Hematemesis, melena, and

Hematochezia

DR.dr. Rustam Effendi YS, Sp.PD-KGEH

dr. Imelda Rey, MKed (PD), Sp.PD

Div. Gastroenterologi-Hepatologi, Dep.Ilmu Penyakit Dalam

FKUSU/RSUP.H.Adam Malik-RSU Dr. Pirngadi Medan

Kuliah GIS-1 ; K-15. 11-10-2014

@ update: 13-10-2015
 Overview
• Definitions
• etiology
• Management
• Initial Patient Assessment
– ABC & Resuscitation
• Differential Diagnosis
• Identify the Source & Stop the Bleeding
– History & Physical
– Endoscopy & Potential Complications
– Other diagnostics tests
• Referal
• Role of Surgery
• Prevention
 Definitions
• Upper GI Bleeding = proximal to ligament of Treitz
• Hematemesis = vomiting of blood
– This is diagnostic of upper GI bleeding
• Melena = passage of tarry or maroon stool
– Can be upper or lower (more commonly upper)
• Hematochezia = Bright red blood per rectum
– Usually characteristic of colonic hemorrhage.

Hematemesis is considered a medical emergency—could

go into hypovolemic shock.
 Acute U.G.I. Bleeding
 Aetiology:
1. Esophageal Varices
2. Chronic peptic ulceration (50% of GI
hemorrhage)
3. Reflux esophagitis, gastric carcinoma, acute
gastric ulcers & erosions.
4. Drugs (Aspirin & NSAIDs)
5. Alcohol
 There can be many cause of hematemesis
• Esophageal varices from portal hypertension (10-20%)
• Peptic Ulcer Disease (PUD) >50% cases
• Gastritis / Duodenitis (15-30%)
– Subset due to NSAID use
• Mallory-Weiss syndrome ec tears at esophageal
mucosa at EG junction (5%)
• Esophagitis (3-5%)
• Malignancy (3%)
• Dieulafoy’s lesion (1-3%)
• Nasopharyngeal bleed – swallowed blood
• Other- Aortoenteric fistula, angiodysplasia, Crohn’s,
hemobilia, hemosuccus pancreaticus
Clinical approach in Acute U.G.I. Bleeding

 Clinical approach:  Clinical approach:

1. recent (24 hrs), then 5. factors include:
hospitalized. – age (60 +)
2. if small amount, no – amount of blood lost
– continuing visible bld
immediate Tx, because
loss.
CVS can compensate
– signs of chronic liver
3. 85% stop bleeding disease
during 48 hrs – classical clinical features of shock
4. history helps in diagnosing 6. liver disease  severe, recurrent
the cause of the hemorrha bleeding (if from varices)
ge, eg: long history of 7. splenomegaly portal
indigestion, or hypertension
previous hem. from ulcers.
 Initial Patient Assessment
• Get to patient’s bedside, assess ABC
• Can the patient protect his airway?
– Does he need to be intubated?
• Is the patient hemodynamically unstable?
– Is he in hemorrhagic shock?
• 2 large bore IV, Bolus 2L fluids, Type & Cross
blood, send CBC & Coags
• Place patient on O2 & continuous monitor
• Place an NGT and lavage with NS
– To confirm if the bleeding source is upper GI
 History & Physical
• History of prior ulcers, NSAID use, stress
• History of Helicobacter pylori & treatment
• Alcohol abuse
– Retching -> Mallory Weiss tear
– Alcoholic cirrhosis -> portal hypertension and
varices
• On Physical Exam, assess hydration
• Look for stigmata of cirrhosis & portal HTN
 Management – Acute UGI Bleed
• Once again, make sure pt is resuscitated
• If anemic and symptomatic, give blood
• Place NGT/lavage (helps for endoscopy)
• Perform Upper endoscopy (EGD)
– For ulcers: if visible clot, visible vessel, or active bleeding,
should cauterize/coagulate and inject sclerosing agent
– For acute variceal bleeding: sclerotherapy + somatostatin
or endoscopic band ligation (EVL). If fail/rebleed: TIPS vs
surgical shunt. Balloon tamponade is an emergency
temporizing measure
• Start proton pump inhibitor (PPI) infusion
 Peptic Ulcers:
Gastric & Dudodenal
Comparing Duodenal
and Gastric Ulcers
 Upper Gastrointestinal Bleeding (UGIB);
Perdarahan Sal.makan bagian atas (PSMBA)
• is potentially life • Signs and symptoms UGIB:
threatening abdominal - Hematemesis
emergency that remains a - Melena
common cause of
hospitalization. - syncope/ presyncope
• UGIB : is bleeding derived - Dyspepsia
from a source proximal to - Epigastric pain
the ligamentum of Treitz. - Heartburn
- Abdominal pain
- Dysphagia
- Weight loss
- Jaundice
 Bleeding Peptic Ulcer ;
Peptic Ulcer Bleeding (PUB)

