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Gastrointestinal Hemorrhage on the Intensive Care Unit

  • S. J. Thomson
  • M. L. Cowan
  • T. M. Rahman
Conference paper

Abstract

Gastrointestinal bleeding in the critical care environment is a relatively common clinical event with an incidence of approximately 100/100,000 population per year in both the UK and the USA [1, 2]. Of these bleeding events, 14% occur in patients already hospitalized. Gastrointestinal bleeding can be the primary reason for admission or can develop as a secondary co-morbid factor. Patients with this complication can have an increased length of stay on the intensive care unit (ICU) and up to a four-fold rise in mortality [3]. This chapter will describe the nature of gastrointestinal bleeding in critical care, the etiologies and risk factors that may predispose to gastrointestinal bleeding, and the variety of therapeutic options available to the clinician. Upper gastrointestinal stress-related mucosal disease, variceal hemorrhage, and lower gastrointestinal bleeding will be considered separately.

Keywords

Gastrointestinal Bleeding Variceal Bleeding Endoscopic Therapy Hepatic Venous Pressure Gradient Bleeding Peptic Ulcer 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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References

  1. 1.
    Rockall TA, Logan RFA, Devlin HB, Northfield TC (1995) Incidence of and mortality from acute upper gastrointestinal hemorrhage in the United Kingdom. BMJ 311: 222–226PubMedGoogle Scholar
  2. 2.
    Arlt GD, Leyh M (2001) Incidence and pathophysiology of peptic ulcer bleeding. Langenbecks Arch Surg 386: 75–81PubMedCrossRefGoogle Scholar
  3. 3.
    Cook DJ, Griffith LE, Walter SD, et al (2001) The attributable mortality and length of intensive care unit stay of clinically important gastrointestinal bleeding in critically ill patients. Crit Care 5: 368–375PubMedCrossRefGoogle Scholar
  4. 4.
    Cook DJ, Fuller HD, Guyatt GH, et al (1994) Risk factors for gastrointestinal bleeding in critically ill patients. Canadian Critical Care Trials Group. N Engl J Med 330: 377–381PubMedCrossRefGoogle Scholar
  5. 5.
    Kolbel CB, Rippel K, Klar H, Singer MV, van Ackern K, Fielder F (2000) Esophageal motility disorders in critically ill patients: a 24-hour manometric study. Intensive Care Med 26: 1421–1427PubMedCrossRefGoogle Scholar
  6. 6.
    Ng FH, Wong SY, Chang CM, et al (2003) High incidence of clopidogrel-associated gastrointestinal bleeding in patients with previous peptic ulcer disease. Aliment Pharmacol Ther 18: 443–449PubMedCrossRefGoogle Scholar
  7. 7.
    Liberopoulous EN, Elisaf MS, Tselepis AD, et al (2006) Upper gastrointestinal haemorrhage complicating antiplatelet treatment with aspirin and/or clopidogrel: where we are now? Platelets 17: 1–6CrossRefGoogle Scholar
  8. 8.
    Kearney PM, Baigent C, Godwin J, Halls H, Emberson JR, Patrono C (2006) Do selective cyclo-oxygenase-2 inhibitors and traditional non-steroidal anti-inflammatory drugs increase the risk of atherothrombosis? Meta-analysis of randomised trials. BMJ 332: 1302–1308PubMedCrossRefGoogle Scholar
  9. 9.
    Chan FK, Wong VW, Suen BY, et al (2007) Combination of a cyclo-oxygenase-2 inhibitor and a proton-pump inhibitor for prevention of recurrent ulcer bleeding in patients at very high risk: a double-blind, randomised trial. Lancet 369: 1621–1626PubMedCrossRefGoogle Scholar
  10. 10.
    Robertson MS, Cade JF, Clancy RL (1999) Helicobacter pylori infection in intensive care: increased prevalence and a new nosocomial infection. Crit Care Med 27: 1276–1280PubMedCrossRefGoogle Scholar
  11. 11.
    Halm U, Halm F, Thein D, Mohr FW, Mossner J (2000) Helicobacter pylori infection: a risk factor for upper gastrointestinal bleeding after cardiac surgery? Crit Care Med 28: 110–113PubMedCrossRefGoogle Scholar
  12. 12.
    Ong SP, Duggan A (2004) Eradication of Helicobacter pylori in clinical situations. Clin Exp Med 4: 30–38PubMedCrossRefGoogle Scholar
  13. 13.
    Gisbert JP, Abraira V (2006) Accuracy of Helicobacter pylori diagnostic tests in patients with bleeding peptic ulcer: a systematic review and meta analysis. Am J Gastroenterol 101: 848–863PubMedCrossRefGoogle Scholar
