HEMATEMESIS AND MELANA

Objectives

-Define hematemesis,melaena and positive occult blood stool and state their
significance with regard to the level of the bleeding source.
-Differentiate the clinical presentations of acute and chronic gastrointestinal bleeding;
differentiate the presentations of bleeding from upper and lower sources.
-Outline according to priority the steps of assessment and initial management in a
patient with gastrointestinal haemorrhage,including the following:
*general systemic evaluation.
*correction of hypovolaemia.
*verification of bleeding(nasogastric tube, rectal examination)
*management triage(prompt surgery vs further studies).
*diagnostic methods sequence for upper gastrointestinal haemorrhage
( endoscopy , angiography, barium studies)
*diagnostic methods sequence for lower gastrointestinal haemorrhage.
( procto-sigmoidoscopy , angiography, barium studies)

-In order of frequency,list the most common causes of upper and lower
gastrointestinal bleeding.
-Identify systemic and synergistic conditions that should be considered in
gastrointestinal bleeding(eg , medications anticouagulants, blood dyscrasias)
-List the criteria for surgical intervention in a patient with gastrointestinal
haemorrhage.
-Discuss the role of the surgeon in the management of patients with gastrointestinal
haemorrhage and the importance of the timing of the surgical intervention.

Definitions and general principles

- the clinical presentation of an upper GI bleed mainly depends on the rate of

bleeding, and whether the patient actively vomits blood or whether his bleed
manifests solely as melena or hematochezia

- a slow upper GI bleed may merely present with a progressive anemia + heme-occult
positive stools

- melena (black, tarry foul-smelling stool) usually signifies the presence of >50ml of
blood and it usually implies a GI source proximal to the cecum (the black color is due
to the effect of bacteria on blood as it passes through the colon - it takes > 12 hours of
transit time for melena to develop)

(* melena can rarely develop as a result of bleeding from right colonic sources =>
always exclude an upper GI bleed before pursuing proximal colonic pathology)

- hematochezia (maroon bloody stools) can come from a proximal GI source if

intestinal transit times are fast, but is usually signifies a lower GI source, and it
usually implies a volume of blood of >200ml
- hematemesis is bloody vomitus and it may be fresh bright-red blood or older coffee-
ground material, and it signifies an upper GIT bleed

- hematemesis accompanies melena in ~ 50% of upper GIT bleeds, and it usually

signifies a larger, brisker bleed

- a patient may occasionally present without any objective signs of GI blood loss, and
the patient may merely present with symptoms of hypovolemia (weakness,
lightheadedness or syncope, dyspnea or angina if the patient has underlying CAD)

- common causes of upper GI bleeding in adults include PUD (50% of adult cases),
esophageal varices (10-15% of adult cases), gastritis (10% of adult cases) and
Mallory-Weiss tears (5-10% of adult cases)

- other common causes in an adult (> 1% incidence) include:- esophagitis,

neoplasm, marginal ulcer, or vascular ectasia (upper gastrointestinal angiodysplasia
or angiomas are mostly idiopathic, but may also be found as part of the Osler-Weber-
Rendu syndrome and in patients with chronic renal failure, aortic stenosis, CREST
and von Willebrands disease)

- rare causes in an adult (< 1% incidence) include:- Dieulafoy's erosion (a large

submucosal artery that protrudes through the gastric mucosa and that is unassociated
with a gastric ulcer), hemobilia, connective tissue disorders, aorto-enteric fistula,
mesenteric ischemia, radiation gastritis, gastric volvulus and blood dyscrasias

(* see the appendix for common causes of upper GI bleeding in pediatric patients
based on age)

- the mortality of acute upper GI bleeding has remained unchanged for the past 50
years (~ 7 - 10% mortality) and there is a much higher mortality in patients, who have
bright red blood in the gastric aspirate

History of the present illness

- if the patient has a history of an acute hematemesis, obtain information on the

amount of blood and the duration of bleeding

- inquire about any history of melena and symptoms of hypovolemia (weakness,

lightheadedness or syncope, dyspnea or angina if the patient has underlying CAD)

- any associated upper abdominal pain suggests PUD, or rarely gastritis, or

uncommon pathology (pancreatic or biliary pathology eroding into the upper GIT,
aortic-enteric fistula, gastric malignancy)

