Page 1470 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 105: Gastrointestinal Hemorrhage 1009

be explained by an aging population with a significantly higher GI TABLE 105-2 Initial Management of Gastrointestinal Hemorrhage
bleeding mortality due to comorbid conditions. In contrast, the mor-
tality from LGI bleeding has decreased dramatically despite an aging Maintain two large-bore IV catheters (14- or 16-gauge peripheral IV/central line)
population, and this is probably due to more aggressive diagnostic and Fluid resuscitate with crystalloids to maintain hemodynamic stability
therapeutic endoscopic intervention. Transfuse packed red cells to maintain hematocrit >30%
The management of GI hemorrhage in the ICU is multidisciplinary,
involving the intensivist, gastroenterologist, radiologist, and surgeon. A Urgent endoscopy with therapeutic intention for refractory hypotension/shock
successful outcome relies on effective fluid resuscitation, maintenance Acid-suppression therapy with IV H RAs or PPIs after endoscopic treatment
2
of adequate perfusion pressure, prompt hemostasis, monitoring of end- Platelet transfusion and fresh frozen plasma/recombinant factor VIIa to correct thrombocy-
organ function, and prevention of multiple-organ failure. topenia and coagulopathy
ECG in patients at risk for myocardial ischemia
CLINICAL CONSIDERATIONS A nasogastric tube should be inserted if the patient has hematemesis
■ PROGNOSTIC FACTORS CVP or Ppw monitoring may be helpful if variceal bleeding is suspected. A CVP

Multiple studies focusing primarily on nonvariceal UGI bleeding have <10 mm Hg may help prevent recurrent variceal bleeding
been designed to define prognostic factors for GI bleeding and to iden- Splanchnic vasoconstrictors (octreotide/terlipressin) in variceal bleeding
tify high-risk patients. 7-10 A common and pivotal feature of these studies Empirical antibiotics in variceal bleeding
is the combined use of clinical variables and endoscopic findings to
guide risk stratification, thereby stressing the importance of integrat- Consultation with interventional radiology and surgery
ing clinical and endoscopic information for optimal decision making.
Table 105-1 outlines the clinical and endoscopic indicators associated
with an increased risk of rebleeding and higher mortality. Other studies In the presence of hypotension or hypovolemic shock, prompt fluid
identified similar prognostic indicators for LGI bleeding. 11-13 resuscitation with crystalloids and packed red blood cells is essential.
■ INITIAL PRESENTATION Monitoring end-organ perfusion and preventing ischemic organ injury
improve survival. In particular, coronary and renal perfusion should
GI bleeding is divided into UGI and LGI bleeding based on its location be assessed. An electrocardiogram should be obtained in patients at
proximal or distal to the ligament of Treitz at the junction of the duode- risk for myocardial ischemia, and renal laboratory parameters and
num and jejunum. UGI bleeding commonly presents with hematemesis urine output should be followed to assess for possible prerenal azo-
and/or melena, and a nasogastric (NG) lavage that yields blood or temia, acute renal failure, and (in cirrhotics) hepatorenal syndrome.
coffee-ground material supports the diagnosis. However, it is important In the subset of patients with suspected variceal hemorrhage, central
to note that a negative or bile-stained NG aspirate (indicating an open venous pressure (CVP) monitoring may be useful to prevent sustained
pylorus) does not exclude a UGI source because the bleeding may be portal hypertension and recurrent bleeding following aggressive fluid
intermittent. 14, 15 In comparison, hematochezia is usually the presenting replacement, with a goal to maintain a euvolemic status. When left-
sign of an LGI source. These distinctions based on presenting signs are sided heart failure coexists, monitoring of pulmonary artery wedge
not absolute because melena can be seen with proximal LGI bleeding pressure (Ppw) may facilitate aggressive fluid resuscitation while
and hematochezia can be present due to massive, brisk UGI bleeding. reducing the risk of cardiogenic pulmonary edema.
■ INITIAL EVALUATION AND MANAGEMENT Gastrointestinal/Endoscopic: Prompt identification and hemostasis of

Table 105-2 outlines the initial evaluation and management for GI the source of GI hemorrhage are essential in improving patient out-
come. In the event that initial fluid resuscitation establishes hemody-
hemorrhage. namic stability, endoscopy may be performed under stable conditions
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Hemodynamic: Regardless of the etiology and site of GI hemorrhage, within the first 24 hours of the bleed. However, more emergent
the initial management should be directed at maintaining hemody- endoscopy with therapeutic hemostatic intent should be considered
namic stability by restoring intravascular volume. Intravenous access for patients with UGI hemorrhage who cannot be stabilized hemo-
with two large-bore IV catheters should be maintained at all times. dynamically with intravascular volume resuscitation and continue to
bleed. For lower GI hemorrhage, some studies have suggested that
early colonoscopy can identify the source of bleeding and improve
outcome in patients with lower GI bleeding. 17,18 However, other
TABLE 105-1 Adverse Clinical and Endoscopic Prognostic Indicators studies have not shown a difference in terms of clinical outcomes and
Clinical indicators cost between urgent colonoscopy as compared with routine elective
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Age >60 years colonoscopy in patients with serious lower GI bleeding. If there is
massive lower gastrointestinal hemorrhage, a bleeding scan followed
Severe comorbidities
by angiography should be considered, as this allows identification of
Onset of bleeding during hospitalization the source of bleeding and allows for therapeutic intervention, with-
Emergency surgery out the need for bowel prep that often limits the utility of colonos-
copy. Absolute contraindications to endoscopy include suspected GI
Clinical shock
perforation, acute uncontrolled unstable angina, severe coagulopathy,
Red blood emesis or NG aspirate untreated respiratory decompensation, and severe patient agitation.
Requiring >5U PRBCs Apart from perforation, other conditions contraindicating endoscopy
can be corrected, following which endoscopy should be performed. In
Endoscopic indicators
the face of massive exsanguination, angiography or emergent surgical
Major stigmata: active bleeding, visible vessel, adherent clot intervention (possibly facilitated by intraoperative endoscopy) should
Ulcer location: posterior duodenal bulb, higher lesser gastric curvature be considered instead of endoscopy.
Ulcer size >2 cm in diameter Recent studies have suggested that the prokinetic agent erythromycin,
given as a single intravenous dose of 250 mg prior to an EGD, improves
High-risk lesions: varices, aortoenteric fistula, malignancy
visualization and diagnosis, and should be considered for patients
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