic ulcer disease 55
Gastritis-duodenitis 20
Esophageal varices 12
Mallory-Weiss tears 8
Neoplasm 3
Angiodysplasia 2

Table 46-2 Causes of Lower Gastrointestinal Bleeding

Cause Prevalence (%)
Diverticular disease 40
Angiodysplasia 20
Colitis 20
Anorectal bleeding (hemorrhoids, anal fissures) 7
Neoplasm 7
Small bowel bleeding 6

5 What risk factors are associated with higher mortality in patients with upper GI tract hemorrhage?

image Shock

image Melena

image Anemia at presentation

image Significant fresh blood in vomit, gastric aspirate, or rectum

image Concurrent sepsis

image Poor general health

image Comorbidities (liver, renal, cardiac disease)

image Large ulcer size

image Persistent bleeding despite endoscopic therapy

image Recurrent bleeding

6 What are the most common causes of GI tract bleeding in critically ill patients?

Although critically ill patients can have any of the usual causes of GI bleeding, they are at particular risk for development of stress-related mucosal disease (SRMD) in the upper GI tract and hypotension-induced colonic ischemia. In addition, the increasing use of rectal tubes for the management of antibiotic- and enteral feeding–associated diarrhea is associated with a rise in incidence of lower GI bleeding (LGIB) due to iatrogenic rectal fissures and ulcers.

7 What are the immediate actions that need to be taken in an acute GI tract hemorrhage in the ICU?

image Ensure patient has at least two large-bore (at least 18 gauge) intravenous catheters.

image Insert Foley and nasogastric catheter (if not already in place), and initiate resuscitation (with crystalloids or blood products) per the local guidelines and policies.

image Consider obtaining a definitive airway in the uncooperative, agitated, or encephalopathic patient at risk for aspiration.

image Aspirate sample from nasogastric tube and perform rectal examination (attempt to localize the source of bleeding).

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