- recent dyspepsia or heartburn suggests esophagitis or gastritis or PUD

- recent violent retching or vigorous coughing suggests a possible Mallory-Weiss

tear, especially if the patient has liberally consumed alcohol
- a previous history of upper GI bleeds is found in patients with esophageal varices
and PUD (60% of rebleeding is from the same site)

- inquire about any underlying PUD, liver disease and esophageal varices, gastric
malignancy or any bleeding diathesis (hematological disorder, anticoagulants, end
stage liver disease)

- inquire about previous aortic graft surgery (recent fever and abdominal tenderness
suggests an aorto-enteric fistula)

- a history of pancreatitis suggests the possibility of rupture of a peri-pancreatic

pseudoaneurysm or vein into a pseudopancreatic cyst and secondary erosion into the
GIT (or simple leakage via the pancreatic duct into the duodenum)

- inquire about recent nosebleeds, which can also subsequently present with coffee-
ground vomitus or hematemesis

- a personal or family history of recurrent nosebleeds suggests Osler-Weber-

Rendu syndrome (hereditary hemorrhagic telangiectasia)

- inquire about heavy alcohol consumption (causes alcoholic gastropathy, gastritis,

PUD and cirrhosis with secondary esophageal varices) or recent aspirin/NSIAD use
(causes gastritis and PUD)

Examination

- first determine the patient's vital signs

- check the nose and throat for evidence of a recent upper airway bleed

- check the skin for cutaneous manifestation of cancer (acanthosis nigricans),

bleeding diathesis (bruising or petechia), connective tissue disease (Ehlers-Danlos
syndrome) or genetic diseases (Peutz-Jeghers disease, Osler-Rendu-Weber syndrome)
or end-stage liver disease (spider nevi, palmar erythema, caput medusae)

- check for jaundice (cirrhosis, or hemobilia = combination of jaundice + abdominal

pain + blood-stained bile)

- check the abdomen for tenderness (PUD perforation, pancreatitis, hemobilia), or

masses (enlarged liver, gastric or pancreatic masses), or pulsations (AAA), or bruits
(AAA, aorto-enteric fistulas), or hyperactive bowel sounds (large upper GI bleed) or
ascites (end-stage liver disease) or testicular atrophy (end-stage liver disease) or
hepatosplenomegaly (liver disease and portal hypertension)

- perform a rectal exam looking for evidence of melena, hematochezia or heme-

occult positive stools

Diagnostic testing
Nasogastric aspiration

- a NGT should be inserted in all patients who present with hematemesis or melena or
hematochezia

- the NGT should be inserted into the stomach and manually aspirated

(* continuous suction is contra-indicated because it may cause gastric mucosal injury

if the stomach wall is constantly sucked against the catheter tip; those same mucosal
injuries may also confound the endoscopic determination of the cause of the GI
bleeding)

- the presence of grossly visible blood or coffee-grounds in the gastric aspirate

confirms an upper GI bleed

(* there is no reason to perform a heme occult test on marginally dark gastric fluid to
see if it is heme positive, because the test is inaccurate and the result does not affect
clinical management => see the outpatient management of an upper GIT bleed)

- a negative gastric aspirate does not exclude an upper GI bleed - the gastric aspirate
could be negative because the bleeding is intermittent; also, >10% of bleeding
duodenal ulcers have a negative gastric aspirate because the blood does not reflux
back into the stomach

(* aspiration of non-bloody bile virtually excludes a duodenal bleed, although

clinicians have difficulty deciding whether aspirated gastric fluid definitely contains
bile based on a visual inspection of the aspirated fluid)

- the NGT should be promptly removed if there is no evidence of active bleeding -

leaving the tube in situ for a prolonged period can cause mucosal lesions and is
uncomfortable for the patient

(* insertion of a NGT is not contra-indicated in the presence of known esophageal

varices or a suspected Mallory-Weiss tear)

- if the patient is actively bleeding => a larger tube (34F) should be used for tap water
irrigation in order to remove large clots (the patient should be placed in the left lateral
decubitus and Trendelenburg position)

(* tap water irrigation should not be performed without first confirming correct NGT
placement on an upright chest X-ray; remember that the absence of free air on an
upright chest x-ray may also help exclude a gastric perforation, which is a contra-
indication to gastric lavage; tap water should be used in 100 - 200cc aliquots until the
aspirate clears => continued bleeding suggests a massive bleed requiring emergency
gastro-enterology consultation + emergency endoscopy +/- emergency surgery; ice
water lavage does not help stop the bleeding and it lowers the core temperature and it
is therefore not indicated; there is no advantage to using sterile water or normal saline
solution when performing gastric lavage)

