Lower GI Bleeding
Domain:
Description: Lower gastrointestinal (GI) bleeding is any bleeding with a source distal to the ligament of Treitz. The clinical manifestation and outcome varies depending on the severity (i.e., from occult to massive), the site of bleeding (i.e., small bowel, colon, rectum) and the underlying cause (e.g., diverticular bleeding, rectal disease, and ischemia). The presence of gross blood, hematochezia or melena in the absence of hematemesis, raises the suspicion of lower GI bleeding. Acute GI bleeding may be life threatening leading to hemodynamic instability and hemorrhagic shock [1, 2].
Feasibility/Equipment: Screening of lower GI bleeding is based on the presence of risk factors (e.g., antiplatelet agents, anticoagulants, use of nonsteroidal anti-inflammatory drugs), clinical suspicion, physical examination (vital signs, such as tachycardia and /or hypotension, cardiopulmonary and abdominal examinations, including digital rectal examination to check the presence of gross blood, hematochezia or melena) and laboratory test (lower hemoglobin, red blood cell and platelet count, lower albumin levels, increased international normalized ratio and creatinine). Computed tomography angiography (CTA) should be considered in first place for hemodynamically unstable patients to confirm diagnosis and to locate the site of bleeding. If CTA has not located the site of bleeding, Upper GI endoscopy may be considered. Emergency laparotomy may be only considered for patients with higher suspicion in whom endoscopy and radiology have failed to locate the bleeding site and diagnosis. Transcatheter embolisation combined with hemodynamic resuscitation and transfusion is the treatment of choice.
The screening and resuscitation is based on daily clinical practice of nurses and medical staff, but site location and treatment need the collaboration of other specialists, such as radiologists, gastroenterologist or even surgeons. Thus, the management of severe cases needs collaborative support and implies organizational issues [1-3].
Scoring information: There is not any ideal score for risk stratification. Shock index ≥1 (i.e., pulse rate divided by systolic blood pressure) may help to stratify patients into stable or unstable [3, 4]. The appropriate threshold for transfusion varies depending on the absence (Hb ≤7 g·dL-1 with target Hb 7−9 g·dL-1 post transfusion) or presence (Hb ≤8 g·dL-1 with target Hb ≥10 g·dL-1 post transfusion) of cardiovascular disease [1-3].
Cost: Despite screening is part of routine daily practice, costs are mild or high, especially if severe, in terms of diagnosis and treatment since transfusions, the collaboration of other specialists, diagnostic and therapeutic tests (e.g., CTA) are needed.
Evidence: Despite hemorrhagic shock and GI bleeding are both associated with high mortality, data is scarce regarding GI bleeding in the ICU setting [5, 6]. However, management is clear based on current recommendations of published guidelines [1-4].
Accuracy / measurement properties: Hematochezia and melena are shown in 36% and 64% of patients with GI bleeding respectively, and mortality rate may be higher than 60% in those with severe GI bleeding (defined as hematemesis, hematochezia, or melena coupled with hemorrhagic shock and/or lactatemia > 2 mmol/l and /or GI bleeding that require the transfusion of more than 5 units of RBC) at the ICU setting [6]. The presence of shock (OR from 1.33 to 6.38) and long-term corticosteroid therapy before admission (OR from 1.32 to 6.71) have been associated with higher mortality, whereas higher albumin levels (OR from 0.35 to 0.84, per 5 g·L-1 increase) has been associated with lower mortality in GI bleeding. The onset of new GI bleeding is infrequent during ICU stay (<2%) but a close monitoring may be needed in those with longer length of ICU stay (OR per additional day from 1.04 to 1.09) and worst renal function (i.e., Creatinine ≥2 × upper limit of normal) on ICU admission (OR from 1.18 to 4.68) [7].
References
1. Whitehurst BD: Lower Gastrointestinal Bleeding. Surg Clin North Am 2018, 98(5):1059-1072.
2. Triantafyllou K, Gkolfakis P, Gralnek IM, Oakland K, Manes G, Radaelli F, Awadie H, Camus Duboc M, Christodoulou D, Fedorov E, Guy RJ, Hollenbach M, Ibrahim M, Neeman Z, Regge D, Rodriguez de Santiago E, Tham TC, Thelin-Schmidt P, van Hooft JE: Diagnosis and management of acute lower gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021, 53(8):850-868.
3. Kate V, Sureshkumar S, Gurushankari B, Kalayarasan R: Acute Upper Non-variceal and Lower Gastrointestinal Bleeding. J Gastrointest Surg 2022, 26:932-949.
4. Oakland K, Chadwick G, East JE, Guy R, Humphries A, Jairath V, McPherson S, Metzner M, Morris AJ, Murphy MF, Tham T, Uberoi R, Veitch AM, Wheeler J, Regan C, Hoare J: Diagnosis and management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology. Gut 2019, 68(5):776-789.
5. Osman D, Djibré M, Silva D, Goulenok C: Gastrointestinal bleeding management by intensivists in adult and children. Reanimation 2012, 21(4):477.
6. Kumar S, Ramos C, Garcia-Carrasquillo RJ, Green PH, Lebwohl B: Incidence and risk factors for gastrointestinal bleeding among patients admitted to medical intensive care units. Frontline Gastroenterol 2017, 8(3):167-173.