Blood is a potent laxative that is why a person with either UGIB or LGIB can also manifest diarrhea. For upper GI issues, the doctor may conduct an endoscopy or an upper GI series/barium swallow. American College of Gastroenterology guideline on the management of Helicobacter pylori infection. Zhao Y, Encinosa W. Hospitalizations for gastrointestinal bleeding in 1998 and 2006. The predictive capacity of the Glasgow-Blatchford score for the risk stratification of upper gastrointestinal bleeding in an emergency department. Gut. Sreedharan A, Martin J, Leontiadis GI, et al. Hemorrhoids can cause GI bleeding. Cochrane Database Syst Rev. 2007;82:286-296.27. This potential risk should be carefully assessed in patients, particularly those at risk for UGIB, as careful risk versus benefit may need to be assessed.34. For lower GI issues, the tests may include a colonoscopy, enteroscopy, or lower GI series/barium enema. Additional assessment of patients presenting with GIB should include a focused patient history aimed at identifying the nature, duration, and potential source of the bleeding, as well as laboratory testing (CBC, BMP, coagulation studies).17,18 When evaluating these patients from a pharmacist perspective, it is important to note any current or recent medication use that may increase the risk of bleeding, including agents such as nonsteroidal anti-inflammatory drugs, antiplatelet agents, and/or anticoagulants. Risk of bleeding is more common in males and … Your doctor will take a medical history, including a history of previous bleeding, conduct a physical exam and possibly order tests. Mayo Clin Proc. Advance online publication March 1, 2016. Epidemiology. Upper gastrointestinal bleeding (UGIB) is the cause of at least 300,000 hospitalizations each year, with an incidence of 48–160 per 100,000 adults annually.1,–3 While approximately 80% of UGIB cases will resolve spontaneously without treatment, the remaining 20% will continue to bleed or rebleed in the future.4 Patients with UGIB have increased risks of mortality, the need for blood transfusions, and the need for surgical procedures, as well as increased lengths of hospital stay … Chronic GI bleeding is insidious not unless secondary signs and symptoms of hemorrhage are apparent. In massive Upper GI hemorrhage, the individual may not only pass out melena but also fresh blood in the stools. 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) … The difference between hematochezia and rectorrhagia is that, in the latter, rectal bleeding is not associated with defecation; instead, it is associated with expulsion of fresh bright red blood without stools. INITIAL EVALUATION — The initial evaluation of a patient with a suspected clinically significant acute upper GI bleed ... in a randomized trial with 280 patients with upper GI bleeding, there were no differences in rebleeding rates or mortality between patients who underwent NGT lavage and those who did not . Understanding the cause and specific differences between the signs and symptoms of upper and lower GI bleeding is essential for proper treatment. -difference of 20 mmHg fall in systolic; 10 mmHg fall in diastolic pressure. Proton pump inhibitors therapy vs H2 receptor antagonists therapy for upper gastrointestinal bleeding after endoscopy: a meta-analysis. Of these, 81.1% had positive findings, 18.9% had peptic ulcer disease, and 7.2% required endoscopic treatment. It is a major concern that should not be taken for granted. 2015;21(20):6341-6351.30. An individual who has this may complain of easy fatigability, shortness of breath, dizziness and anemia caused by the bleeding. ABSTRACT: Gastrointestinal bleeds (GIBs) are a significant source of hospitalizations in the United States. The authors suggest the that guidelines be updated to recommend intermittent PPI therapy in endoscopically treated GIB.27 In practice, many institutions now favor intermittent dosing in order to decrease resource use and overall cost. Reproduction in whole or in part without permission is prohibited. Lower GI bleeding: The lower GI tract includes much of the small intestine, large intestine or bowels, rectum, and anus. Abdom Imaging. Risk of death from a GI bleed is between 5% and 30%. Pharmacists can also provide recommendations to the healthcare team regarding which medications may provide benefit to each GIB case. Every year, about 100,000 people in the United States go to the hospital for upper GI bleeding. Learn vocabulary, terms, and more with flashcards, games, and other study tools. To find out whether you have a GI condition, your gastroenterologist will perform diagnostic tests. 