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In the Clinic |

Acute Gastrointestinal Bleeding

Meeta Prasad Kerlin, MD, MSCE; and Jeffrey L. Tokar, MD
Ann Intern Med. 2013;159(3):ITC2-1. doi:10.7326/0003-4819-159-3-201308060-01002
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Acute gastrointestinal (GI) bleeding is common in both the outpatient setting and the emergency department. Annual U.S. incidence rates over the past decade are approximately 90–108 per 100 000 persons (1), leading to approximately 300 000 hospitalizations annually. Most cases are due to nonvariceal sources of bleeding (e.g., peptic ulcers) and continue to be associated with significant mortality (3–14%) and health economic burden (13). The incidence of nonvariceal bleeding may be decreasing in the West largely because of decreased incidence of Helicobacter pylori infection and increased awareness and implementation of ulcer-prevention strategies in users of nonsteroidal anti-inflammatory drugs (NSAIDs) (1). However, identifying patients with acute GI bleeding who are in danger of serious adverse events and establishing evidence-based treatment plans are essential in both primary and specialty care.

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Grahic Jump Location
Appendix Figure.

Duodenal ulcer with a non-bleeding visible arterial vessel before (Panel A) and following (Panel B) endoscopically applied bipolar electrocoagulation to coapt the arterial walls, reducing the risk for further bleeding-related complications.

Grahic Jump Location

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Gastrointestinal Bleeding
Posted on August 30, 2013
Joseph D. Feuerstein MD, Daniel A. Leffler MD MS
Beth Israel Deaconess Medical Center Division of Gastroenterology, Harvard Medical School
Conflict of Interest: None Declared
We complement Drs. Kerlin and Tokar for a very good and thorough review of acute gastrointestinal bleeding (1). We would just like to point out a few areas of discrepancy in the literature. We disagree with their recommendation that colonoscopy be done within 12-24 hours of presentation for a lower gastrointestinal bleed. The only study indicating that colonoscopy altered outcomes in diverticular bleeds was by Jensen et al. in the New England Journal of Medicine (2). Follow up studies by Green and Laine did not show any reduction in need for colectomy, change in clinical outcome, or reduction in cost. As a result early endoscopy within 24 hours has not been shown to be superior to elective colonoscopy within 72 hours (3, 4). Furthermore, the authors fail to indicate that the currently more utilized test of choice for diverticular hemorrhage is emergent CT angiography. With the improvement in CT angiography, localization of the lesion is feasible with subsequent interventional angiography successfully treating any bleeding vessel (5, 6).
Additionally, for prevention of GI bleeding, the authors comment that patients with chronic liver disease, nonselective beta blockade can reduce portal pressures thereby reducing variceal bleeding. However, the current American Association for the Study of Liver Diseases does not recommend beta blockade for all patients with chronic liver disease (7). Primary prophylaxis is indicated in patients with underlying cirrhosis who on endoscopy have medium varices, large varicies or small varices with high risk stigmata (e.g. red wale marks). Alternatively, beta blockade can be used in patients with cirrhosis without high risk features, but, as the AASLD guidelines note, long term benefit has not been established. Secondary prophylaxis is indicated after any variceal bleed (7). Additionally, regarding the treatment for variceal hemorrhage, the authors advise that if balloon tamponade is utilized, the balloon should be inflated for no more than 12 hours. Published trials of the Sengstaken-Blakemore or Minnesota tube effectively use the gastric balloons inflated for up to 24 hours (8, 9). In the rare situation that an esophageal balloon is used, then deflating the esophageal balloon every 6-12 hours is indicated to avoid esophageal pressure necrosis (9). We do commend Drs Kerlin and Tokar for writing a very good summary of this broad topic of GI bleeding.
Joseph D. Feuerstein, MD
Gastroenterology Fellow
Division of Gastroenterology at Beth Israel Deaconess Medical Center
Boston, MA

Daniel A. Leffler, MD, MS
Director of Quality Improvement
Division of Gastroenterology at Beth Israel Deaconess Medical Center
Boston, MA

