Gastrointestinal hemorrhage: Difference between revisions
imported>Robert Badgett m (→Glasgow-Blatchford bleeding score: Fixed Hb) |
imported>Howard C. Berkowitz (Occult blood v. specific tests at first mention -- perhaps occult blood should move to another article) |
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===Upper gastrointestinal tract bleeding=== | ===Upper gastrointestinal tract bleeding=== | ||
====Summary==== | ====Summary==== | ||
The diagnosis of upper GI bleeding is assumed when hematemesis is documented. In the absence of hematemesis, an upper source for GI bleeding is likely in the presence of at least two factors among: black stool, age < 50 years, and blood urea nitrogen/creatinine ratio 30 or more.<ref name="pmid16635697">{{cite journal |author=Witting MD, Magder L, Heins AE, Mattu A, Granja CA, Baumgarten M |title=ED predictors of upper gastrointestinal tract bleeding in patients without hematemesis |journal=Am J Emerg Med |volume=24 |issue=3 |pages=280–5 |year=2006 |pmid=16635697 |doi=10.1016/j.ajem.2005.11.005 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-6757(05)00427-4}}</ref> In the absence of these findings, consider a nasogastric aspirate to determine the source of bleeding. If the aspirate is positive, an upper GI bleed is greater than 50%, but not high enough to be certain. If the aspirate is negative, the source of a GI bleed is likely lower. The accuracy of the aspirate is improved by using | The diagnosis of upper GI bleeding is assumed when hematemesis is documented. In the absence of hematemesis, an upper source for GI bleeding is likely in the presence of at least two factors among: black stool, age < 50 years, and blood urea nitrogen/creatinine ratio 30 or more.<ref name="pmid16635697">{{cite journal |author=Witting MD, Magder L, Heins AE, Mattu A, Granja CA, Baumgarten M |title=ED predictors of upper gastrointestinal tract bleeding in patients without hematemesis |journal=Am J Emerg Med |volume=24 |issue=3 |pages=280–5 |year=2006 |pmid=16635697 |doi=10.1016/j.ajem.2005.11.005 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-6757(05)00427-4}}</ref> In the absence of these findings, consider a nasogastric aspirate to determine the source of bleeding. If the aspirate is positive, an upper GI bleed is greater than 50%, but not high enough to be certain. If the aspirate is negative, the source of a GI bleed is likely lower. The accuracy of the aspirate is improved by using a chemical [[occult blood]] test on stool.<ref name="pmid9928705">{{cite journal |author=Ernst AA, Haynes ML, Nick TG, Weiss SJ |title=Usefulness of the blood urea nitrogen/creatinine ratio in gastrointestinal bleeding |journal=Am J Emerg Med |volume=17 |issue=1 |pages=70–2 |year=1999 |pmid=9928705 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-6757(99)90021-9}}</ref> | ||
====Clinical predictors==== | ====Clinical predictors==== | ||
Two [[clinical prediction rule]]s, the Glasgow-Blatchford bleeding score and the Rockall score, can help identify patients at risk of complications.<ref name="pmid19091393">{{cite journal| author=Stanley AJ, Ashley D, Dalton HR, Mowat C, Gaya DR, Thompson E et al.| title=Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation. | journal=Lancet | year= 2009 | volume= 373 | issue= 9657 | pages= 42-7 | pmid=19091393 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&retmode=ref&cmd=prlinks&id=19091393 | doi=10.1016/S0140-6736(08)61769-9 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&retmode=ref&cmd=prlinks&id=19451570 Review in: Ann Intern Med. 2009 May 19;150(10):JC5-14] </ref> A cohort of 325 patients reported that the odds ratios for the strongest predictors were: black stool, 16.6, age < 50 years, 8.4, and blood urea nitrogen/creatinine ratio 30 or more, 10.0.<ref name="pmid16635697">{{cite journal |author=Witting MD, Magder L, Heins AE, Mattu A, Granja CA, Baumgarten M |title=ED predictors of upper gastrointestinal tract bleeding in patients without hematemesis |journal=Am J Emerg Med |volume=24 |issue=3 |pages=280–5 |year=2006 |pmid=16635697 |doi=10.1016/j.ajem.2005.11.005 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-6757(05)00427-4}}</ref> Seven (5%) of 151 with none of these factors had an upper GI tract bleed, versus 63 (93%) of 68 with 2 or 3 factors. Ernst found similar results.