Chest X-ray
- has no diagnostic utility in the absence of any clinical suspicion of pulmonary
aspiration, or a gastric perforation, or a large full-thickness Mallory-Weiss tear
causing secondary pleural space soiling

Abdominal X-ray

- has no clinical utility in the diagnostic evaluation of an upper GI bleed due to PUD,
gastritis, esophageal varices or esophagitis

BUN

- a BUN level > 40 in the presence of a normal serum creatinine is suggestive of an

upper GI bleed

Hematocrit

- the absolute level does not correlate with the presence, or degree, of an upper GI
bleed

- the hematocrit can be normal despite overt evidence of hypovolemic shock, because
it takes many hours for the hematocrit to stabilize following an acute bleed

- a low initial hemoglobin could be due to occult GI bleeding preceding the ED visit,
or it could be due to an anemia that is unrelated to the GI bleed eg. chronic anemia
secondary to liver disease or renal failure

- the final hemoglobin level depends on the amount of continued bleeding, but it is
also affected by the volume of crystalloid fluid +/- packed cells infused during that
same time period

- serial hemoglobin levels are used to roughly quantify the degree of active bleeding
and the adequacy of red blood cell replacement

Coagulation studies

- a PT and PTT and platelet count are routinely indicated, especially if the patient
has a history of liver disease, a known coagulopathy or anticoagulant use

Blood typing

- a type and screen should routinely be performed

- a type-and-crossmatch should be performed if there is any evidence of significant

bleeding or hemodynamic instability => the number of ordered units depends on the
degree of bleeding and the hemodynamic status of the patient (usually 2 - 4 units in an
adult)

Liver function tests

- indicative of baseline liver function in patients with liver disease and should
routinely be ordered

ECG

- should be performed in all elderly patients with a significant GIT bleed because
there is a high incidence of silent AMIs secondary to hypovolemic shock

- any ischemic ECG changes warrants patient admission to an ICU to exclude

secondary cardiac ischemia

ED management

Fluid recuscitation

- first ensure hemodynamic stability by normal saline fluid administration

- fluid administration is tailored to the patient's needs; caution is advisable in elderly

patients at risk of CHF, or in renal failure patients and in patients with cirrhosis;
vasopressors are contra-indicated in hypovolemic patients

- packed cells should be administered if > 30cc/kg of normal saline is required to

acutely recuscitate a hypovolemic patient; the threshold should be lower if the patient
is obviously anemic

- the requirement for packed cells depends on the initial hemoglobin level + rate of
bleeding + presence of underlying ischemic heart disease => the "target"
hemoglobin level should be flexible and ~ 10 g/dl in elderly patients with ischemic
heart disease and poor cardiovascular reserve, and 6 - 8 g/dl in young, previously
healthy patients

(* rigid guidelines for the administration of blood products should be avoided => use
your clinical judgement => the transfusion requirment should be based on the:- i)
patient's age, ii) presence of co-morbidities, iii) patient's cardiovascular reserve, iv)
baseline hematocrit, v) rate of bleeding and vi) clinical efficacy of therapy

- serial vital signs + serial hemoglobin levels are the best indicators of the balance
between ongoing bleeding and ongoing fluid recuscitation

Correct any coagulopathy

- correct any coagulopathy prn with 10 - 15 ml/kg of FFP (if PT > 1.5) and/or platelet
transfusions (if platelet count < 50,000/cu.mm)

(* avoid giving FFP and platelets based on an empirical formula relating to the
number of units of transfused packed cells; transfusion decisions should also be
affected by the presence of other coagulopathies eg. DIC, or the presence of
qualitative platelet defects induced by renal failure or aspirin/NSIADs)
- do not empirically give large doses of vitamin K (10mg) to patients taking warfarin
for critically important reasons (eg. mechanical heart valve) because the patient will
become resistant to coumadin for an extended period of time => use FFP to
temporarily correct the anticoagulant-induced coagulopathy during the acute bleeding
period => prothromin complexes are only used if FFP is not effective

(* small doses of sc vitamin K - 1mg - may be acceptable)