1. Pharmacists of many specialties are in a unique position to assist in the treatment and management of GIB patients. Chaimoff C, Creter D, Djaldetti M. The effect of pH on platelet and coagulation factor activities. Lower GI Bleed. 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). 1999;92:44-50.7. 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. Occasionally, a brisk upper GI bleeding (UGIB) manifests as hematochezia (red or maroon stools); the redder the stool, the more rapid the transit, which suggests a large upper tract hemorrhage. An upper GI bleed occurs in 50 to 150 per 100,000 adults per year. What is the difference between an upper and lower GI bleed? 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. Am J Gastroenterol. Unlike UGIB, available literature evaluating PPI use in LGIB does not show benefit. 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 … Am J Gastroenterol. All rights reserved. Ann Gastroenterol. Each type can present with different hallmark presentations and require different management. 2016;22(48):10477-10481. 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. Many bleeding episodes re… 1995;90:568–573.8. One of the most commonly used organizing frameworks in gastrointestinal bleeding is the differentiation between upper gastrointestinal bleeding (UGIB) and lower gastrointestinal bleeding (LGIB). Upper GIB is dependent on endoscopic therapy and may benefit from various pharmacologic treatments in specific scenarios, such as proton pump inhibitors and macrolides. 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. 3. Information regarding the use of tranexamic acid in treating lower GI … Trends on gastrointestinal bleeding and mortality: where are we standing? Am J Gastroenterol. Cheng H, Sheu B. Comparison of mortality from peptic ulcer bleed between patients with or without peptic ulcer antecedents. The medications for upper GI bleed are to treat ulcers, which is generally why you bleed in your upper GI tract. 2007;25:623-642.17. Zhang YS, Li Q, He BS, et al. Outpatient pharmacists are in a prime position to proactively watch for potential risk factors in patients, including high-dose NSAIDs and anticoagulants, and reduce the chance of GIB at the front line. Considerations. Hematochezia refers to the passage of bright red blood via the rectum. Treatment depends on the source of the bleeding. At presentation, workup of any suspected GIB is initially similar, wherever the origin of the bleed. Rahman R, Nguyen D, Sohail U, et al. 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. The first-line regimens for H pylori eradication are detailed in TABLE 7 based on the American College of Gastroenterology’s guidelines on the management of H pylori infection.33 Once the infection is resolved, this group of patients typically does not need to receive maintenance antisecretory therapy unless they require nonsteroidal anti-inflammatory drugs or antithrombotic therapy, with which long-term antisecretory therapy is necessary, as their use can significantly increase the risk of rebleeding.17,18. Immediate evaluation should focus on the patient’s hemodynamic stability. Define the source of Upper GI bleeding -Proximal to the ligament of Treitz. 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. 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. Statistical Brief #65. Specifically, stratification may provide insight into factors such as timing of endoscopy or colonoscopy, necessary level of care, and timing of discharge. Intermittent vs continuous proton pump inhibitor therapy for high-risk bleeding ulcers: a systematic review and meta-analysis. 2010(7):CD005415.26. Azithromycin may carry some logistical advantages, such as not requiring reconstitution and generally greater availability due to its use in empiric pneumonia treatment.32, Patients diagnosed with bleeding associated with Helicobacter pylori infection should be treated via guideline-based eradication therapy, with a goal of complete infection resolution.17 Available literature indicates that eradication of H pylori is significantly more effective than antisecretory treatment alone in patients with UGIB. 