<ref name="pmid9928705">{{cite journal |author=Ernst AA, Haynes ML, Nick TG, Weiss SJ |title=Usefulness of the blood urea nitrogen/creatinine ratio in gastrointestinal bleeding |journal=Am J Emerg Med |volume=17 |issue=1 |pages=70–2 |year=1999 |pmid=9928705 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-6757(99)90021-9}}</ref> | Two [[clinical prediction rule]]s, the Glasgow-Blatchford bleeding score and the Rockall score, can help identify patients at risk of complications.<ref name="pmid19091393">{{cite journal| author=Stanley AJ, Ashley D, Dalton HR, Mowat C, Gaya DR, Thompson E et al.| title=Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation. | journal=Lancet | year= 2009 | volume= 373 | issue= 9657 | pages= 42-7 | pmid=19091393 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&retmode=ref&cmd=prlinks&id=19091393 | doi=10.1016/S0140-6736(08)61769-9 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&retmode=ref&cmd=prlinks&id=19451570 Review in: Ann Intern Med. 2009 May 19;150(10):JC5-14] </ref> A cohort of 325 patients reported that the odds ratios for the strongest predictors were: black stool, 16.6, age < 50 years, 8.4, and blood urea nitrogen/creatinine ratio 30 or more, 10.0.<ref name="pmid16635697">{{cite journal |author=Witting MD, Magder L, Heins AE, Mattu A, Granja CA, Baumgarten M |title=ED predictors of upper gastrointestinal tract bleeding in patients without hematemesis |journal=Am J Emerg Med |volume=24 |issue=3 |pages=280–5 |year=2006 |pmid=16635697 |doi=10.1016/j.ajem.2005.11.005 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-6757(05)00427-4}}</ref> Seven (5%) of 151 with none of these factors had an upper GI tract bleed, versus 63 (93%) of 68 with 2 or 3 factors. Ernst found similar results.<ref name="pmid9928705">{{cite journal |author=Ernst AA, Haynes ML, Nick TG, Weiss SJ |title=Usefulness of the blood urea nitrogen/creatinine ratio in gastrointestinal bleeding |journal=Am J Emerg Med |volume=17 |issue=1 |pages=70–2 |year=1999 |pmid=9928705 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-6757(99)90021-9}}</ref> | ||
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! Finding !! Sensitivity !! Specificity !! Positive predictive value<br>(prevalence of 39%)!! Negative predictive value<br>(prevalence of 39%) | ! Finding !! Sensitivity !! Specificity !! Positive predictive value<br>(prevalence of 39%)!! Negative predictive value<br>(prevalence of 39%) | ||
|- | |- | ||
! Gastroccult | ! Gastroccult (occult blood) | ||
| 95% || 82% || 77% || 96% | | 95% || 82% || 77% || 96% | ||
|- | |- | ||
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====Esophagogastroduodenoscopy==== | ====Esophagogastroduodenoscopy==== | ||
Esophagogastroduodenoscopy (EGD) can help determine the cause of the bleeding. Intravenous erythromycin prior to endoscopy can help clear the stomach of blood to improve the exam.<ref name="pmid17848180">{{cite journal |author=Winstead NS, Wilcox CM |title=Erythromycin prior to endoscopy for acute upper gastrointestinal haemorrhage: a cost-effectiveness analysis |journal=Aliment. Pharmacol. Ther. |volume=26 |issue=10 |pages=1371–7 |year=2007 |pmid=17848180 |doi=10.1111/j.1365-2036.2007.03516.x}}</ref> | [[Esophagogastroduodenoscopy]](EGD) can help determine the cause of the bleeding. Intravenous [[erythromycin]] prior to endoscopy can help clear the stomach of blood to improve the exam.<ref name="pmid17848180">{{cite journal |author=Winstead NS, Wilcox CM |title=Erythromycin prior to endoscopy for acute upper gastrointestinal haemorrhage: a cost-effectiveness analysis |journal=Aliment. Pharmacol. Ther. |volume=26 |issue=10 |pages=1371–7 |year=2007 |pmid=17848180 |doi=10.1111/j.1365-2036.2007.03516.x}}</ref> | ||
===Lower gastrointestinal tract bleeding=== | ===Lower gastrointestinal tract bleeding=== | ||
Revision as of 21:21, 14 June 2010
Gastrointestinal hemorrhage (GI bleeding) is defined as "bleeding in any segment of the gastrointestinal tract from esophagus to rectum."[1]
Diagnosis
Upper gastrointestinal tract bleeding
Summary
The diagnosis of upper GI bleeding is assumed when hematemesis is documented. In the absence of hematemesis, an upper source for GI bleeding is likely in the presence of at least two factors among: black stool, age < 50 years, and blood urea nitrogen/creatinine ratio 30 or more.[2] In the absence of these findings, consider a nasogastric aspirate to determine the source of bleeding. If the aspirate is positive, an upper GI bleed is greater than 50%, but not high enough to be certain. If the aspirate is negative, the source of a GI bleed is likely lower. The accuracy of the aspirate is improved by using a chemical occult blood test on stool.[3]