Emergency endoscopy

- patients with i) active upper GI bleeding manifested by hematemesis +

hemodynamic instability, ii) massive upper GI bleeding, or iii) suspected
esophageal variceal bleeding should undergo emergency endoscopy after initiating
fluid and medical recuscitation

- gastric lavage with room temperature tap water should be used to clear the stomach
prn prior to endoscopy

- endoscopy may need to be performed in the operating room if there is massive

bleeding and life-threatening shock => emergency surgery may be necessary

- endotracheal intubation may be required to protect the airway from aspiration if the
bleeding is massive or if the patient has significantly altered mental status =>
temporarily delay upper endoscopy until airway management and hemodynamic
stability is secured

- endoscopy should also be performed promptly if the patient has a history of a

previous abdominal aortic aneurysm repair - in order to exclude the possibility of
an aorto-enteric fistula (70% are found in the duodenum and 90% present with a
herald bleed prior to a massive bleed)

(*failure to recognize a "herald" bleed may result in death from a subsequent sudden
exanguinating bleed)

- endoscopy can be temporarily delayed if the non-variceal bleeding patient (who is

also not at risk of bleeding from an aorto-enteric fistula) has self-limited bleeding =>
diagnostic accuracy is not altered if endoscopy is performed within 24 hours; middle-
of-the-night diagnostic endoscopy should be avoided in stable patients with self-
limited bleeding if well-trained personnel are not readily available

- endoscopy is successful in making the diagnosis in 80 - 95% of patients with an

upper GI bleed if it is performed within 24 hours of a recent bleed => 10 % of patients
have a negative upper endoscopy study because i) the bleeding may have ceased and
the lesion may have healed rapidly eg. Mallory-Weiss tear, ii) the true source of the
bleeding was from an epistaxis or hemoptysis, iii) the bleeding lesion is technically
difficult to see eg. Dieulafoy's lesion, iv) the bleeding is distal to the proximal
duodenum and inaccesible to upper endoscopy, or v) the story/evidence of upper GI
bleeding was fabricated eg. Munchausens syndrome with blood from another source
(* there is no role for diagnostic upper GI radiography in patients with upper GI
bleeds)

Surgical consultation

- indications for surgical consultation include:-

 GI bleeding that is associated with a co-existing condition that may warrant

surgery eg. suspected gastric perforation, obstruction, or malignancy
 GI bleeding associated with severe abdominal pain and/or tenderness
 GI bleeding after recent GI surgery
 GI bleeding that is massive and life-threatening
 GI bleeding that fails to respond to endoscopic therapy, or if prior surgery or
anatomic abnormality makes the bleeding lesion inaccessible to endoscopic
management
 GI bleeding that is associated with endoscopic stigmata of a high risk of
rebleeding
 GI bleeding from esophageal varices
 GI bleeding associated with suspected mesenteric vasculopathy
 GI bleeding from a suspected aorto-enteric fistula

Empiric acid suppression therapy

- there is some evidence that empiric administration of H2 antagonists (eg.

ranatidine) may decrease the rate of re-bleeding in non-variceal bleeding patients
with ulcers

- continuous IV infusion may be better than bolus administration

- acid suppression using omeprazole is an alternative treatment that is gaining favor

- there is no need to administer these agents in the ED => defer the decision to the
admitting physician

Vasopressin and octreotide acetate

- vasopressin has only been shown to be beneficial for esophageal variceal bleeding,
and it should not be used empirically for upper GI bleeding of undetermined cause

- vasopressin is less effective than endoscopic therapy, but it can be initiated as a stop-
gap measure until endoscopy can be performed (or if endoscopy is unsuccessful)

- vasopressin can be given via selective arterial infusion (eg. superior mesenteric
artery) or via a central venous line => the simpler IV route is preferred because there
is no significant difference in effect between intra-arterial and intravenous infusions

- a standard mixture of vasopressin is 100 units in 250 mg 5DW (0.4 units/ml) =>
starting dose of 0.3 units/min for 30 minutes followed by increments of 0.3 unit/min
until hemostasis is achieved, or side-effects develop, or a maximum dose of 0.9
units/min is reached
- vasopressin has significant side-effects (myocardial ischemia and infarction,
mesenteric ischemia or infarction, cerebral ischemia, cutaneous ischemic necrosis and
acrocyanosis) => vasopressin should be used with extreme caution in patients with
underlying CAD or vascular disease => a concomitant NTG infusion is often
administered if vasopressin must be utilized in CAD patients (presuming that the
systolic blood pressure is > 100mmHg)

