Gastrointestinal (GI) bleeding may occur anywhere throughout the length of the digestive tract — from the mouth to the anus. With a large number of potential causes and levels of severity, gastroenterologists and nurses must be prepared to contend with many different bleeding scenarios.
“The spectrum of GI bleeding is broad and diverse,” says Don Rockey, MD, chief of the digestive and liver diseases division of internal medicine at the University of Texas Southwestern Medical Center at Dallas. “We can see people who are basically exsanguinating; we can see people who just have trivial amounts of blood loss. The management of those two types of patients varies diametrically. This is a wideranging topic.”
“Divisions of upper GI bleeding (proximal to the ligament of Treitz) and lower GI bleeding (distal to the ligament of Treitz) are most commonly referred to for locations, and severity/duration is indicated by acute/chronic, gross/ occult, and obscure (unknown origin),” says Sarah Eisenbacher, CGRN, manager of endoscopy for the Digestive Health Center at Wake Forest University Baptist Medical Center.
In terms of presentation, patients oftentimes present vomiting blood if the bleed originates from the upper GI tract. “The most common cause is ulcers; it’s been the most common cause for the last 100 years,” Rockey says. He also points out that the use of non-steroidal anti-inflammatory medications, including aspirin, is an important factor to bear in mind when assessing the cause of bleeds from ulcers. “That’s a big problem now and it’s very important to emphasize. This is probably going to continue to become more common. On rare occasions, you can have bleeding from an ulcer caused by aspirin or another non-steroidal in an unusual place like the colon or the small intestine — it can cause ulcers there as well.”
“Acute bleeding is often presented with frank symptoms,” Eisenbacher continues. “Upper GI sources demonstrate hematemesis (vomiting of bright red blood or “coffee ground”- appearing material) or melena (stool that is black, tarry, sticky, loose, and/or malodorous in nature).” She also explains that although these symptoms present most commonly from the upper GI tract, ingestion of iron or bismuth may cause the same types of stool alterations.
According to the American Society for Gastrointestinal Endoscopy (ASGE), upper GI bleeding can result from:
- Peptic ulcer disease (35 percent to 50 percent)
- Gastroduodenal erosions (8 percent to 15 percent)
- Esophagitis (5 percent to 15 percent — commonly GERD, infection, caustic ingestion or radiation)
- Varices (5 percent to 10 percent)
- Mallory-Weiss tear (15 percent — bleeding is generally self-limited; however, uncontrolled bleeding may require angiographic therapy or surgery)
- Vascular malformations (5 percent — sporadic lesions or in association with other disorders such as cirrhosis, renal failure, Dieulafoy’s lesion, etc.)
Colon bleeding, Rockey notes, is usually seen in elderly people who have diverticula or vascular ectasias. These conditions are oftentimes just a product of aging. Patients who experience bleeding from the colon are usually older, in their 60s or above, while those who present with an upper GI bleed are usually younger, usually in their 40s or so, according to Rockey.
Hematochezia (bright red blood from the rectum) is often associated with the lower GI tract; however, a massive upper GI source can present these same symptoms, Eisenbacher points out. “Tachycardia, pallor, hypotension, and agitation or irritability can be symptoms of shock and require immediate intervention,” she continues. “Again, with no single indicators as hard-and-fast rules, patients with severe blood loss may have bradycardia due to vagal response; therefore postural vital signs can assist with assessment. Postural hypotension of greater than 10 mmhg can be indicative of volume loss. Hemodynamics may also be uncompromised with acute bleeding. With such differentials, consideration of the entire clinical picture is essential for accurate diagnosis and intervention. Intensive care unit (ICU) admission for acute GI bleeding is common, and multiple factors begin to play in hemodynamic resuscitation depending on the patient’s clinical complexity.”
ASGE describes common causes for lower GI bleeding as:
- Colonic neoplasia/malignancy
- Colitis (radiation/ischemic/ulcerative)
“The most important initial management principle is that you have to stabilize the patient hemodynamically,” Rockey says. “We need to make sure the patient is hemodynamically stable before we proceed with any other either diagnostic or therapeutic intervention.” He points out that inadequate or inappropriate clinician response to bleeds can cause serious trouble; endoscopic therapy on a patient who is not hemodynamically stable and/or does not have stable vital signs should be avoided.