  14. 14.
    Zullo A, De Francesco V, Hassan C, Morini S, Vaira D (2007) The sequential therapy regimen for Helicobacter pylori eradications pooled data analysis. Gut 56: 1353–1357PubMedCrossRefGoogle Scholar
  15. 15.
    Cook DJ, Reeve BK, Guyatt GH, et al (1996) Stress ulcer prophylaxis in critically ill patients: resolving discordant meta-analyses. JAMA 275: 308–314PubMedCrossRefGoogle Scholar
  16. 16.
    Stollman N, Metz DC (2005) Pathophysiology and prophylaxis of stress ulcer in intensive care unit patients. J Crit Care 20: 35–45PubMedCrossRefGoogle Scholar
  17. 17.
    Lau JY, Sung JJ, Lee KK, et al (2000) Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. N Engl J Med 343: 310–316PubMedCrossRefGoogle Scholar
  18. 18.
    Lau JY, Leung WK, Wu JC, et al (2007) Omeprazole before endoscopy in patients with gastrointestinal bleeding. N Engl J Med 356: 1631–1640PubMedCrossRefGoogle Scholar
  19. 19.
    Rockall TA, Logan RF, Devlin HB, Northfield TC (1996) Risk assessment after acute upper gastrointestinal haemorrhage. Gut 38: 316–321PubMedCrossRefGoogle Scholar
  20. 20.
    American College of Surgeons (1997) Advanced Trauma Life Support Course, ChicagoGoogle Scholar
  21. 21.
    British Society of Gastroenterology Endoscopy Committee (2002) Non variceal upper gastrointestinal haemorrhage: guidelines. Gut 51(suppl iv): iv1–6Google Scholar
  22. 22.
    Rudolph SJ, Landsverk BK, Freeman ML (2003) Endotracheal intubation for airway protection during endoscopy for severe upper GI haemorrhage. Gastrointest Endosc 57: 58–61PubMedCrossRefGoogle Scholar
  23. 23.
    Love DG (1999) Management of hemorrhagic events in patients receiving anticoagulant therapy. J Thromb Thrombolysis 7: 149–152PubMedCrossRefGoogle Scholar
  24. 24.
    Bosch J, Thabut D, Bendsten F, et al (2004) Recombinant factor VIIa for upper gastrointestinal bleeding in patients with cirrhosis: a randomized, double-blind trial. Gastroenterology 127: 1123–1130PubMedCrossRefGoogle Scholar
  25. 25.
    Hedner U (2007) Recombinant factor VIIa: its background, development and clinical use. Curr Opin Hematol 14: 225–229PubMedCrossRefGoogle Scholar
  26. 26.
    Cooper GS, Chak A, Way LE, Hammar PJ, Harper DL, Rosenthal GE (1999) Early endoscopy in upper gastrointestinal haemorrhage: associations with recurrent bleeding, surgery and length of hospital stay. Gastrointest Endosc 49: 145–152PubMedCrossRefGoogle Scholar
  27. 27.
    Winstead NS, Wilcox CM (2007) Erythromycin prior to endoscopy for acute upper gastrointestinal haemorrhage: a cost effectiveness analysis. Aliment Pharmacol Ther 26: 1371–1377PubMedCrossRefGoogle Scholar
  28. 28.
    Cook DJ, Gayatt GH, Salena BJ, Laine LA (1992) Endoscopic therapy for acute non-variceal upper haemorrhage: a meta analysis. Gastroenterology 102: 139–148PubMedGoogle Scholar
  29. 29.
    Chung SS, Lau JY, Sung JJ, et al (1997) Randomised comparison between adrenaline injection alone and adrenaline injection plus heat probe treatment for actively bleeding peptic ulcers. BMJ 314: 1307–1311PubMedGoogle Scholar
  30. 30.
    Lau JY, Sung JJ, Lam YH, et al (1999) Endoscopic retreatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of bleeding ulcers. N Engl J Med 340: 751–756PubMedCrossRefGoogle Scholar
  31. 31.
    Lefkovitz Z, Cappell MS, Lookstein R, Mitty HA, Gerard PS (2002) Radiologic diagnosis and treatment of intestinal haemorrhage and ischaemia. Med Clin North Am 86: 1357–1399PubMedCrossRefGoogle Scholar
  32. 32.
    Schenker MP, Duszak R Jr, Soulen MC, et al (2001) Upper gastro intestinal haemorrhage and trans catheter embolotherapy: clinical and technical factors impact in success and survival. J Vasc Interv Radiol 12: 1263–1271PubMedCrossRefGoogle Scholar
  33. 33.
    D’Othee BJ, Surapaneni P, Rabkin D, Nasser I, Clouse M (2006) Microcoil embolization for acute lower gastrointestinal bleeding. Cardiovasc Intervent Radiol 29: 49–58CrossRefGoogle Scholar
  34. 34.
    Silver A, Bendick P, Wasvary H (2005) Safety and efficacy of superselective angio embolisation in control of lower gastro intestinal haemorrhage. Am J Surg 189: 361–363PubMedCrossRefGoogle Scholar
