Prognostic systems for UGI hemorrhage have been more widely adopted than those for LGI

hemorrhage. One widely used system is the Rockall score for assessing the risk of death and rebleeding

in patients with UGI hemorrhage (Table 65-4). Using this model, Rockall et al. found that rebleeding

occurred in less than 5% of patients and mortality was virtually zero (0% to 0.2%) in patients with

scores of 0 to 2. In contrast, a fourth to nearly one-half of patients with a Rockall score of 5 to 8+

rebled; the mortality rate for these patients was 11% to 41%. In this study, rebleeding significantly

affected the likelihood of death, particularly for patients with intermediate scores of 3 or 4 and 5 to 7 in

which there was a three- to fivefold increase in mortality rates.26

The Rockall classification has been widely accepted as accurate and importantly has been externally

validated.27–30 However, the full classification scheme requires endoscopic assessment. An alternative

scoring system – the Glasgow–Blatchford bleeding score (GBS) – is based on clear and readily available

clinical and laboratory indices without the need for endoscopy Table 65-5. It was designed to predict

need for clinical intervention due to UGI hemorrhage. This scoring system has been subjected to multiinstitutional trials and found to be at least as effective as and possibly more accurate than the Rockall

system.31,32 These authors suggested that patients with a score of 0 can be safely managed as

outpatients.

Conversely, patients with LGI bleeding typically present with less hemodynamic instability. Factors

that is indicative of a severe lower GIB thus necessitating more urgent intervention include:

Heart rate >100/min

Initial systolic blood pressure 115 mm Hg or less

History of syncope

Nontender abdominal examination

Bleeding per rectum during the first 4 hours of evaluation

History of aspirin use

Charlson Comorbidity Index score of more than 2.33

INITIAL EVALUATION AND RESUSCITATION

Upon presentation, two large-bore intravenous lines should be placed in peripheral veins and

intravascular volume resuscitation begun with an isotonic saline solution. Most patients stop bleeding

spontaneously, and crystalloid volume resuscitation is all that is required. Blood is drawn for type and

crossmatch, complete blood count with platelet count, electrolyte measurement, liver function tests, and

coagulation profiles. It is important to emphasize that on presentation, the hematocrit or hemoglobin

level may not accurately reflect the magnitude of acute blood loss. Estimates of the severity of

hemorrhage must be based on clinical parameters.

The massively bleeding patient should receive packed red blood cells (RBCs) to restore intravascular

volume and oxygen-carrying capacity. The decision to transfuse blood or blood products depends on the

1682

individual needs of the patient and the cause of the bleeding. The risks of the blood products (i.e.,

infection and allergic reactions) must be weighed against the risks of withholding transfusion (i.e.,

anemia, decreased oxygen-carrying capacity, coagulopathy). In general, blood products are used early in

the management of patients with limited cardiac and pulmonary reserve (who are unable to withstand

or compensate for an acute reduction in their systemic oxygen delivery) and those with lesions that are

at particular high risk for continued or recurrent hemorrhage (e.g., gastroesophageal varices).

Careful hemodynamic monitoring of these potentially critically ill patients is vital to successful

management. There are no clear recommendations, but it seems reasonable for those patients who are

actively bleeding and those who have recently sustained significant hemorrhage to be admitted to an

intensive care unit for close monitoring of hemodynamic parameters and evidence of continued or

recurring hemorrhage. The presence of significant underlying illnesses, such as cardiac, renal, hepatic,

or pulmonary insufficiency, may necessitate noninvasive monitoring or invasive cardiac monitoring

with central venous and arterial catheters. The information gained from these devices allows cardiac

performance to be optimized during intravascular volume replacement. The placement of a urinary

catheter and frequent monitoring of heart rate, blood pressure, urine output, and mental status are the

minimum necessary to monitor patients who have suffered GI hemorrhage. The importance of prompt,

adequate resuscitation and diligent observation cannot be overemphasized as the cornerstone for

managing these potentially mortally ill patients.

