Gastrointestinal hemorrhage

Gastrointestinal hemorrhage (GI bleeding) is defined as "bleeding in any segment of the gastrointestinal tract from esophagus to rectum."

Diagnosis

Upper gastrointestinal tract bleeding

Summary

The diagnosis of upper GI bleeding is assumed when hematemesis is documented. In the absence of hematemesis, an upper source for GI bleeding is likely in the presence of at least two factors among: black stool, age < 50 years, and blood urea nitrogen/creatinine ratio 30 or more. In the absence of these findings, consider a nasogastric aspirate to determine the source of bleeding. If the aspirate is positive, an upper GI bleed is greater than 50%, but not high enough to be certain. If the aspirate is negative, the source of a GI bleed is likely lower. The accuracy of the aspirate is improved by using a chemical occult blood test on stool.

Clinical predictors

Several clinical prediction rules, the Glasgow-Blatchford bleeding score, the Rockall score, and the PNED Score can help identify patients at risk of complications. A cohort of 325 patients reported that the odds ratios for the strongest predictors were: black stool, 16.6, age < 50 years, 8.4, and blood urea nitrogen/creatinine ratio 30 or more, 10.0. Seven (5%) of 151 with none of these factors had an upper GI tract bleed, versus 63 (93%) of 68 with 2 or 3 factors. Ernst found similar results.

Glasgow-Blatchford bleeding score

• Blood urea nitrogen level
  • 6.5 to 7.9 mmol/L = 2
  • 8.0 to 9.9 mmol/L = 3
  • 10 to 25 mmol/L = 4
  • > 25 mmol/L = 6)
• Hemoglobin level
  • Men
    • 12.0 to 12.9 g/dL = 1
    • 10.0 to 11.9 g/dL = 3
    • < 10.0 g/dL = 6
  • Women
    • 10.0 to 11.9 g/dL = 1
    • < 10.0 g/dL = 6
• Systolic blood pressure
  • 100 to 109 mm Hg = 1
  • 90 to 99 mm Hg = 2
  • < 90 mmHg = 3
• Other markers
  • Heart rate ≥ 100/min = 1
  • Melena = 1
  • Syncope = 2
  • Hepatic disease = 2
  • Heart failure = 2

Low risk is 0 points.

Nasogastric aspirate

The nasogastric aspirate can help determine the location of bleeding and thus direct initial diagnostic and treatment plans; however, the sensitivity is low. Witting found that nasogastric aspirate has sensitivity 42%, specificity 91%, negative predictive value 64%, positive predictive value 92% and overall accuracy of 66% in differentiating upper GI bleeding from bleeding distal to the ligament of Treitz. Thus, in this study a positive aspirate is more helpful than a negative aspirate. In a smaller study, Cuellar found a sensitivity of 79% and specificity of 55%, somewhat opposite results from Witting. Cuellar also studied the appearance of the aspirate and the results are in the table.

Determining whether blood is in the gastric aspirate

Finding	Sensitivity	Specificity	Positive predictive value (prevalence of 39%)	Negative predictive value (prevalence of 39%)
Gastroccult (occult blood)	95%	82%	77%	96%
Physician assessment	79%	55%	53%	20%

Determining whether blood is in gastric contents, either vomited or aspirated specimens, is surprisingly difficult. Slide tests are based on orthotolidine (Hematest reagent tablets and Bili-Labstix) or guaiac (Hemoccult and Gastroccult). Rosenthal found orthotolidine-based tests more sensitive than specific; the Hemoccult test's sensitivity reduced by the acidic environment; and the Gastroccult test be the most accurate.

Holman used simulated gastric specimens and found the Hemoccult test to have significant problems with non-specificity and false-positive results, whereas the Gastroccult test was very accurate. Holman found that by 120 seconds after the developer was applied, the Hemoccult test was positive on all control samples.

Esophagogastroduodenoscopy

Esophagogastroduodenoscopy(EGD) can help determine the cause of the bleeding. Intravenous erythromycin prior to endoscopy can help clear the stomach of blood to improve the exam.

Treatment

Upper gastrointestinal tract bleeding

Clinical practice guidelines address the management of nonvariceal bleeding. Most patients should receive esophagogastroduodenoscopy and some patients need a second look esophagogastroduodenoscopy.

Some patients may be treated as outpatients.

"In acute upper gastrointestinal bleeding, administration of intravenous erythromycin provides satisfactory endoscopic conditions, without the need for a nasogastric tube and gastric lavage.".

Prognosis

Upper gastrointestinal tract bleeding

The AIMS65 may be better a clinical prediction rule than the Glasgow-Blatchford system (GBS) in predicting mortality but the GBS may better predict the need for blood transfusion. AIMS65 values of 2 are considered abnormal. The components of the AIMS65 are:

• Albumin less than 3.0 g/dL
• International normalized ratio greater than 1.5
• Mental status abnormal
• Systolic blood pressure 90 mm Hg or lower
• Age older than 65 years

For patients with nonvariceal upper gastrointestinal tract bleeding, the Blatchford score is a clinical prediction rule for predicting patients that will require blood transfusion, endoscopic or surgical management for bleeding control.

The Blatchford score is high risk if the patient has any of the following:

• Blood urea nitrogen ≥18.2 (mg/dL)
• Hemoglobin level
  • for men <13 (g/dL)
  • for women <12 (g/dL)
• Systolic blood pressure <109(mm Hg)
• Pulse rate ≥100 beats/min
• Melena
• Syncope
• Hepatic disease
• Heart failure

In a study in which 69.5% of the patients were had blood transfusion, endoscopic or surgical management, the accuracy of the score is:

• sensitivity = 99.6%
• specificity = 25.0%

which yielded:

• positive predictive value = 75.2%
• negative predictive value = 96.4%

The Blatchford score out performed Rockall score in one comparison.