  35. 35.
    Schepis F, Camma C, Niceforo D, et al (2001) Which patients with cirrhosis should undergo endoscopic screening for esophageal varices detection? Hepatology 33: 333–338PubMedCrossRefGoogle Scholar
  36. 36.
    Bosch J, Grozmann R (1994) Portal hypertension in cirrhosis: Natural history. In: Bosch J (ed) Portal Hypertension: Pathophysiology and Treatment. Blackwell Scientific, Cambridge, pp 72–92Google Scholar
  37. 37.
    Carbonell N, Pauwels A, Serfaty L, Fourdan O, Levy VG, Poupon R (2004) Improved survival after variceal bleeding in patients with cirrhosis over the past two decades. Hepatology 40: 652–659PubMedCrossRefGoogle Scholar
  38. 38.
    de Franchis R, Primignani M (2001) Natural history of portal hypertension in patients with cirrhosis. Clin Liver Dis 5: 645–663PubMedCrossRefGoogle Scholar
  39. 39.
    Goulis J, Armonis A, Patch D, Sabin C, Greenslade L, Burroughs A (1998) Bacterial infection is independently associated with failure to control bleeding in cirrhotic patients with gastrointestinal haemorrhage. Hepatology 27: 1207–1212PubMedCrossRefGoogle Scholar
  40. 40.
    Soares-Weiser K, Brezis M, Tur-Kaspa R, Leibovici L (2002) Antibiotic prophylaxis for cirrhotic patients with gastrointestinal bleeding. Cochrane Database Syst Rev CD002907Google Scholar
  41. 41.
    Ioannou GN, Doust J, Rockey DC (2003) Systematic review: terlipressin in acute oesophageal variceal haemorrhage. Aliment Pharmacol Ther 17: 53–64PubMedCrossRefGoogle Scholar
  42. 42.
    Avgerinos A, Nevens F, Raptis S, Fevery J (1997) Early administration of somatostatin and efficacy of sclerotherapy in acute oesophageal variceal bleeds: the European Acute Bleeding Oesophageal Variceal Episodes (ABOVE) randomised trial. Lancet 350: 1495–1499PubMedCrossRefGoogle Scholar
  43. 43.
    Gross M, Schiemann U, Muhlhofer A, Zoller WG (2001) Meta-analysis: efficacy of therapeutic regimens in ongoing variceal bleeding. Endoscopy 33: 737–746PubMedCrossRefGoogle Scholar
  44. 44.
    Seewald S, Sriram PV, Naga M, et al (2002) Cyanoacrylate glue in gastric variceal bleeding. Endoscopy 34: 926–932PubMedCrossRefGoogle Scholar
  45. 45.
    Abraldes JG, Dell’Era A, Bosch J (2004) Medical management of variceal bleeding in patients with cirrhosis. Can J Gastroenterol 18: 109–113PubMedGoogle Scholar
  46. 46.
    Panes J, Teres J, Bosch J, Rodes J (1988) Efficacy of balloon tamponade in treatment of bleeding gastric and esophageal varices. Results in 151 consecutive episodes. Dig Dis Sci 33: 454–459PubMedCrossRefGoogle Scholar
  47. 47.
    Monescillo A, Martinez-Lagares F, Ruiz-del-Arbol L, et al (2004) Influence of Portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding. Hepatology 40: 793–801PubMedGoogle Scholar
  48. 48.
    Rössle M, Siegerstetter V, Huber M, Ochs A (1998) The first decade of the transjugular intrahepatic portosystemic shunt (TIPS): state of the art. Liver 18: 73–89PubMedGoogle Scholar
  49. 49.
    Romaozinho JM, Pontes JM, Lerias M, Ferreira M, Freitas D (2004) Dieulafoy’s lesion: Management and long-term outcome. Endoscopy 36: 416–420PubMedCrossRefGoogle Scholar
  50. 50.
    Longstreth GF (1997) Epidemiology and outcome of patients hospitalized with acute lower gastrointestinal hemorrhage: a population-based study. Am J Gastroenterol 92: 419–424PubMedGoogle Scholar
  51. 51.
    Vernava AM 3rd, Moore BA, Longo WE, Johnson FE (1997) Lower gastrointestinal bleeding. Dis Colon Rectum 40: 846–858PubMedCrossRefGoogle Scholar
  52. 52.
    Green BT, Rockey DC, Portwood G, et al (2005) Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial. Am J Gastroenterol 100: 2395–2402PubMedCrossRefGoogle Scholar
  53. 53.
    Edelman DA, Sugawa C (2007) Lower gastrointestinal bleeding: a review. Surg Endosc 21: 514–520PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science + Business Media Inc. 2008

Authors and Affiliations

  • S. J. Thomson
    • 1
  • M. L. Cowan
    • 2
  • T. M. Rahman
    • 2
  1. 1.Department of Intensive CareSt George’s HospitalLondonUK
  2. 2.Department of GastroenterologySt George’s HospitalLondonUK

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