- octreotide acetate, a long-acting synthetic analog of somastain, reduces portal

hypertension in patients with an acute variceal bleed

- octreotide is as effective as vasopressin, but it has fewer side-effects (given as a 50 -

100 mcg IV bolus and then infused at 25 - 50 mcg/hour) => it is now the preferred
agent to induce splanchnic vasocontriction and reduce portal venous pressure in
patients with a variceal bleed

- octreotide can be used in addition to endoscopic therapy of esophageal varices, or

alone if endoscopy is unavailable or unsuccessful

Balloon tamponade

- effective in temporarily stopping bleeding from esophageal varices; can be used

prior to endoscopy as a stop-gap measure or after failed therapeutic endoscopy

- it is associated with a high rate of complications

- accurate balloon placement requires special expertise => it has therefore fallen into
disfavor and is less frequently utilized

- should never be inserted blindly by inexperienced personnel

Shunt surgery for variceal bleeding

- may be required if endoscopic and medical therapy fails to control an acute

esophago-gastric variceal bleed

- transjugular intrahepatic portosystemic shunt (TIPS) is a radiologic alternative

to a surgical shunt and it is now used more frequently - especially in patients who are
poor surgical candidates or who are awaiting liver transplantation

Arteriography

- arteriographic embolisation therapy is used selectively - if bleeding is so massive

that endoscopic evaluation and therapy is not feasible, or if vascular anomalies or
hemobilia are the source of the bleeding

- transcatheter angiographic embolization of the bleeding artery responsible for an

ulcer hemorrhage may be indicated if endoscopic therapy fails and the patient is a
poor operative candidate => embolization is successful in ~ 50% of cases
(* there is a only small risk of iatrogenic GI infarction following embolization therapy
of proximal bleeds because of the good blood supply)

Emergency surgery

- may be required if ulcer bleeding is unresponsive to endoscopic therapy and/or

arteriographic embolization therapy

- also required if endoscopy reveals a non-ulcer bleeding site in the duodenum in a

patient with a previous history of aortic aneurysm surgery

- rarely required for ongoing bleeding from rare entities such as angiodysplasia or
Dieulafoy's lesion

Outpatient management

- if a patient presents to the ED with a history of hematemesis, but has no clinical

evidence of active bleeding + the nasogastric aspirate is negative (or equivocally
positive for coffee-ground material) => observe the patient for 6 hours => it may be
acceptable to discharge the patient if there is no evidence of GI bleeding in the ED
and the following criteriae are fulfilled:-

 patient is asymptomatic and hemodynamically stable

 there is no evidence of melanotic stools
 patient has no significant underlying disease (hepatic disease, PUD, CAD)
 patient has no history of varices or aortic surgery
 hemoglobin > 10g/dl
 age < 60 years
 patient is reliable and will comply with follow-up within 24 hours of ED
discharge

Appendix

Clinical risk factors suggesting a high probability of a poor outcome in

patients with non-variceal bleeds => consider ICU admission

 age greater than 60 years

 comorbid medical illnesses
 persistent hypotension
 severe coagulopathy
 onset of bleeding in the hospital (secondary bleeding)
 transfusion of 6 units or more of packed erythrocytes for a single bleed
 severe bleeding - red blood in the stomach or hematochezia
 high risk lesions - aorto-enteric fistula, malignancy, esophageal varices
 rebleeding from the same lesion during hospitalization

Some definite ICU admission criteriae

 hemodynamic instability
 severe bleeding - hematemesis or hematochezia
  active bleeding + two or more co-morbidities
 patient requires intubation to protect the airway or provide mechanical
ventilation
 patient has severe underlying coronary artery disease
 endoscopy shows ulcer with stigmata of recent hemorrhage
 requirement for multiple blood transfusions
 any bleeding from esophageal varices

Risk of re-bleeding, need for surgery and mortality rate based on

the endoscopic appearance of an ulcer
Ulcer appearance Rebleeding risk Need for Mortality rate
surgery
Clean base 5% 0.5% 2%
Flat spot 10% 6% 3%
Adherent clot 22% 10% 7%
Visible vessel 43% 34% 11%
Active bleeding 55% 35% 11%

T.Subramaniam(Siva)

Dept of Surgery