• Approximately 80-85% bleeding stops

spontaneously
• Remaining 15-20% recurrent or continuous
bleeding
• Early risk- stratification facilitates appropriate level
of care
• Multidisciplinary approach
 INITIAL MANAGEMENT:
TREAT SHOCK

• Critical question: which patients will

rebleed?
Clinical Predictors of Poor Outcomes

• Older age (>60years)

• Severe comorbidity
• Active bleeding
• Hypotension or shock
• RBC transfusion6 unit
• Inpatient bleeding
• Severe coagulopathy
Adler DG et al. Gastrointest Endosc 2004; 60:497-504
 UGIB / PUB
Forrest I Active bleeding
Ia Active pulsation 90%
Ib Active oozing 30%

Forrest II Bleeding stigmata

IIa Visible vessel 50%
IIb Clot 20%
IIc Black base <5%

Forrest III No bleeding signs

Clear ulcer base <5%
Spurting bleeding
Application of a clip in upper
GI bleeding
 Diagnosis; work up includes the following

• Orthostatic blood pressure • Computed Tomography (CT)

• Complete blood count with scanning and USG may be
differential (CBC). indicated for the evaluation of
--- Hemoglobin level. the folloowing:
• Basic metabolic profile, LFT, - Liver disease with cirrhosis
RFT, coagulation profile - cholecystitis with bleeding
• calcium and gastrin level. - Pancreatitis with pseudocyst
• Endoscopy and bleeding/haemorrhage
• Chest radiography - Aortoenteric fistula
• NGT
• Angiography (If bleeding
persists and endoscopy fails to
identify a bleeding site)
•
 Management
• Secure the airway
• Insert bilateral, 16-gauge (minimum), upper extremity, peripheral
intravenous (iv) lines
• Replace each mililiter of blood loss with 3 mL of crystaloid fluid
• In patients with severe coexisting medical ilnesses, pulmonary
artery catheter insertion for monitoring hemodynamic cardiac
performance
• Foley catheter: evaljuation of urinary output as a guide to renal
perfusion.
• Endoscopic hemostatic therapy for bleeding ulcers and varices.
• Surgical repair of perforated viscus.
• For high-risk peptic ulcer patients, high-dose iv PPI
 Indications for surgery in ptns with PUB:

• Severe, life-threatening hemorrhage not responsive

to resuscitative efforts.
• Failure of medical therapy and endoscopic
hemostasis with persistent recurrent bleeding
• A coexisting reason for surgery (eg, perforation,
obstruction, malignancy)
• Prolonged bleding, with loss of 50% or more of the
patient’s blood volume
• A second hospitalization for PUB(peptic ulcer
bleeding).
 Outline

• Triage & timing of endoscopy

• Optimal endoscopic management

• Adequate pharmacologic therapy

 Endoscopic Risk Stratification

Endoscopic Finding Rebleed Mortality

Active bleeding 55% 11%
Visible vessels 43% 11%
Adherent dot 22% 7%
Flat spots 10% 3%
CLEAN UCLER BASE 5% 2%
Laine et al. NEJM 1994; 331:717
 Risk Stratification Using
Risk Score(Ⅰ)
• Baylor Bleeding score (1993)1
• Cedars-Sinai Medical Score (1996)2
• Rockall Score (1996)3
• Blatchford Score (2000)4

1SaeedZA et al. Am J Gastroenterol 1993; 88:1842-9

2Hay JA et al. Am J Med 1996; 100:313-22

3Rockall TA et al. Gut 1996; 38:316-21

4Blatchford O et al. Lancet 2000; 356:1318-21

 The Rockall risk score scheme
Value Score

0 1 2 3

Age (years) <60 60-79 >80 －

Shock No shock (systolic Tachycardia Hypotension －

BP100, pulse<100) (systolic BP100, (systolic BP<100)
pulse>100)

Comorbidity No major － Cardiac failure, Renal failure, liver

comorbidity ischemic heart failure, disseminated
disease, any major malignancy
comorbidity

