-difference of 20 mmHg fall in systolic; 10 mmHg fall in diastolic pressure. 2009;2:21-30.5. 2015;25(3):415-428.14. Differences between upper and lower GI bleeds: Lower GI bleed: - Hemorrhoids: swelling and inflammation of blood vessels surrounding rectum.-Can be caused by any condition that causes increase in pressure such as: pregnancy, straining stool, chronic ocnstipation, anal intercourse, and diarrhea.-S/S: bright red blood during defacation, itching and possibly small … Bariatric Surgery for the Treatment of Type 2 Diabetes Mellitus: What Are the Options? Epidemiology and risk factors for upper gastrointestinal bleeding. 1. Tests might include: 1. 10 Melena refers to a characteristic odor along with tarry black … Gastroenterology. 4. Hematochezia is commonly associated with lower gastrointestinal bleeding, but may also occur from a brisk upper gastrointestinal bleed. Upper GI bleeding: The upper GI tract includes the esophagus (the tube from the mouth to the stomach), stomach, and first part of the small intestine. Thirty-seven patients (67%) with a supratherapeutic international normalized ratio and GI bleeding underwent upper endoscopy. You may need a complete blood count, a test to see how fast your blood clots, a platelet count and liver function tests. Chronic GI bleeding is insidious not unless secondary signs and symptoms of hemorrhage are apparent. Lower GI Bleed. For patients with acute UGIB, there are several clinical prediction tools that have been developed, including two well-evaluated tools cited in evidence-based guidelines: the Blatchford score (TABLE 4) and the Rockall score (TABLE 5).17-20 The Rockall score utilizes clinical data immediately at presentation.19 Factors assessing the severity of the bleed, such as systolic blood pressure and heart rate, are assessed alongside patient characteristics, such as age and comorbid conditions, resulting in a tool to assess prognostic outcomes and potentially mortality. Define the source of Upper GI bleeding -Proximal to the ligament of Treitz. Pharmacists can also provide recommendations to the healthcare team regarding which medications may provide benefit to each GIB case. It takes approximately 50-100 ml of blood to cause melena, chances are below the said approximation, the person with GI bleeding may manifest Fecal Occult Blood (FOB) which can only be confirmed through Fecal Occult Blood Test (FOBT). Lower gastrointestinal bleeding (LGIB) is a frequent cause of hospital admission and is a factor in hospital morbidity and mortality. Proton pump inhibitor therapy for peptic ulcer bleeding: Cochrane collaboration meta-analysis of randomized controlled trials. Risk factors associated with upper gastrointestinal bleeding and with mortality. A bolus IV dose followed by infusion was long the normal course of therapy and remains the treatment of choice in currently available guidelines, but data suggest that twice-daily IV bolus dosing is noninferior in outcomes of rebleeding, mortality, and length of hospital stay.17,27 Recent literature has demonstrated that intermittent PPI use was noninferior and offers a clear benefit in drug dose, cost, and resource utilization. In addition to drinking barium, air is often inserted into the bowel for a lower GI X-ray. Information regarding the use of tranexamic acid in treating lower GI … Trials evaluating UGIB and LGIB have demonstrated that while PPIs do not demonstrate improved outcomes in LGIB, they may actually increase risk of LGIB.34 Theorized mechanisms for this increased risk often focus on possible changes in microbiota, and thus may potentiate possible risk from NSAIDs. Wilcox CM, Cryer BL, Henk HJ, et al. Blatchford O, Murray W, Blatchford M. A risk score to predict need for treatment for uppergastrointestinal haemorrhage. An individual wit… Gastrointestinal bleeding. Hematochezia (red or maroon blood in the stool) usually indicates the presence of lower GI bleeding or a brisk upper GI bleed. Management of acute upper and lower gastrointestinal bleeding. Healthcare Cost and Utilization Project (HCUP) statistical briefs. Blood in stools, which takes on various forms depending on the site of bleeding – it can either be dark colored stools or fresh blood passing through the rectum. Epidemiology. In massive Upper GI