“I once had a patient whose airway was not entirely secure and he coded,” Rockey continues. “It’s very important initially to ensure hemodynamic stability. After that, it becomes a matter of assessing what you think the cause of the bleeding is — whether it’s upper or lower GI tract cause — and then going after it diagnostically, because we can’t treat it until we know what it is. We need to make a diagnosis, and once we do that, then we can entertain treatment.”
As a gastroenterologist, as they say, “When you’re a hammer everything looks like a nail;” we advocate endoscopy, but that’s not to say there aren’t other approaches. So generally we use an endoscopic approach, but there are other important modalities that are available that we sometimes need to use.”
Eisenbacher also notes that variceal hemorrhage warrants mention due to the risk of re-bleed and mortality rates. “I would surmise that failing to control a case of massive acute upper GI bleeding is many endoscopy nurses’ worst fear,” she says. “When visibility is minimal and all therapies have been exhausted, balloon tamponade with the Sengstaken-Blakemore tube, Minnesota tube, or the Linton-Nachlas balloon is an alternative. Although this therapy poses significant complication rates in itself, the benefits can outweigh the risks. Hemostasis by this means may be enough to stabilize the patient for surgery or other treatment options and, if completed properly, can improve mortality.”
Inadequately prepared staff poses a risk for the use of the tamponade therapy, and education and training can easily reduce this risk, Eisenbacher says. “Preparing a ‘kit’ or ‘box’ with all necessary supplies and routine review will improve staff awareness when the event of ‘Oh my gosh! Where is all this blood coming from?’ does occur. Endotracheal intubation prior to balloon insertion is recommended for airway protection during massive upper GI bleeding events.”
Eisenbacher notes that the hemorrhage kit at her facility travels on a mobile cart and is supplied with the following:
- Tamponade balloon (they utilize Minnesota Tube)
- Two wall suction setups (one for gastric and one for esophageal ports — and oral suction temporarily during insertion)
- Manometer (needed to check balloon pressures)
- Two 60 cc Foley or Cone tip syringes to insufflate the tamponade balloons
- Padded hemostats or plastic clamps (two to four) for the balloon ports
- Topical anesthetic or lubricant for the naris
- Tape to secure tube
- Marker to mark tubing placement
- Scissors (to remain at bedside for emergency)
- Catcher’s mask for temporary traction to tube (over-the-bed traction with a one-pound [500 cc bag saline] may also be used).
“Proper policy and procedure may vary from facility to facility, and the manufacturer’s instructions for the tamponade balloon also dictate protocols,” she adds. Given the many possibilities and sources that exist to produce GI bleeding, unusual or difficult cases are bound to occur. From a patient with an exsanguinating bleed who is on the verge of coding to a patient who has recurrent bleeding from a source that is difficult to identify, Rockey contends that patience and thoroughness are key. “I can remember a couple patients where we’ve done endoscopy five times upper, five times lower, we’ve done small bowel X-rays, we’ve done CAT scans, and haven’t been able to find anything, and then one day we do a particular intervention and find it,” he says. “It’s really a matter of persistence. I can remember very clean cases where someone is bleeding and you go in and find an ulcer with a vessel and you cauterize it, and they do well. I can also remember a couple patients where there were some very unusual causes of GI bleeding.” Rockey recalls one memorable case in which a patient had a fistula between the aorta and the duodenum, causing massive blood loss. Although arterial bleeds usually originate from one of the branches off the celiac, this case demonstrates that virtually anything is possible.
Tools and Technologies to Address Bleeds
With the challenges that can be presented in diagnosing and treating difficult GI bleeds, manufacturers continue to develop new and innovative products to assist clinicians in this effort.