Diagnosis Mallory-Weiss tear, All other diagnoses Malignancy of upper －

no lesion identified gastrointestinal tract
and no SRH
Major stigmata of None or dark spot － Blood in upper －
recent hemorrhage only gastrointestinal tract,
adherent clot, visible
or spurting vessel
Maximum additive score prior to diagnosis=7, maximum additive score following diagnosis=11. BP, blood
pressure; SRH, stigmata of recent hemorrhage
 Blatchford admission risk markers
Admission risk marker Score component value
Blood urea (mMol/I)
6.5-8.0 2
8.0-10.0 3
10.0-25.0 4
>25 6
Hb (g/I) for men (gr/dL)
120-130 ( 12-13 gr/dL) 1
100-120 ( 10-11,9) 3
<100 ( < 10,0). 6
Hb (g/I) for women
100-120 (10-11,9) 1
<100 (<10) 6
 Blatchford admission risk markers (con’t)
Admission risk marker Score component value
Systolic blood pressure (mm Hg)
100-109 1
90-99 2
<90 3
Other markers
Pulse>100 per min 1
Presentation with melena 1
Presentation with syncope 2
Hepatic disease 2
Cardiac failure 2

Scor > 6 need intervention

 Risk Stratification Using Risk
Score (Ⅱ)
• Incorporating clinical & endoscopic parameters
• Aiding clinical decisions such as the need for urgent
intervention & the prediction of continue or recurrent
bleeding
• Requiring adaptation to reflect advances in endoscopic
and pharmacological homeostasis
• “Ultimate” risk score should include additional variables to
account for inpatient bleeding, use of NSAIDs, low-dose
aspirin, anticoagulants, pre-endoscopic PPI therapy,
mortality
 Role of Endoscopy

• Identify high-risk lesions

– Indication for endoscopic therapy
– Reduces morbidity & mortality
• Identify patients with low risk for rebleeding
– Possible outpatient care
– Reduces costs
 Timing of Endoscopy
• Early endoscopy is recommended for safe & prompt discharge
for low-risk patients & improve outcomes for high-risk patients
• Several studies & a systematic review support use of early
endoscopy
• Timing varies from 1-24 hours, but 24 hours is the most
commonly used cutoff point

Spiegel BM et al. Arch Intern Med 2001; 161:1393-1404

Dulai GS.
Gastrointest Endosc 2006; 64:310-2
 Potential Triage for UGI Bleeding
UGIB (Non-variceal)
Stable
Hemodynamics

Blatchford score <2 Blatchford score 2

(10%) (90%)

Outpatient care Urgent

Elective Endoscopy; PPI Endoscopy

Definitive Care based on Rockall Rockall Score3

endoscopic findings score<3 High Risk
(20-30%) Stigmata

High Risk No High Outpatient Endoscopic

Stigmata Risk Care Therapy Hospital
Endoscopic Stigmata PPI Admission ICU
Therapy Outpatient H. Pylori Care based on
Therapy Treatment comorbidity
 Pharmacological therapy

 Splanchnic blood pressure modifiers

- vasopressin, somatostatin, octreotide

 Anti-fibrinolytic agents

- tranexamic acid
 Acid suppressing agents

- Proton pump inhibitors (PPIs)

 Management
· Immediate management:
*Emergency management: Emergency management (cntd):
1. History + exam. 5. Bld transfusion in case of :
2. Monitor: pulse & BP /30 a) shock
min b) Hb < 7 g/dl
3. Bld sample: Hb, urea, 6. Urgent endoscopy.
electrolytes, grouping & 7. Surgery when recommended
cross-matching
4. I.v. access
 Management
• Shock management
3. Circulation:
ABC:
expand circulating volume:
1. Airway: endotracheal tube, blood, colloids, crystalloids
oropharyngeal airway. support CVS function:
*Give oxygen vasodilators
2.Breathing: * Monitor:
support respiratory function skin color, peripheral temp.,
* Monitor: resp. rate, bld urine flow,
gases, chest radiograph BP,
ECG
 Management
 General Investigations:
1. Hb, PCV
2. CBC (WBC … etc)
3. Bld glucose
4. Platelets, coagulation
5. Urea, creatinine, electrolytes
6. Liver biochem.
7. Acid-base state
8. Imaging: chest & abd. radiography, US, CT
 Management
General management: **General management:
 Blood volume  Drug therapy
proton pump inhibitors
1. restore volume to normal
 Factors in reassessment
2. transfusion 1. age: ≥ 60  > mortality
 Endoscopy 2. recurrent hemorrhage:
1. shock, suspected liver +++ mortality
disease or 3. re-bleeding: mostly within
the 1st 48 hrs
continued bleeding
4. surgical procedures in case
2. control varices or ulcers to of severe
reduce re-bleeding bleeding.
 Symptoms and signs
Suggest upper
Gastrointestinal
bleeding