Table 65-5 Glasgow–Blatchford Bleeding Score (GBS)

DIAGNOSTIC APPROACH

5 After the restoration of circulating blood volume, the next step is to identify the source of bleeding so

that definitive therapy may be instituted. If the patient presents with hematemesis, localization of the

bleeding to the esophagus, stomach, or duodenum is relatively straightforward and

esophagogastroduodenoscopy (EGD) should be performed promptly to identify the source of bleeding.

When blood or coffee-ground guaiac-positive material is present in the gastric aspirate, EGD will likely

define the site of bleeding. Bright red blood per rectum strongly suggests a lower GI source of bleeding

unless the patient is hemodynamically unstable in which case the hemorrhage may originate from a

source proximal to the ligament of Treitz. A general algorithm for evaluating patients with acute UGI

and LGI hemorrhage is presented in Algorithm 65-1.

1683

Algorithm 65-1. Diagnostic steps in the evaluation of gastrointestinal hemorrhage.

Table 65-6 Predictors of Persistent or Recurrent Bleeding in Patients with

Nonvariceal UGI Hemorrhage

Gastric Aspiration

Recent studies have called into question the routine placement of nasogastric tubes (NGTs) in all

1684

patients with suspected GI bleeding. In patients with hematemesis, gastric aspiration is not necessary to

obtain a diagnosis of a UGI bleed. However, it can provide useful information regarding the rate of

hemorrhage. Knowing the degree to which a patient is bleeding may help guide clinical decision

making, such as the need to initiate octreotide, transfuse blood emergently, urgently perform an EGD,

or determine whether or not ICU monitoring is necessary.34

In the absence of hematemesis, aspiration of gastric fluid after the placement of a NGT may be used

to distinguish between a UGI and LGI source of bleeding. Two studies with more than 700 patients

found that the presence of blood in the gastric aspirate was a good indicator of a UGI source; however,

its absence was unreliable in predicting the presence or absence of a UGI source.35,36 In one study of

220 patients with UGI sources of bleeding, the sensitivity, specificity, and accuracy of the nasogastric

aspirate was 42% (95% confidence interval [CI] = 32, 51%), 91% (95% CI = 83, 95%), and 66% (95%

CI = 59, 72%), respectively.36 While a clear aspirate does not rule out a UGI source of bleeding,

aspiration of blood confirms it. Additionally, placing an NGT may help remove blood from the gastric

lumen to improve visualization once the EGD is performed. However, NGT placement can be associated

with pain, aspiration, and pneumothorax.37 Additionally, other less invasive methods may indicate a

UGI source (black stool, BUN/creatinine ratio >30, and age younger than 50 years). Due to these

factors, NGT placement prior to EGD should not be routine but instead individualized to each patient.

Endoscopy

Esophagogastroduodenoscopy

EGD will identify the site of bleeding in about 95% of cases of UGI bleeding and is the initial diagnostic

study for patients suspected of bleeding from the esophagus, stomach, or duodenum.38 The sensitivity of

the procedure is significantly enhanced when performed within the first 24 hours of presentation.4 A

systematic review of the literature found that early endoscopy (i.e., performed within 24 hours of

admission) was associated with a decreased transfusion requirement and decreased length of stay.39 A

prospective, randomized trial found that early endoscopy allowed the triaging of 46% of patients to

outpatient care without any adverse effects.40 Previous consensus guidelines and several cohort studies

have related various endoscopic stigmata of recent or active hemorrhage to a heightened risk of

rebleeding or continued bleeding.41–44 Laine and Peterson41 analyzed data from 37 prospective trials in

which patients with bleeding ulcers did not receive endoscopic therapy; they found that the rate of

further bleeding was less than 5% for those patients with a clean ulcer base and increased to 10% for

patients with a flat spot, 22% for those with an adherent clot, 43% for those with a nonbleeding visible

vessel, and 55% for those with active bleeding. Endoscopic features predictive of persistent or recurrent

bleeding and mortality are shown in Tables 65-6, 65-7, and 65-8. In addition to these ulcer-specific

factors, endoscopy allows identification of lesions with a high risk of continued hemorrhage and

mortality (i.e., gastroesophageal varices), and those with a low risk (e.g., Mallory–Weiss tears). The

efficacy of endoscopy-based modalities to control UGI hemorrhage is discussed in subsequent sections.