Clinical predictors
Two clinical prediction rules, the Glasgow-Blatchford bleeding score and the Rockall score, can help identify patients at risk of complications.[4] A cohort of 325 patients reported that the odds ratios for the strongest predictors were: black stool, 16.6, age < 50 years, 8.4, and blood urea nitrogen/creatinine ratio 30 or more, 10.0.[2] Seven (5%) of 151 with none of these factors had an upper GI tract bleed, versus 63 (93%) of 68 with 2 or 3 factors. Ernst found similar results.[3]
Glasgow-Blatchford bleeding score
- Blood urea nitrogen level
- 6.5 to 7.9 mmol/L = 2
- 8.0 to 9.9 mmol/L = 3
- 10 to 25 mmol/L = 4
- > 25 mmol/L = 6)
- Hemoglobin level
- Men
- 12.0 to 12.9 g/dL = 1
- 10.0 to 11.9 g/dL = 3
- < 10.0 g/dL = 6
- Women
- 10.0 to 11.9 g/dL = 1
- < 10.0 g/dL = 6
- Men
- Systolic blood pressure
- 100 to 109 mm Hg = 1
- 90 to 99 mm Hg = 2
- < 90 mmHg = 3
- Other markers
- Heart rate ≥ 100/min = 1
- Melena = 1
- Syncope = 2
- Hepatic disease = 2
- Heart failure = 2
Low risk is 0 points.
Nasogastric aspirate
The nasogastric aspirate can help determine the location of bleeding and thus direct initial diagnostic and treatment plans; however, the sensitivity is low.[5] Witting found that nasogastric aspirate has sensitivity 42%, specificity 91%, negative predictive value 64%, positive predictive value 92% and overall accuracy of 66% in differentiating upper GI bleeding from bleeding distal to the ligament of Treitz.[6] Thus, in this study a positive aspirate is more helpful than a negative aspirate. In a smaller study, Cuellar found a sensitivity of 79% and specificity of 55%[7], somewhat opposite results from Witting. Cuellar also studied the appearance of the aspirate and the results are in the table.
| Finding | Sensitivity | Specificity | Positive predictive value (prevalence of 39%) |
Negative predictive value (prevalence of 39%) |
|---|---|---|---|---|
| Gastroccult (occult blood) | 95% | 82% | 77% | 96% |
| Physician assessment | 79% | 55% | 53% | 20% |
Determining whether blood is in gastric contents, either vomited or aspirated specimens, is surprisingly difficult. Slide tests are based on orthotolidine (Hematest reagent tablets and Bili-Labstix) or guaiac (Hemoccult and Gastroccult). Rosenthal found orthotolidine-based tests more sensitive than specific; the Hemoccult test's sensitivity reduced by the acidic environment; and the Gastroccult test be the most accurate.[8]
Holman used simulated gastric specimens and found the Hemoccult test to have significant problems with non-specificity and false-positive results, whereas the Gastroccult test was very accurate.[9] Holman found that by 120 seconds after the developer was applied, the Hemoccult test was positive on all control samples.[9]
Esophagogastroduodenoscopy
Esophagogastroduodenoscopy(EGD) can help determine the cause of the bleeding. Intravenous erythromycin prior to endoscopy can help clear the stomach of blood to improve the exam.[10]
Lower gastrointestinal tract bleeding
Treatment
Upper gastrointestinal tract bleeding
Clinical practice guidelines address the management of nonvariceal bleeding.[11] Most patients should receive esophagogastroduodenoscopy and some patients need a second look esophagogastroduodenoscopy.[11]
Some patients may be treated as outpatients.[12]
Lower gastrointestinal tract bleeding
Prognosis
Upper gastrointestinal tract bleeding
For patients with nonvariceal upper gastrointestinal tract bleeding, the Blatchford score is a clinical prediction rule for predicting patients that will require blood transfusion, endoscopic or surgical management for bleeding control.[13]
The Blatchford score is high risk if the patient has any of the following:
- Blood urea nitrogen ≥18.2 (mg/dL)
- Hemoglobin level
- for men <13 (g/dL)
- for women <12 (g/dL)
- Systolic blood pressure <109(mm Hg)
- Pulse rate ≥100 beats/min
- Melena
- Syncope
- Hepatic disease
- Heart failure
In a study in which 69.5% of the patients were had blood transfusion, endoscopic or surgical management, the accuracy of the score is:
- sensitivity = 99.6%
- specificity = 25.0%
which yielded:
- positive predictive value = 75.2%
- negative predictive value = 96.4%
The Blatchford score out performed Rockall score in one comparison.[13]
Lower gastrointestinal tract bleeding
References
- ↑ National Library of Medicine. Gastrointestinal Hemorrhage. Retrieved on 2007-11-09.