Clinical and/or Clinically stable with an

Endoscopic triage Ulcer that has a clean base
or pigment spot

Actively bleeding Ulcer with a clot or Conservative treatment and

ulcer adherent vessel early discharge

High-dose intravenous proton-pump inhibitors and Eradication of Helicobacter

endoscopic therapy (injection + Clipping ) pylori using triple therapy

Bleeding Bleeding under control

uncontrolled

Surgery Repeat Recurrent

endoscopic bleeding
therapy
 Other Diagnostic Tests
• If bleeding is unresolved with endoscopy or endoscopy is
contraindicated
• 1. Angiography (Diagnostic & Therapeutic)
– Intra-arterial vasopressin
– Embolization
• 2. Tagged red blood cell (TRBC) scan
– Only diagnostic & usually for occult bleeding
– More sensitive than angiography
– Can detect bleeding rate of 0.1-0.5 mL/min
GFOBT: for occult bleeding.
 Role of Surgery
• If medical and endoscopic therapy fail

• In the event that bleeding source is

unidentified -> exploratory laparotomy

• Recurrent bleeding peptic ulcers

– Anti-ulcer surgery (i.e. vagotomy/antrectomy, or
vagotomy/pyloroplasty, or selective vagot)
 Prevention
• After the acute situation is resolved, educate
patient on preventive measures
• Top 2 reasons for ulcers: Hpylori & NSAID
• 1. Testing for H.pylori (i.e. antral biopsy during
endoscopy)
• 2. Treat H.pylori (amoxicill, clarithromycin
x1wk plus PPI x4wk)
• 3. Reduce intake of NSAID
 Take Home Points
• Always, always perform ABC’s first & resuscitate with
two #16ga IV’s & isotonic crystalloids (blood if pt doesn’t
respond)
• NGT/lavage to confirm active bleeding
• Focused H&P looking for common causes: ulcers,
varices, “-itis”, Mallory-Weiss, AVM
• Endoscopy is 1st line for acute UGIB
– Don’t forget to start intravenous PPI infusion
• Endoscopy has associated complications
• Angio or surgery if still bleeding
 Management
I. Supportive :
• Oxygen; infusion crystaloid; severe----ICU.
• Blood transfusion (AGC Guideline--- if Hb < 7 gr/dL).
• Fasting
• Monitoring hemodynamic---- intubation.
II. NGT:
• AGC G (2012): NGT(-); Others NGT, for detecting bleedi(+) .
• water, room temperature.
• PPI for UGIB non varices. (Omeprazol, Panto-, Esome-;
Lanso-; Rabepra-).—for maintenaining pH > 6.
• Somatostatin : reducing gastric acid and Splanchnic blood
flow.
III. Endoscopic Treatment:
IV. Arterial Embolisation.
V. Transjugular inttra hepatic portosytemic stent shunt (TIPS);
for variceal bleeding that cannnot stop with pharmacology or
endoscopic treatment.
V. Surgery.
 Lower gastrointestinal haemorrhage
 Investigation:
 Causes:
• Most patients are stable and
• Diverticular disease can be investigated once
• Angiodysplasia bleeding has stopped
• Inflammatory bowel  In the actively bleeding patient
disease consider :
• Ischaemic colitis • Colonoscopy - can be difficult
• Infective colitis • Selective mesenteric
angiography
• Colorectal carcinoma
• Requires continued bleeding
• Hemorrhoid of >1 ml/minute
• May show angiodysplastic
lesions even once bleeding has
ceased
•Radionuclide scanning
•Uses technetium-99m labeled red blood cells
 Management Lower GI bleeding

• Acute bleeding tends to be • If right-sided

self limiting angiodysplasia perform a
• Consider selective right hemicolectomy
mesenteric embolisation if • If bleeding diverticular
life threatening disease perform a sigmoid
haemorrhage colectomy
• If bleeding persists perform • If source of colonic
endoscopy to exclude upper bleeding unclear perform a
GI cause subtotal colectomy and
• Proceed to laparotomy and end-ileostomy
consider on-table lavage an
panendoscopy

REY- Im,Rey
Rustam Effendi YS, IMELDA REY
Kuliah, GIS- K-15), 11-10-2014.
FKUSU Medan.