Lower gastrointestinal bleeding initial resuscitation

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]

Overview

The aims of treatment in a patient presenting with lower gastrointestinal bleeding are to resuscitate the patient, identify the source of blood loss and stop any ongoing bleeding, and reduce the risk of a recurrent bleed. It is essential to identify patients who are high risk. This would include elderly patients; those with severe ongoing bleeding or recurrent bleeding; and patients with multiple comorbid conditions, in particular, those patients with cardiac, renal, respiratory, and liver disease. Treatment depends on the mode of presentation, the severity of the bleed, and the underlying pathology. Bleeding points can be treated with endoscopy, interventional radiology, or surgery. After identification of the source of bleeding using endoscopy, therapeutic options include monopolar or bipolar diathermy, argon plasma coagulation (APC), epinephrine injections, and endoloops and hemoclips, used individually or in combination. These methods can be used to treat many of the causes of LGIB, including diverticular bleeding, angiodysplasia, radiation proctitis, and post-polypectomy bleeding interventional radiology can be used to visualize a bleeding vessel and to stop the bleeding through embolization of the vessel. Surgery may be required if less invasive measures cannot be applied or are not effective.

Initial Resuscitation

Initial Evaluation

• In patients with acute lower gastrointestinal bleeding who are unstable rapid assessment and resuscitation should be initiated even before diagnostic evaluation.
• The initial steps in the management of a patient with lower gastrointestinal bleeding are to assess the severity of bleeding, and then institute fluid and blood resuscitation as needed.
• Once hemodynamic stability is achieved, nasogastric lavage should be performed to rule of upper GI source.
• Equilibration between the intravascular and extravascular volumes cannot be achieved until 24 to 72 hours after bleeding has occurred.

Role of Nasogastric tube (NGT)

• Nasogastric tube (NGT) lavage is recommended in all patients with lower gastrointestinal bleeding once the patient is stabilized.
• A carefully placed nasogastric tube (NGT) with irrigation and aspiration of bile is necessary to ensure sampling of duodenal contents.
• If there is a bloody NGT aspirate then an esophagogastroduodenoscopy (EGD) is warranted (11 to 15% of patients despite “negative” NGT aspirates are due to upper GI bleeding).
• Obtaining clear fluid favors a lower GI source of bleeding.

Workup and Initial Management
Initial Evaluation	Airway Breathing, Circulation
Supportive Therapy	Ensure patent and protected airway Intubate if needed Consider mechanical ventilation 2 large-bore, peripheral intravenous lines Can consider large-bore central venous catheter or intraosseous line if rapid transfuser will be needed
Blood transfusion	Resuscitate with 1:1:1 of packed red blood cells (PRBCs) to fresh frozen plasma (FFP) to platelets. Consider massive transfusion protocol Res:Low riskto a target hemoglobin of 7 mg/dL. Consider Sengstaken-Blakemore tube for control of immediately life-threatening upper GI bleeding

Assessment of severity of bleeding

Bleeding severity	Vital signs	Blood loss
Minor	Normal	<10%
Moderate	Postural hypotension	10-20%
Severe	Shock	>25%

Fluid resuscitation

• Two large caliber (16-gauge) peripheral catheters or a central venous line should be inserted in patients who are hemodynamically unstable.
• The rate of fluid resuscitation is proportional to the severity of bleeding with the goal of restoring and maintaining the patient’s blood pressure.
• Infusion of 500 mL of normal saline or lactated Ringer's solution over 30 minutes is preferred treatment for patients with active bleeding before blood type matching and blood transfusion.
• Intensive monitoring with a pulmonary artery catheter is recommended to monitor the response of initial resuscitation efforts and any complications of fluid overload.
• If the blood pressure fails to respond to initial resuscitation, the rate of fluid administration should be increased and urgent intervention (eg, angiography) considered.

Blood transfusion

• Patients with severe bleeding need to be transfused.
• Fresh frozen plasma, platelets, or both should be given to patients with coagulopathy who are actively bleeding and to those who have received more than 10 units of packed erythrocytes.

Indications for transfusion
Age	Target Hematocrit
Elderly patient ( >45)	30%
Younger patient (<45)	25%
Patients with portal hypertension	28%

Triage and consultations

• All patients with visible rectal bleeding warrants an immediate evaluation in all cases. The timing and setting of the evaluation depends upon the severity of bleeding and the patient's comorbid illnesses.
• A gastroenterology consultation should be obtained early in the hospital course of patients with acute lower GI bleeding.

Evaluation setting	Patient catagories
ICU	Patients with high-risk features.
Outpatient	Patients with low-risk features.†
Regular Ward	Most other patients can be admitted to a regular medical ward.♦
†: Low-risk features include a young, otherwise healthy patient with minor, self-limited rectal bleeding suspected to be from an anal source) ♦: Requires continuous electrocardiogram monitoring and pulse oximetry.

Risk stratification

• Clinical features can predict the risk of complications in patients with presumed acute lower GI bleeding. These features can also be used to categorize patients as either low or high risk.
• The presence of more number of high-risk features directly correlates with the likelihood of a poor outcome.

High-risk features

Hemodynamic instability (hypotension, tachycardia, orthostasis, syncope) Persistent bleeding Significant comorbid illnesses Advanced age Bleeding that occurs in a patient who is hospitalized for another reason A prior history of bleeding from diverticulosis or angiodysplasia Current aspirin use Prolonged prothrombin time A non-tender abdomen Anemia An elevated blood urea nitrogen level An abnormal white blood cell count

Lower GI bleeding