Trends on gastrointestinal bleeding and mortality: where are we standing? Rare causes of UGIB. ABSTRACT: Gastrointestinal bleeds (GIBs) are a significant source of hospitalizations in the United States. 2000;356:1318-1321.21. September 2008. www.sign.ac.uk/assets/sign105.pdf.10. Revista Española de Enfermedades Digestivas. Hematochezia is commonly associated with lower gastrointestinal bleeding, but may also occur from a brisk upper gastrointestinal bleed. There are important differences in the etiologies between the 2 sources. Differentiating Upper and Lower GI Bleeds Initial Presentation and Risk Stratification. Upper gastrointestinal bleeding (UGIB) is bleeding in the GI tract that occurs near the ligament of Treitz which is proximal to the pylorus and the duodenum. End result for majority of Upper GI bleeding-Spontaneous resolution for most. Lower gastrointestinal bleeding (LGIB) occurs when any section of the lower gastrointestinal tract (jejunum, ileum, cecum, colon, rectum, anus) begins to 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). Learn vocabulary, terms, and more with flashcards, games, and other study tools. Jaundice if bleeding is related to liver diseases, Hematochezia – fresh blood in stools may be due to hemorrhoids or anal fissure, Bloody diarrhea is typical of Colitis, the inflammation of the colon. Required fields are marked *, Notify me of followup comments via e-mail, March 12, 2015 • 1 comment. However, patients for whom endoscopy cannot be performed or will be delayed have demonstrated a potential decrease in risk of rebleeding through utilization of PPI. Strate L, Grainek IM. 2012;107:345-360.18. Understanding the cause and specific differences between the signs and symptoms of upper and lower GI bleeding is essential for proper treatment. Often, an individual manifests hematemesis, vomiting of fresh blood or coffee ground vomitus. An individual who has this may complain of easy fatigability, shortness of breath, dizziness and anemia caused by the bleeding. What is the difference between an upper and lower GI bleed? 2010(7):CD005415.26. 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. Trials evaluating UGIB and LGIB have demonstrated that while PPIs do not demonstrate improved outcomes in LGIB, they may actually increase risk of LGIB.34 Theorized mechanisms for this increased risk often focus on possible changes in microbiota, and thus may potentiate possible risk from NSAIDs. Ann Gastroenterol. Bariatric Surgery for the Treatment of Type 2 Diabetes Mellitus: What Are the Options? 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. Matthew B, et al. Rev Med Inst Mex Seguro Soc. 2008;33:395-397.11. Immediate evaluation should focus on the patient’s hemodynamic stability. Pre-endoscopic erythromycin administration in upper gastrointestinal bleeding: an updated meta-analysis and systematic review. The predictive capacity of the Glasgow-Blatchford score for the risk stratification of upper gastrointestinal bleeding in an emergency department. An upper GI bleed is more common than lower GI bleed. A tube is passed through your nose into your stomach to remove your stomach contents… Historically, distinction of upper GIB (UGIB)and lower GIB (LGIB) was based on the location of bleeding in relation to the ligament of Treitz.9,10 With this definition, bleeding proximal to the ligament of Treitz is categorized as an UGIB, while bleeding distal to the ligament of Treitz is categorized as a LGIB. ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding. Gastroenterol Clin North Am. A single dose of 250 mg or 3 mg/kg is generally well tolerated.17,30 A 2016 meta-analysis concluded erythromycin use prior to endoscopy significantly decreased the need for second-look endoscopy and length of hospital stay, and thus it carries a recommendation to be used in the European Society of Gastrointestinal Endoscopy guidelines.30,31, It is fair to wonder if possible benefit is a class effect or specific to erythromycin. Upper GIB is dependent on endoscopic therapy and may benefit from various pharmacologic treatments in specific scenarios, such as proton pump inhibitors and macrolides. Epidemiology and risk factors for upper gastrointestinal bleeding. Thirty-seven patients (67%) with a supratherapeutic international normalized ratio and GI bleeding underwent upper endoscopy. How common is GI bleeding? Hematochezia tends to occur in patients older than 65 years of age and has an associated mortality of 21%. Rahman R, Nguyen D, Sohail U, et al. Zhao Y, Encinosa W. Hospitalizations for gastrointestinal bleeding in 1998 and 2006. Risk assessment after acute upper gastrointestinal haemorrhage. Proton pump inhibitors (PPIs) are the drug class most associated with treatment of UGIB. World J Gastrointest Endosc. Barium is used only for diagnostic studies of the GI tract. Strate L. Lower GI bleeding: epidemiology and diagnosis. Management of lower GIB is focused on colonoscopy and mechanically treating bleeds, with little pharmacological intervention. 