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. Evidence suggests PPIs decrease incidence of high-risk stigmata of hemorrhage at time of endoscopy but do not affect rebleeding, necessary surgery, or mortality.17,26 Postendoscopic therapy, PPIs can be used both acutely and chronically.17. Dig Liver Dis. A lower GI bleed is estimated to occur in 20 to 30 per 100,000 per year. 2009;2:21-30.5. There aren't really any medications for lower GI bleed, at least not direct ones. Gastrointestinal bleeding (GIB) is a relatively common medical issue, causing a significant portion of morbidity, hospitalizations, and even mortality annually in the United States. Applicability of the Rockall score in patients undergoing endoscopic therapy for upper gastrointestinal bleeding. Out of the 806 charts reviewed, patients with variceal bleeding, lower gastrointestinal bleeding, insignificant bleeds with no drop in H/H and stable vitals, GI bleed not being the presenting complaint on admission, patients on … Revista Española de Enfermedades Digestivas. 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). 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. Management of IBS With Concomitant Major Depressive Disorder. 2015;107(5):262-267.22. Considering H2 antagonists (H2As) are used with similar intent in other disease states, their use in UGIB has been investigated alongside PPIs. Intravenous proton pump inhibitors for peptic ulcer bleeding: clinical benefits and limits. 2007; 102:1808-1825.34. 2000;356:1318-1321.21. Stool tests. Am J Surg. Tielleman T, Bujanda D, Cryer B, et al. These outcomes have proved controversial; however, they offer evidence that patients with LGIB do not benefit from PPI therapy. 2009;47(2):179-184.15. Acute GI bleeding occurs when there is a sudden and significant blood loss due to bleeding. 1996;38:316-321.20. World Congress at ACG2017. Differentiating Upper and Lower GI Bleeds Initial Presentation and Risk Stratification. There are important differences in the etiologies between the 2 sources. 2. Whelan CT, Chen C, Kaboli P, et al. Acute GI Bleed; Acute GI bleeding occurs when there is a sudden and significant blood loss due to bleeding. 2017;47:218-230.19. South Med J. What is the difference between a colonoscopy and a lower GI test? Am J Gastroenterol. 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. Risk assessment and stratification is clinically useful to help distinguish patients at high and low risk of adverse outcomes.17,18 In stratifying patients into evaluated risk groups, initial informed decision-making can be made. Practice Parameters Committee of the American College of Gastroenterology. If pt rebleeds it is a 10 fold increase in mortality. 2016,29:312-317.31. This varies from lower GI bleeding (LGIB), which occurs farther down the GI tract. End result for majority of Upper GI bleeding-Spontaneous resolution for most. To inhibit this process, inhibition of gastric acid secretion intended to raise stomach pH to 6 or higher can help stabilize clots and improve clinical outcomes.24, PPIs are unique in that they have potential application both pre- and postendoscopy. Copyright © 2000 - 2021 Jobson Medical Information LLC unless otherwise noted. Clin Exp Gastroenterol. 2015;47:1-46.32. Your email address will not be published. It results in about 300,000 hospital admissions a year in the United States. Analysis of 3,294 cases of upper gastrointestinal bleeding in military medical facilities. 2012;18(11):1154-1158.2. ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding. Background: Lower GI hemorrhage is a common source of morbidity and mortality. An individual wit… December 2008.3. The amount of GI bleeding may be so small that it can only be detected on a … World J Gastrointest Pathophysiol. … Gastroenterol Clin North Am. 2011;3(3):49-56.29. Raju GS, et al. Nasogastric lavage. El-Tawil A. 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. Identification and resuscitation of the trauma patient in shock. Gralnek IM, Dumonceau JM, Kuipers EJ, et al. Emerg Med Clin N Am. Acute overt lower gastrointestinal bleeding (LGIB) accounts for ˜20% of all cases of gastrointestinal (GI) bleeding, usually leads to hospital admission with invasive diagnostic evaluations, and consumes significant medical resources (1, 2, 3). Wilcox CM, Clark WS. Appropriate dosing and administration of PPI have been evaluated closely in recent years (TABLE 6). 