- Aggressive intravenous resuscitation with fluids and blood, and airway protection are crucial in the management of the acutely bleeding patient.
- Endoscopy should be performed with therapeutic intent for both upper and lower gastrointestinal bleeding.
- Pharmacologic therapy should be used as an adjunct to endoscopic therapy.
- An early team approach, involving medical, radiologic, and surgical personnel, should be implemented.
- In the setting of severe bleeding or bleeding refractory to endoscopic therapy, angiographic and surgical therapies should be instituted promptly.
Gastrointestinal (GI) hemorrhage continues to be a frequent indication for intensive care management, with over 300,000 hospitalizations reported annually in the United States.1 Upper GI (UGI) bleeding has continued to predominate, with lower GI (LGI) bleeding constituting approximately 25% of all GI bleeding.2 Despite improved diagnostic and therapeutic modalities in the last two decades, the mortality rates for upper and lower GI hemorrhage have demonstrated different trends. Mortality from UGI bleeding has remained stable at 10%,3 and this could be explained by an aging population with a significantly higher GI bleeding mortality due to comorbid conditions.4 In contrast, the mortality from LGI bleeding has decreased dramatically despite an aging population, and this is probably due to more aggressive diagnostic and therapeutic endoscopic intervention.
The management of GI hemorrhage in the ICU is multidisciplinary, involving the intensivist, gastroenterologist, radiologist, and surgeon. A successful outcome relies on effective fluid resuscitation, maintenance of adequate perfusion pressure, prompt hemostasis, monitoring of end-organ function, and prevention of multiple-organ failure.
Multiple studies focusing primarily on nonvariceal UGI bleeding have been designed to define prognostic factors for GI bleeding and to identify high-risk patients.5–7 A common and pivotal feature of these studies is the combined use of clinical variables and endoscopic findings to guide risk stratification, thereby stressing the importance of integrating clinical and endoscopic information for optimal decision making. Table 82-1 outlines the clinical and endoscopic indicators associated with an increased risk of rebleeding and higher mortality. A recent study has identified similar prognostic indicators for LGI bleeding.8
++ Table Graphic Jump Location Table 82–1. Adverse Clinical and Endoscopic Prognostic Indicators ||Download (.pdf)
Table 82–1. Adverse Clinical and Endoscopic Prognostic Indicators
| Age >60 years|
| Severe comorbidities|
| Onset of bleeding during hospitalization|
| Emergency surgery|
| Clinical shock|
| Red blood emesis or NG aspirate|
| Requiring >5 U PRBC|
| Major stigmata: active bleeding, visible vessel, adherent clot|
| Ulcer location: posterior duodenal bulb, higher lesser gastric curvature|
| Ulcer size >2 cm in diamet|
| High-risk lesions: varices, aortoenteric fistula, malignancy|
GI bleeding is divided into UGI and LGI bleeding based on its location proximal or distal to the ligament of Treitz at the junction of the duodenum and jejunum. UGI bleeding commonly presents with hematemesis and/or melena, and a nasogastric ...