hemorrhage, the individual may not only pass out melena but also fresh blood in the stools. Lancet. The raw estimated rate of hospitalization secondary to any type of GIB in the U.S. is estimated to be about 375 per 100,000 per year.1-3 For acute GIB events, some studies identify a 30-day mortality rate as high as 14%, while others report a range between 6% and 10% per year, with rates increasing in patients with advancing age and a higher number of associated underlying comorbidities.4-7 It is estimated that more than $2.5 billion is spent annually to care for inpatient management of GIB.8, Given the nature of GIB, it is important to differentiate the disease state, as location of the bleed can dictate both presentation and treatment (TABLES 1-3). To find out whether you have a GI condition, your gastroenterologist will perform diagnostic tests. Endoscopy. They may be in a position to assist in multiple areas during the initial evaluation and management. J Hosp Med. Reproduction in whole or in part without permission is prohibited. World J Gastrointest Endosc. Gastrointestinal (GI) bleeding is a common clinical problem frequently requiring hospitalization. Proton pump inhibitors (PPIs) are the drug class most associated with treatment of UGIB. Proton pump inhibitors therapy vs H2 receptor antagonists therapy for upper gastrointestinal bleeding after endoscopy: a meta-analysis. The overall mortality for severe GI bleeding is approximately 8 percent, but this number is diminishing with the arrival of superior diagnostic techniques and newer medical treatments. 2007;25:623-642.17. Duodenum (first part of the small intestines), Mallory-Weiss tear (tear in the lower esophagus), Melena or Melenic stools  (black, tarry and foul smelling stools or dark-colored stools), Red Hematemesis – vomiting of fresh blood. 2012;107:345-360.18. Rev Med Inst Mex Seguro Soc. 3. El-Tawil A. GI bleeding is also called bleeding in the digestive tract, upper GI bleeding, or lower GI bleeding. Mayo Clin Proc. 2009;47(2):179-184.15. Initial medication reconciliation may reveal details relevant to diagnosis and treatment of patients, such as identifying outpatient NSAID or anticoagulant use. Curbing the costs of GI bleeding. Every year, about 100,000 people in the United States go to the hospital for upper GI bleeding. The level of bleeding can range from mild to severe and can be life-threatening.Sophisticated imaging technology, when needed, can usually locate the cause of the bleeding. Considerations. One of the most commonly used organizing frameworks in gastrointestinal bleeding is the differentiation between upper gastrointestinal bleeding (UGIB) and lower gastrointestinal bleeding (LGIB). Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane Database Syst Rev. Johanson JF. Bleeding from any pathology in the esophagus, stomach, or second part of the duodenum is called... Lower GIT Bleeding. Fecal occult blood (FOB) refers to blood in the feces that is not visibly apparent (unlike other types of blood in stool such as melena or hematochezia).A fecal occult blood test (FOBT) checks for hidden (occult) blood in the stool (feces). Tranexamic acid is an antifibrinolytic that has been shown to reduce blood loss in a variety of clinical conditions. Leontiadis GI , Sharma VK , Howden CW. For lower GI issues, the tests may include a colonoscopy, enteroscopy, or lower GI series/barium enema. Strate L. Lower GI bleeding: epidemiology and diagnosis. How common is GI bleeding? Whelan CT, Chen C, Kaboli P, et al. This resuscitation should begin with intravenous fluids but may also require transfusions of packed red blood cells. Gastrointestinal (GI) bleeding is a symptom of a disorder in your digestive tract. Considering H2 antagonists (H2As) are used with similar intent in other disease states, their use in UGIB has been investigated alongside PPIs. Blood tests. 2017;47:218-230.19. 2006;38:12-17.24. Of these, 81.1% had positive findings, 18.9% had peptic ulcer disease, and 7.2% required endoscopic treatment. 2010(7):CD005415.26. Laine L, Jensen DM. Matthew B, et al. 2015;107(5):262-267.22. Am J Gastroenterol. The blood often appears in stool or vomit but isn't always visible, though it may cause the stool to look black or tarry. 2016;111:459-474.23. 