1. Prasad Kerlin M, Tokar JL. Acute gastrointestinal bleeding. Ann Intern Med. 2013;159(3):ITC2-1.
2. Jensen DM, Machicado GA, Jutabha R, Kovacs TOG. Urgent Colonoscopy for the Diagnosis and Treatment of Severe Diverticular Hemorrhage. New England Journal of Medicine. 2000;342(2):78-82.
3. Green BT, Rockey DC, Portwood G, Tarnasky PR, Guarisco S, Branch MS, et al. Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial. The American journal of gastroenterology. 2005;100(11):2395-402.
4. Laine L, Shah A. Randomized trial of urgent vs. elective colonoscopy in patients hospitalized with lower GI bleeding. The American journal of gastroenterology. 2010;105(12):2636-41.
5. Martí M, Artigas JM, Garzón G, Álvarez-Sala R, Soto JA. Acute lower intestinal bleeding: feasibility and diagnostic performance of CT angiography. Radiology. 2012;262(1):109-16.
6. Loffroy R. Multidetector CT Angiography for the Detection of Colonic Diverticular Bleeding: When, How, and Why? Digestive diseases and sciences. 2013:1-3.
7. Garcia‐Tsao G, Sanyal AJ, Grace ND, Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46(3):922-38.
8. Feneyrou B, Hanana J, Daures JP, Prioton JB. Initial control of bleeding from esophageal varices with the Sengstaken-Blakemore tube: experience in 82 patients. The American journal of surgery. 1988;155(3):509-11.
9. Vlavianos P, Gimson A, Westaby D, Williams R. Balloon tamponade in variceal bleeding: use and misuse. BMJ: British Medical Journal. 1989;298(6681):1158.
Author's Response
Posted on October 2, 2013
Meeta Prasad Kerlin, MD MSCE, Jeffrey Tokar, MD
University of Pennsylvania
Conflict of Interest: None Declared
We thank Drs. Feuerstein and Leffler for their comments.

Regarding the management of patients with varices, they accurately point out that the AASLD does not advocate the use of non-selective beta-blockers for primary prophylaxis of variceal bleeding for all patients with chronic liver disease, only those with higher-risk varices. We agree that in our practices, many patients with small, low-risk varices typically do not routinely receive beta-blockers for primary prophylaxis. That said, the AASLD guidelines [1] do not recommend that patients with small varices should never receive beta-blockers but state that “prophylaxis with beta-blockers should be used in patients with small varices who are at high risk for bleeding; that is, those with advanced liver disease and the presence of red wale marks on varices” and that “other patients with small varices can receive beta-blockers to prevent variceal growth, although their long-term benefit has not been well established”. A subsequent expert review recommends that “these agents are considered optional” in patients with low-risk varices [2]. Our article also states that with balloon tamponade for acute management of variceal hemorrhage, the balloon should not be inflated for more than 12 hours. We were referring to the esophageal balloon, which can induce pressure necrosis of the esophagus. Indeed, the gastric balloon can safely be inflated for up to 24 hours. Our intent was to reduce the risk of misinterpretation and inadvertent inflation of the esophageal balloon continuously for 24 hours.
The comments regarding management of patients with acute lower GI bleeding (LGIB) are also valuable. They accurately point out that performing colonoscopy within 12-24 hours remains controversial. We stated the same in our article, and that the opportunity for intervention may be limited, hoping to highlight these limitations of colonoscopy. Although colonoscopy is still performed within 24 hours at many institutions, we agree that existing data are inadequate to make absolute recommendations. We also appreciate their reminder that CT angiography is a useful diagnostic test for LGIB, although we are unaware of data supporting their assertion that it is “the currently more utilized test of choice”. The article they reference, albeit encouraging, had a relatively small sample size and was recognized by its own authors as a feasibility study [3]. Furthermore, we believe that urgent CT angiography is not always available, that there remains a paucity of comparative data, and that professional guidelines advocating its use as the initial test are lacking.

Meeta Prasad Kerlin, MD MSCE
Jeffrey Tokar, MD

1. Garcia-Tsao G, Sanyal AJ, Grace ND, et al; Practice Guidelines Committee of American Association for Study of Liver Diseases; Practice Parameters Committee of American College of Gastroenterology. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Am J Gastroenterol. 2007 Sep;102(9):2086-102.
2. Garcia-Tsao G, Bosch J. Management of varices and variceal hemorrhage in cirrhosis. N Engl J Med. 2010 Mar 4;362(9):823-32. doi: 10.1056/NEJMra0901512.
3. Martí M, Artigas JM, Garzón G, et al. Acute lower intestinal bleeding: feasibility and diagnostic performance of CT angiography. Radiology. 2012;262(1):109-16.
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