The Carr-Locke Injection Needle from US Endoscopy is such a product. Co-developed by US Endoscopy and David Carr-Locke, MD, director of endoscopy at Brigham and Women’s Hospital, the needle is designed to address challenging anatomical presentations, such as those encountered during ERCP (endoscopic retrograde cholangiopancreatography). “We developed a product line in the mid- to late-1990s called the ARTICULATOR™ Injection Needle, and that is similar to the Carr- Locke needle in that the construction is like a biopsy forcep; it uses a spring coil sheath vs. a plastic catheter,” says Dean Secrest, vice president of research and development at US Endoscopy. “That in itself has inherent performance advantages when it comes to ‘pushability’ of the instrument through the channel, kink resistance, and inherent stability in the construction.”
While the ARTICULATOR needle performed well, some “ultrachallenging” performance conditions in endoscopy still required something that performed better than what US Endoscopy was offering, particularly in biliary endoscopy, which involves a sideviewing duodenoscope, Secrest explains. “You have this elevator that allows you to manipulate the instrument to achieve a 90-degree angle to the endoscope with your instrument. Those conditions lead to more challenges on the device in terms of performing the same function as what they would normally perform in an upper endoscopy or colonoscopy. So we continued to get feedback from our customers that performance improvements were needed on our needles, and that was the genesis for starting the Carr-Locke injection needle program. We discovered ways to enhance the performance in the areas of friction and articulation. In other words, the scope could be in any articulated position, including a duodenoscope, and our needle would still project, would still allow injection media to flow through it easily, and perform in these challenging conditions.”
In terms of clinical applications of the Carr-Locke needle, Secrest points to colonoscopy, where polyps in the cecum or postpolypectomy bleeds in the cecum may occur. “In those two instances, you can use it to lift the polyp with saline, to inject a bed of saline underneath the mucosa or polyp to provide an insulated cushion, or mucosectomy or polypectomy,” he explains. “The right side of the colon is challenging because you’re deep into the body, the scope is articulated, and you may also be doing a turn maneuver in the cecum, which adds additional articulation to the needle. That’s a prime example that we hear of where the Carr-Locke needle is performing at the highest level.”
Biliary endoscopy is another prime example, according to Secrest. “Here you not only have significant articulation going through the esophagus, through the stomach, into the C-loop of the duodenum, but also the side view and the elevator condition where the device is coming off the side of the instrument as opposed to the end of the instrument. In our testing, those are the most stringent conditions. Post-sphincterotomy bleeds are a concern for biliary endoscopists, also ulcers in the duodenum where you’re treating an ulcer with injection therapy, and then you also have the same duodenal polyps or ampullary polyps that are typically injected with a saline bed prior to lifting because of the concerns of the thinner wall of the duodenal mucosa.”
Another offering is Boston Scientific’s Resolution® Clip Device, used for hemostasis, endoscopic marking, closure, and anchoring jejunal feeding tubes. The device comes pre-loaded, and is designed to be ready to use, which can be essential for emergency bleeding situations. It is engineered to enable opening and closing up to five times prior to deployment, aiding in repositioning of the clip should that be desired. With a jaw that is 11 mm-wide, it is designed to be able to grasp a sizable amount of tissue. The handle is designed to deliver a familiar actuation for opening and closing the jaws and provides tactile feedback upon closing of jaws, indicating that the clip is about to be deployed. In addition, the Resolution Clip Device is compatible with gastroscopes and colonoscopes with working channels equal to or greater than 2.8.
Two animal studies assessing effectiveness, safety, and ulcer healing rates of Resolution Clip in controlling hemostasis compared with other endoscopic hemoclips, thermal coagulation and epinephrine injection treatments have shown positive results. “These studies provide new endoscopic comparative laboratory data concerning the strengths and weaknesses of various techniques for hemostasis of bleeding acute gastric ulcers,” said Dennis M. Jensen, MD, professor of medicine in the gastrointestinal division at the University of California Los Angeles (UCLA) school of medicine, in a press release from Boston Scientific. “The Resolution Clip had significantly higher retention rates compared to the other approved hemostatic clips that were studied. We look forward to prospective, comparative human clinical studies that will help us define and understand the best clinical indications and applications of these newer hemoclips compared to older hemostasis methods such as thermocoagulation.”