2008;33:395-397.11. Negligence of this condition may cause a life, thus once manifested prompt and early medical therapy is very vital. Other tests look for globin, DNA, or other blood factors including transferrin, while conventional stool guaiac tests look for heme 1 About 20 to 33 percent of GI bleeding episodes in Western countries are in the lower GI … Am J Gastroenterol. If pt rebleeds it is a 10 fold increase in mortality. Constipation and straining during bowel movements cause hemorrhoids to swell. Sachar H, Vaidya K, Laine L, et al. This deficit is likely due to H2As’ inferiority at maintaining gastric pH over 6.0, the approximate pH where coagulation processes can function.29, In effort to improve visualization during endoscopy and thus decrease need for repeat endoscopy, IV erythromycin, an antimicrobial macrolide that also acts as a prokinetic agent, is commonly utilized. End result for majority of Upper GI bleeding-Spontaneous resolution for most. Rodriguez-Hernandez H, Rodríguez-Morán M, González JL, et al. Hematochezia refers to the passage of bright red blood via the rectum. Understanding the cause and specific differences between the signs and symptoms of upper and lower GI bleeding is essential for proper treatment. Cheng H, Sheu B. Prior to Endoscopy: Resuscitation •Adequate resuscitation and stabilization is essential prior to endoscopy to minimize procedure associated complications •500 ccs of NS over 30 minutes while being type and crossed •Amount of blood transfusion should be carefully considered –more is not always better (see next slide) … 2007;82:286-296.27. Your doctor will take a medical history, including a history of previous bleeding, conduct a physical exam and possibly order tests. Clin Exp Gastroenterol. Filter criteria of upper gastrointestinal bleeding and dates from 01/01/2017 to 12/31/2017 were used to extract the list of patients with a GI bleed. American Gastroenterological Association (AGA) Institute medical position statement on obscure gastrointestinal bleeding. UGIB w/mortality for older pt is d/t. World Congress at ACG2017. There are important differences in the etiologies between the 2 sources. Hemorrhoids can cause GI bleeding. Causes of UGIB. Strate L, Grainek IM. Differentiating Upper and Lower GI Bleeds Initial Presentation and Risk Stratification. Causes and outcome of upper and lower gastrointestinal bleeding: the Grady Hospital experience. Advance online publication March 1, 2016. Statistical Brief #65. The ligament of Treitz (the suspensory ligament of the duodenum): anatomic and radiographic correlation. Zhao Y, Encinosa W. Hospitalizations for gastrointestinal bleeding in 1998 and 2006. ABSTRACT: Gastrointestinal bleeds (GIBs) are a significant source of hospitalizations in the United States. To comment on this article, contact rdavidson@uspharmcist.com. Required fields are marked *, Notify me of followup comments via e-mail, March 12, 2015 • 1 comment. Tielleman T, Bujanda D, Cryer B, et al. 2. Blood is a potent laxative that is why a person with either UGIB or LGIB can also manifest diarrhea. Stool tests. An individual who has this may complain of easy fatigability, shortness of breath, dizziness and anemia caused by the bleeding. Similarly, the Blatchford score uses both clinical and laboratory data to assist in predicting risk of intervention and mortality.20 For acute LGIB, the available prognostic rules to assess risk are limited and less validated when compared with UGIB.22, Proton pump inhibitors (PPIs) are the drug class most associated with treatment of UGIB. Yavorski RT, Wong RK, Maydonovitch C, et al. These outcomes have proved controversial; however, they offer evidence that patients with LGIB do not benefit from PPI therapy. Practice Parameters Committee of the American College of Gastroenterology. Certain Patients Need More Sedation During Endoscopic Procedures, PPI Use in Infants With Acid Reflux Increases Early Fracture Risks. 