2017;47:218-230.19. Am J Gastroenterol. Garcia Rodriguez LA, Ruigómez A, Hasselgren G, et al. 1978;136(2):257-259.25. Statistical Brief #65. In an UGIB patient, gastric acid can inhibit platelet aggregation and weaken potential coagulation, leading to an impairment in bleeding cessation. 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. Gralnek IM, Dumonceau JM, Kuipers EJ, et al. Leontiadis GI , Sharma VK , Howden CW. 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. Blood loss stage where BP is decreased-3. 2015;47:1-46.32. Pharmacists can provide effective service to these patients at multiple points of patient care. What is the difference between a colonoscopy and a lower GI test? Similarly, inpatient clinical pharmacists can also have a large role in GIB treatment. 2014;5(4):467-478.12. 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. 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). To find out whether you have a GI condition, your gastroenterologist will perform diagnostic tests. Tranexamic acid is an antifibrinolytic that has been shown to reduce blood loss in a variety of clinical conditions. 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 … Acute GI bleeding occurs when there is a sudden and significant blood loss due to bleeding. Similarly, the Blatchford score uses both clinical and laboratory data to assist in predicting risk of intervention and mortality.20 For acute LGIB, the available prognostic rules to assess risk are limited and less validated when compared with UGIB.22, Proton pump inhibitors (PPIs) are the drug class most associated with treatment of UGIB. Lower GI Bleed. Cocchi MN, Kimlin E, Walsh M, et al. Am J Gastroenterol. Fecal occult blood (FOB) refers to blood in the feces that is not visibly apparent (unlike other types of blood in stool such as melena or hematochezia).A fecal occult blood test (FOBT) checks for hidden (occult) blood in the stool (feces). 2016;111:459-474.23. Start studying Upper and Lower GI Bleed. Sreedharan A, Martin J, Leontiadis GI, et al. It requires prompt treatment once diagnosed otherwise this can lead to hypovolemic shock and even death. A Comparison of Azithromycin to Erythromycin Infusions in Improving Visualization of Endoscopy for Upper Gastrointestinal Bleeding. GI bleeding can occur in any of these organs. They may be in a position to assist in multiple areas during the initial evaluation and management. I don’t have insurance ever since my Medicaid ran out i understand it’s a serious condition but i feel helpless without insurance is there any other way to seek help with this? GI bleeding is not a disease, but a symptom of a disease. 1. Nasogastric lavage. Management of patients with ulcer bleeding. Hematochezia (red or maroon blood in the stool) usually indicates the presence of lower GI bleeding or a brisk upper GI bleed. Considerations. Constipation and straining during bowel movements cause hemorrhoids to swell. 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 death from a GI bleed is between 5% and 30%. This process shows differences that might not be seen on standard X-rays. 4. Rockall T, Logan R, Devlin H, et al. Raju GS, et al. Intravenous proton pump inhibitors for peptic ulcer bleeding: clinical benefits and limits. Considering H2 antagonists (H2As) are used with similar intent in other disease states, their use in UGIB has been investigated alongside PPIs. Mortality associated with gastrointestinal bleeding events: comparing short-term clinical outcomes of patients hospitalized for upper GI bleeding and acute myocardial infarction in a US managed care setting. Lower GI bleeding: The lower GI tract includes much of the small intestine, large intestine or bowels, rectum, and anus. They may also complain of anorexia and unexplained weight loss. GI Bleed Mortality. GIBs are categorized into two types: upper GI bleeds and lower GI bleeds. It results in about 300,000 hospital admissions a year in the United States. 1995;90:568–573.8. In addition to drinking barium, air is often inserted into the bowel for a lower GI X-ray. Identification and resuscitation of the trauma patient in shock. The amount of GI bleeding may be so small that it can only be detected on a … 2016,29:312-317.31. 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 … Acute GI Bleed; Acute GI bleeding occurs when there is a sudden and significant blood loss due to bleeding.
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