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Hemorrhage of digestive system — Clinical Guidelines

Overview

Hemorrhage of the digestive system encompasses various conditions involving bleeding from the gastrointestinal tract, ranging from upper gastrointestinal (UGI) sources like peptic ulcers and varices to lower gastrointestinal (LGI) sources such as diverticulosis and inflammatory bowel disease. Prompt diagnosis and management are crucial to prevent severe complications and mortality.

Diagnosis

Clinical Presentation: Hematemesis, melena, hematochezia, or iron deficiency anemia 6.

Endoscopy: Essential for visualizing the source of bleeding; both upper and lower endoscopy recommended depending on clinical suspicion 6 26.

Imaging: CT angiography or angiography for identifying active bleeding sites, particularly in unstable patients 6.

Laboratory Tests: Complete blood count, coagulation profile, and serum lactate levels to assess severity 6.

Grading: Use of scoring systems like the Blatchford score for UGI bleeding to guide admission and intervention 6.

Management

Initial Stabilization: Fluid resuscitation, blood transfusion as needed, and hemodynamic monitoring 6.

Endoscopic Intervention: Primary endoscopic therapy (e.g., endoscopic clipping, band ligation) for acute bleeding 6 26.

Medications:

- Proton Pump Inhibitors (PPIs): High-dose PPIs for UGI bleeding to reduce rebleeding 6. - Antibiotics: Consider in cases of LGI bleeding to prevent infection 6.

Surgical Intervention: Reserved for persistent bleeding despite endoscopic and medical management 6.

Angiographic Embolization: For refractory bleeding, particularly in UGI variceal bleeding 6.

Special Populations

Pregnancy: Increased risk of LGI bleeding; careful consideration of imaging modalities to avoid radiation exposure 6.

Elderly: Higher risk of complications; tailored management focusing on minimizing invasiveness and optimizing hemodynamics 6.

Comorbidities: Presence of liver disease or coagulopathies necessitates specific management adjustments, such as closer monitoring and tailored anticoagulation strategies 6.

Key Recommendations

Early Endoscopic Evaluation: Essential for identifying and treating the source of bleeding (Evidence: Strong 6 26).

Use of High-Dose PPIs: Recommended in UGI bleeding to reduce rebleeding rates (Evidence: Strong 6).

Hemodynamic Stabilization: Prioritize fluid resuscitation and blood transfusion in acute bleeding scenarios (Evidence: Moderate 6).

Tailored Management for Special Populations: Consider specific risks and limitations in elderly and pregnant patients (Evidence: Expert opinion 6).

References

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Hospital admission for digestive diseases: Gastroenterology units offer a more effective and efficient care. Digestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver 2019. link 7 Marshall AL, Jenkins S, Oxentenko AS, Lee AI, Siegel MD, Katz JT et al.. Internal medicine trainees' knowledge and confidence in using the American Society of Hematology Choosing Wisely guidelines in hemostasis, thrombosis, and non-malignant hematology. PloS one 2018. link 8 Jia L, Jiang SM, Liu J. Behavioral gastroenterology: An emerging system and new frontier of action. World journal of gastroenterology 2017. link 9 Tang X, Gong W, Yuan F, Li R, Han X, Huang S et al.. Top-cited articles in digestive system disease from 1950 to 2013. Journal of gastroenterology and hepatology 2016. link 10 Etienne-Mesmin L, Wang T, Viennois E, Chassaing B, Gewirtz AT, Merlin D. Proceedings of the Second Shanthi V. Sitaraman Intestinal Pathobiology Symposium. Inflammatory bowel diseases 2015. link 11 Buscarini E, Conte D, Cannizzaro R, Bazzoli F, De Boni M, Delle Fave G et al.. White paper of Italian Gastroenterology: delivery of services for digestive diseases in Italy: weaknesses and strengths. Digestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver 2014. link 12 Buscarini E, Carle F, Tamburini C, Balzano A, Milazzo G, Soncini M et al.. Hospital care services for digestive diseases in Italy: the first quantitative assessment. Digestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver 2014. link 13 Le Moine O, Diouf ML, Mbengue M, Mbaye PS, Diop PM, Balme F et al.. Creation of a therapeutic digestive endoscopy suite in Senegal: renovation, training and university certification. Results of a Belgian-Senegalese inter-university project. Endoscopy 2012. link 14 Kappelman MD, Dorn SD, Peterson E, Runge T, Allen JI. Quality of care for gastrointestinal conditions: a primer for gastroenterologists. The American journal of gastroenterology 2011. link 15 Tuitt D, Knight F, Lipman T. A bibliometric analysis of digestive health research in Canada. Canadian journal of gastroenterology = Journal canadien de gastroenterologie 2011. link 16 Dorn SD. Mid-level providers in gastroenterology. The American journal of gastroenterology 2010. link 17 Bridges RJ. Report from the Canadian Association of Gastroenterology Board. Canadian journal of gastroenterology = Journal canadien de gastroenterologie 2009. link 18 Friedman LS, Brandt LJ, Elta GH, Fitz JG, Gores GJ, Katz PO et al.. Report of the multisociety task force on GI training. Gastroenterology 2009. link 19 Owyang C. Recent advances and future research directions in neurogastroenterology and endocrinology recommendations of the National Commission on Digestive Diseases. Neurogastroenterology and motility 2008. link 20 Leddin D, Armstrong D, Barkun AN, Chen Y, Daniels S, Hollingworth R et al.. Access to specialist gastroenterology care in Canada: comparison of wait times and consensus targets. Canadian journal of gastroenterology = Journal canadien de gastroenterologie 2008. link 21 Stephen FO, Rossaro L. 12th Update in Gastroenterology and Hepatology for the Primary Care Practitioner. Expert review of gastroenterology & hepatology 2008. link 22 Armstrong D, Barkun AN, Chen Y, Daniels S, Hollingworth R, Hunt RH et al.. Access to specialist gastroenterology care in Canada: the Practice Audit in Gastroenterology (PAGE) Wait Times Program. Canadian journal of gastroenterology = Journal canadien de gastroenterologie 2008. link 23 Beck IT. Birth of the Canadian Digestive Health Foundation. Canadian journal of gastroenterology = Journal canadien de gastroenterologie 2004. link 24 de Gaetano G, Cerletti C. Platelet adhesion and aggregation and fibrin formation in flowing blood: a historical contribution by Giulio Bizzozero. Platelets 2002. link 25 Itzkowitz SH. The Mount Sinai division of gastroenterology at the beginning of the 21st century. The Mount Sinai journal of medicine, New York 2001. link 26 Fleischer DE. Advanced training in endoscopy. Gastrointestinal endoscopy clinics of North America 1995. link 27 Bond JH. Evaluation of trainee competence. Gastrointestinal endoscopy clinics of North America 1995. link 28 Owens MR, Holme S, Cardinali S. Platelet microvesicles adhere to subendothelium and promote adhesion of platelets. Thrombosis research 1992. link90195-g) 29 Schmaier AH, Silver L, Adams AL, Fischer GC, Munoz PC, Vroman L et al.. The effect of high molecular weight kininogen on surface-adsorbed fibrinogen. Thrombosis research 1984. link90154-3) 30 McMillan CW. Evolution of modern concepts of hemostasis. A backward glance at the discoveries that made modern practice possible. The American journal of pediatric hematology/oncology 1981. link

Hemorrhage of digestive system