1996;38:316-321.20. Lower GI bleeding: The lower GI tract includes much of the small intestine, large intestine or bowels, rectum, and anus. Trends on gastrointestinal bleeding and mortality: where are we standing? There aren't really any medications for lower GI bleed, at least not direct ones. In the setting of pre-endoscopy, guidelines do not form consensus on their use, but they may decrease proportion of patients with high risk of stigmata of hemorrhage at the time of the procedure.25 Despite potential benefit in this population, evidence suggests PPI use does not affect rebleeding, necessary surgery, or mortality, leading to some clinical controversy regarding their application. Risk assessment after acute upper gastrointestinal haemorrhage. GI bleeding is not a disease, but a symptom of a disease. Mortality associated with gastrointestinal bleeding events: comparing short-term clinical outcomes of patients hospitalized for upper GI bleeding and acute myocardial infarction in a US managed care setting. After the initial assessment and risk stratification and once the patient is hemodynamically stable, colonoscopy preceded by colon cleansing is the initial diagnostic procedure for most patients presenting with a LGIB.21 Management of LGIB mostly includes nonpharmacologic interventions; however, there are still opportunities for pharmacists to be involved in patient care. Historically, distinction of upper GIB (UGIB)and lower GIB (LGIB) was based on the location of bleeding in relation to the ligament of Treitz.9,10 With this definition, bleeding proximal to the ligament of Treitz is categorized as an UGIB, while bleeding distal to the ligament of Treitz is categorized as a LGIB. If untreated, gastritis can lead to ulcers or worn-away areas of the stomach lining that can bleed in your GI tract. 2014;5(4):467-478.12. Nasogastric lavage. Am J Gastroenterol. J R Coll Physicians Edinb. Background: Lower GI hemorrhage is a common source of morbidity and mortality. Coffee Ground Hematemesis – vomiting of blood altered by stomach acids and enzymes. Jaundice if bleeding is related to liver diseases, Hematochezia – fresh blood in stools may be due to hemorrhoids or anal fissure, Bloody diarrhea is typical of Colitis, the inflammation of the colon. It is also important to locate the site of the bleeding and do all measures to stop it. Thirty-eight percent of the patients with a supratherapeutic international normalized ratio underwent lower endoscopy; of these, … A 2015 meta-analysis evaluating the two classes in the setting of UGIB found that while difference in mortality was found to be nonsignificant, outcomes such as recurrent bleeding rate and receiving surgery rate displayed clear benefit in PPIs. Your email address will not be published. Gastrointestinal bleeding is not a disease it is a condition caused by tissue damage of the GI tract. September 2008. www.sign.ac.uk/assets/sign105.pdf.10. Interestingly, the rate of bleeding in the upper GI tract was similar between the two doses of dabigatran studied (110 and 150 mg) as compared with warfarin, whereas lower GI bleeding (which included colonic, jejunal, and ileal sources) was more frequent in patients treated with dabigatran as compared with warfarin (relative risk [RR] 1.78 for dabigatran 110 mg and … Gastrointestinal bleeding (GIB) is a relatively common medical issue, causing a significant portion of morbidity, hospitalizations, and even mortality annually in the United States. World J Gastrointest Pathophysiol. A Comparison of Azithromycin to Erythromycin Infusions in Improving Visualization of Endoscopy for Upper Gastrointestinal Bleeding. Unlike UGIB, available literature evaluating PPI use in LGIB does not show benefit. 1978;136(2):257-259.25. El-Tawil A. World J Gastroenterol. An upper GI bleed is more common than lower GI bleed. 2000;356:1318-1321.21. This varies from lower GI bleeding (LGIB), which occurs farther down the GI tract. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Zhang YS, Li Q, He BS, et al. Early identification of these factors may help expedite both diagnosis and appropriate treatment response. This priority has been well established in other hemorrhagic models and remains true in cases of GIB.16-18 Physical assessment of blood pressure, heart rate, and orthostatic status should be performed, and resuscitation provided as appropriate. Blood loss stage where BP is decreased-3. 2015;47:1-46.32. Learn vocabulary, terms, and more with flashcards, games, and other study tools. JAMA Intern Med. It requires prompt treatment once diagnosed otherwise this can lead to hypovolemic shock and even death.