2007;133(5):1694-1696.13. 1978;136(2):257-259.25. Trends on gastrointestinal bleeding and mortality: where are we standing? 2010;5(3):141-147.4. Bariatric Surgery for the Treatment of Type 2 Diabetes Mellitus: What Are the Options? Negligence of this condition may cause a life, thus once manifested prompt and early medical therapy is very vital. Rev Med Inst Mex Seguro Soc. They may also complain of anorexia and unexplained weight loss. GI bleeding is also called bleeding in the digestive tract, upper GI bleeding, or lower GI bleeding. 2015;25(3):415-428.14. To comment on this article, contact rdavidson@uspharmcist.com. The bleeding can be chronic or acute. Constipation and straining during bowel movements cause hemorrhoids to swell. 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 … The gastrointestinal tract is prone to serious tissue damage caused by trauma and certain GI diseases, which can lead to bleeding. Of course, these patients would likely present hemodynamically unstable from the rapid blood loss. Wilcox CM, Cryer BL, Henk HJ, et al. Often, an individual manifests hematemesis, vomiting of fresh blood or coffee ground vomitus. J R Coll Physicians Edinb. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Management of lower GIB is focused on colonoscopy and mechanically treating bleeds, with little pharmacological intervention. Other tests look for globin, DNA, or other blood factors including transferrin, while conventional stool guaiac tests look for heme Kim, SK, Cho CD, Wojtowycz AR. Initial medication reconciliation may reveal details relevant to diagnosis and treatment of patients, such as identifying outpatient NSAID or anticoagulant use. It requires prompt treatment once diagnosed otherwise this can lead to hypovolemic shock and even death. Sachar H, Vaidya K, Laine L, et al. Diagnosis of gastrointestinal bleeding: a practical guide for clinicians. Endoscopy. 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. Hematochezia (red or maroon blood in the stool) usually indicates the presence of lower GI bleeding or a brisk upper GI bleed. 1998;9(4):452-456.6. World J Gastroenterol. September 2008. www.sign.ac.uk/assets/sign105.pdf.10. World J Gastrointest Endosc. Gastrointest Endosc Clin N Am. Thirty-eight percent of the patients with a supratherapeutic international normalized ratio underwent lower endoscopy; of these, … Barium is used only for diagnostic studies of the GI tract. See “ Differential diagnosis of lower gastrointestinal bleeding in children.” Bleeding from the upper respiratory tract (e.g., nocturnal nosebleeds) can be mistaken for GI bleeding because the blood can be swallowed and vomited or appear in the stool as melena.Careful examination and history taking is the key to differentiating respiratory sources of bleeding from GI … 2008;33:395-397.11. 2012;107:345-360.18. Blood tests. Coffee Ground Hematemesis – vomiting of blood altered by stomach acids and enzymes. Lower gastrointestinal bleeding (LGIB) occurs when any section of the lower gastrointestinal tract (jejunum, ileum, cecum, colon, rectum, anus) begins to bleed… Strate L. Lower GI bleeding: epidemiology and diagnosis. This process shows differences that might not be seen on standard X-rays. There are many possible causes of GI bleeding, including hemorrhoids, peptic ulcers, tears or inflammation in the esophagus, diverticulosis and diverticulitis, ulcerative colitis and Crohn's disease, colonic polyps, or cancer in the colon, stomach or esophagus. American Gastroenterological Association (AGA) Institute medical position statement on obscure gastrointestinal bleeding. Pre-endoscopic erythromycin administration in upper gastrointestinal bleeding: an updated meta-analysis and systematic review. JAMA Intern Med. Siau K, Chapman W, Sharma N, et alManagement of acute upper gastrointestinal bleeding: an update for the general physician. You may need a complete blood count, a test to see how fast your blood clots, a platelet count and liver function tests. Certain Patients Need More Sedation During Endoscopic Procedures, PPI Use in Infants With Acid Reflux Increases Early Fracture Risks.
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