- ↑ 2.0 2.1 Witting MD, Magder L, Heins AE, Mattu A, Granja CA, Baumgarten M (2006). "ED predictors of upper gastrointestinal tract bleeding in patients without hematemesis". Am J Emerg Med 24 (3): 280–5. DOI:10.1016/j.ajem.2005.11.005. PMID 16635697. Research Blogging.
- ↑ 3.0 3.1 Ernst AA, Haynes ML, Nick TG, Weiss SJ (1999). "Usefulness of the blood urea nitrogen/creatinine ratio in gastrointestinal bleeding". Am J Emerg Med 17 (1): 70–2. PMID 9928705. [e]
- ↑ Stanley AJ, Ashley D, Dalton HR, Mowat C, Gaya DR, Thompson E et al. (2009). "Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation.". Lancet 373 (9657): 42-7. DOI:10.1016/S0140-6736(08)61769-9. PMID 19091393. Research Blogging. Review in: Ann Intern Med. 2009 May 19;150(10):JC5-14
- ↑ Palamidessi N, Sinert R, Falzon L, Zehtabchi S (2010). "Nasogastric aspiration and lavage in emergency department patients with hematochezia or melena without hematemesis.". Acad Emerg Med 17 (2): 126-32. DOI:10.1111/j.1553-2712.2009.00609.x. PMID 20370741. Research Blogging.
- ↑ Witting MD, Magder L, Heins AE, Mattu A, Granja CA, Baumgarten M (2004). "Usefulness and validity of diagnostic nasogastric aspiration in patients without hematemesis". Ann Emerg Med 43 (4): 525–32. DOI:10.1016/S0196064403009417. PMID 15039700. Research Blogging.
- ↑ 7.0 7.1 Cuellar RE, Gavaler JS, Alexander JA, et al (1990). "Gastrointestinal tract hemorrhage. The value of a nasogastric aspirate". Arch. Intern. Med. 150 (7): 1381–4. PMID 2196022. [e]
summary of these results is available at the Evidence-Based On-Call database and through the Wayback Archive Cite error: Invalid
<ref>tag; name "pmid2196022" defined multiple times with different content - ↑ Rosenthal P, Thompson J, Singh M (1984). "Detection of occult blood in gastric juice". J. Clin. Gastroenterol. 6 (2): 119–21. PMID 6715849. [e]
- ↑ 9.0 9.1 Holman JS, Shwed JA (1992). "Influence of sucralfate on the detection of occult blood in simulated gastric fluid by two screening tests". Clin Pharm 11 (7): 625–7. PMID 1617913. [e]
- ↑ Winstead NS, Wilcox CM (2007). "Erythromycin prior to endoscopy for acute upper gastrointestinal haemorrhage: a cost-effectiveness analysis". Aliment. Pharmacol. Ther. 26 (10): 1371–7. DOI:10.1111/j.1365-2036.2007.03516.x. PMID 17848180. Research Blogging.
- ↑ 11.0 11.1 Barkun AN, Bardou M, Kuipers EJ, Sung J, Hunt RH, Martel M et al. (2010). "International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding.". Ann Intern Med 152 (2): 101-13. DOI:10.1059/0003-4819-152-2-201001190-00009. PMID 20083829. Research Blogging.
- ↑ Cooper GS, Kou TD, Wong RC (January 2009). "Outpatient management of nonvariceal upper gastrointestinal hemorrhage: unexpected mortality in Medicare beneficiaries". Gastroenterology 136 (1): 108–14. DOI:10.1053/j.gastro.2008.09.030. PMID 19010328. Research Blogging.
- ↑ 13.0 13.1 Chen IC, Hung MS, Chiu TF, Chen JC, Hsiao CT (2007). "Risk scoring systems to predict need for clinical intervention for patients with nonvariceal upper gastrointestinal tract bleeding". The American journal of emergency medicine 25 (7): 774–9. DOI:10.1016/j.ajem.2006.12.024. PMID 17870480. Research Blogging.