Colonoscopy

Although the efficacy of colonoscopy in determining the cause of occult GI bleeding is undisputed,

historically its role in the evaluation of patients with acute LGI bleeding was less well agreed upon.

Recently however, newer studies have established it as the procedure of choice for patients with

suspected LGI bleeding despite its limitations.45–48 Colonic lavage with a polyethylene glycol solution

can be used to clear the lumen of clot and stool providing adequate visualization of the mucosa,49 but

others have reported good visualization of the mucosa even in the absence of mechanical bowel

preparation.50

Studies have shown a diagnosis is made in 74% to 100% of patients with an LGI bleed undergoing

colonoscopy, and a pool analysis of six recent studies found a composite yield of 91% for

colonoscopy.47,48,51,52 A meta-analysis examined the role of colonoscopy as the primary diagnostic

modality for patients with acute lower GI bleeding and found that 69% (range 48% to 90%) of urgent

colonoscopies identified a source or a presumptive source of bleeding.53 Even in the setting of

unprepped bowel, urgent colonoscopy has been shown to identify bleeding colon and distal ileal lesions

in 82 of 85 patients (97%).50 Stigmata of recent hemorrhage for LGI bleeding are similar to those of

UGI lesions and include an actively bleeding site, a nonbleeding visible vessel, and an adherent clot;

these findings have been associated with continued hemorrhage and therefore the need for urgent

colectomy.7,54 Jensen et al.45 reported that 25% to 50% of patients with any of these three factors

continued to bleed or rebled and ultimately required urgent colectomy. Others have found colonoscopy

1685

to be less accurate in the diagnosis of LGI bleeding, for example, Al Qahtani et al.55 reported a series of

136 patients in which colonoscopy identified only 45% of the sources of bleeding.

Enteroscopy

For those patients who present with hematochezia in whom the initial EGD and colonoscopy is

nondiagnostic, repeating these studies before evaluating the small intestine is warranted given the very

small frequency in which the bleeding originates from the small intestine (1%). Repeating the EGD and

colonoscopy when the patient is better resuscitated will often detect lesions such as ulcers or vascular

ectasias that were obscured by blood at the initial endoscopy or the vasoconstriction of the GI mucosa

that accompanies hemorrhagic shock.

Endoscopy of the small bowel with an enteroscope or a pediatric colonoscope will allow inspection of

the proximal 60 cm of the jejunum56 and the use of a long videoenteroscope may allow visualization of

100 to 150 cm of intestine beyond the ligament of Treitz.57 Jensen et al.58 in an experience with more

than 200 patients with obscure sources of GI bleeding reported success in identifying the etiology in

79% of instances using enteroscopy. In their experience, vascular ectasias and postbulbar ulcers were

the most common causes of obscure GI bleeding.

Table 65-7 Predictors of Mortality in Patients with Nonvariceal UGI Hemorrhage

Intraoperative enteroscopy using a combination of push enteroscopes per os and per rectum or via

enterotomy can allow examination of the entire small bowel. While the endoscopist manipulates the

scope, the surgeon manually advances the bowel over the endoscope. After the bowel is telescoped onto

the endoscope it is slowly withdrawn while the endoscopist examines the mucosal lumen and the

surgeon watches the transilluminated bowel wall. While this technique can be effective, it is limited by

its invasive nature.59

Double Balloon Enteroscopy

This technique utilizes a long enteroscope and a long overtube. Both the overtube and the enteroscope

have balloons at the end. When the balloon of the enteroscope is inflated it “grabs” the mucosal surface

and allows advancement of the overtube whose balloon is deflated. The overtube balloon is then

inflated while the enteroscope balloon is deflated. The enteroscope is then advanced while the inflated

overtube balloon grips the mucosa. Using these alternate inflation–deflation cycles, long distance

advancement of the enteroscope has been achieved.2 In one U.S. multicenter study, the average distance

achieved was 360 cm with a diagnosis made in 43% of cases.60 In some cases lesions may be seen that

are missed by other techniques.61

1686