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Gastrointestinal Bleeding in Critically Ill Cancer Patients

Causes and Management

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Oncologic Critical Care

Abstract

Cancer patients are at higher risk factor for gastrointestinal (GI) hemorrhage. In addition, the cancer diagnosis predicts poorer outcomes from the hemorrhage. Management is complicated by the expanded differential for sources of bleeding not only from the cancer but its therapy. In addition, cancer or its therapy can lead to bone marrow suppression with resulting thrombocytopenia that can exacerbate blood loss. New targeted therapy agents have unique properties leading to unusual adverse events like perforation and immune-mediated colitis. However, management strategies exist and are of proven benefit in these challenging patients. Endoscopy plays a critical role not only in establishing etiology but in control of hemorrhage. Direct tumor bleeding is problematic but does respond to endoscopic measures although recurrence rates are high. Additional nonendoscopic therapy directed toward tumor may be beneficial in reducing recurrence rates. Overall prognosis in GI bleeding is good, but cancer patients have higher risk of rebleeding and mortality.

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References

  1. Ananthakrishnan AN, McGinley EL, Saeian K. Higher hospital volume is associated with lower mortality in acute nonvariceal upper-GI hemorrhage. Gastrointest Endosc. 2009;70:422–32.

    Article  Google Scholar 

  2. Aoki T, Nagata N, Niikura R, Shimbo T, Tanaka S, Sekine K, Kishida Y, Watanabe K, Sakurai T, Yokoi C, et al. Recurrence and mortality among patients hospitalized for acute lower gastrointestinal bleeding. Clin Gastroenterol Hepatol. 2015;13:488–494 e481.

    Article  Google Scholar 

  3. Aoki T, Nagata N, Shimbo T, Niikura R, Sakurai T, Moriyasu S, Okubo H, Sekine K, Watanabe K, Yokoi C, et al. Development and validation of a risk scoring system for severe acute lower gastrointestinal bleeding. Clin Gastroenterol Hepatol. 2016;14:1562–1570 e1562.

    Article  Google Scholar 

  4. Arnold D, Fuchs CS, Tabernero J, Ohtsu A, Zhu AX, Garon EB, Mackey JR, Paz-Ares L, Baron AD, Okusaka T, et al. Meta-analysis of individual patient safety data from six randomized, placebo-controlled trials with the antiangiogenic VEGFR2-binding monoclonal antibody ramucirumab. Ann Oncol. 2017;28:2932–42.

    Article  CAS  Google Scholar 

  5. Assi H, Abdel-Samad N. Severe gastrointestinal hemorrhage during targeted therapy for advanced breast carcinoma. Curr Oncol. 2014;21:e732–5.

    Article  CAS  Google Scholar 

  6. Barkun AN, Martel M. The role of early colonoscopy in acute lower GI bleeding: summarizing conflicting data in the presence of society recommendations. Gastrointest Endosc. 2017;86:118–9.

    Article  Google Scholar 

  7. Bose D, Meric-Bernstam F, Hofstetter W, Reardon DA, Flaherty KT, Ellis LM. Vascular endothelial growth factor targeted therapy in the perioperative setting: implications for patient care. Lancet Oncol. 2010;11:373–82.

    Article  CAS  Google Scholar 

  8. Boussios S, Pentheroudakis G, Katsanos K, Pavlidis N. Systemic treatment-induced gastrointestinal toxicity: incidence, clinical presentation and management. Ann Gastroenterol. 2012;25:106–18.

    PubMed  PubMed Central  Google Scholar 

  9. Brahmer JR, Lacchetti C, Schneider BJ, Atkins MB, Brassil KJ, Caterino JM, Chau I, Ernstoff MS, Gardner JM, Ginex P, et al. Management of immune-related adverse events in patients treated with immune checkpoint inhibitor therapy: American society of clinical oncology clinical practice guideline. J Clin Oncol. 2018;36:1714–68.

    Article  Google Scholar 

  10. Brandler J, Baruah A, Zeb M, Mehfooz A, Pophali P, Wong Kee Song L, AbuDayyeh B, Gostout C, Mara K, Dierkhising R, et al. Efficacy of over-the-scope clips in management of high-risk gastrointestinal bleeding. Clin Gastroenterol Hepatol. 2018;16:690–696 e691.

    Article  Google Scholar 

  11. Burger RA, Brady MF, Bookman MA, Monk BJ, Walker JL, Homesley HD, Fowler J, Greer BE, Boente M, Fleming GF, et al. Risk factors for GI adverse events in a phase III randomized trial of bevacizumab in first-line therapy of advanced ovarian cancer: a Gynecologic Oncology Group Study. J Clin Oncol. 2014;32:1210–7.

    Article  CAS  Google Scholar 

  12. Camus M, Jensen DM, Ohning GV, Kovacs TO, Jutabha R, Ghassemi KA, Machicado GA, Dulai GS, Jensen ME, Gornbein JA. Comparison of three risk scores to predict outcomes of severe lower gastrointestinal bleeding. J Clin Gastroenterol. 2016;50:52–8.

    Article  Google Scholar 

  13. Cao D, Guo CH, Liu JW, Yang X, Li Q. Bleeding after bevacizumab treatment in patients with metastatic colorectal cancer. Tumori. 2015;101:46–51.

    Article  CAS  Google Scholar 

  14. Cavallaro LG, Monica F, Germana B, Marin R, Sturniolo GC, Saia M. Time trends and outcome of gastrointestinal bleeding in the Veneto region: a retrospective population based study from 2001 to 2010. Dig Liver Dis. 2014;46:313–7.

    Article  Google Scholar 

  15. Cortes J, Calvo V, Ramirez-Merino N, O'Shaughnessy J, Brufsky A, Robert N, Vidal M, Munoz E, Perez J, Dawood S, et al. Adverse events risk associated with bevacizumab addition to breast cancer chemotherapy: a meta-analysis. Ann Oncol. 2012;23:1130–7.

    Article  CAS  Google Scholar 

  16. Crist M, Hansen E, Chablani L, Guancial E. Examining the bleeding incidences associated with targeted therapies used in metastatic renal cell carcinoma. Crit Rev Oncol Hematol. 2017;120:151–62.

    Article  Google Scholar 

  17. Crooks CJ, West J, Card TR. Comorbidities affect risk of nonvariceal upper gastrointestinal bleeding. Gastroenterology. 2013;144:1384–93, 1393 e1381-1382; quiz e1318-1389

    Article  Google Scholar 

  18. Decousus H, Tapson VF, Bergmann JF, Chong BH, Froehlich JB, Kakkar AK, Merli GJ, Monreal M, Nakamura M, Pavanello R, et al. Factors at admission associated with bleeding risk in medical patients: findings from the IMPROVE investigators. Chest. 2011;139:69–79.

    Article  Google Scholar 

  19. Duan SJ, Gao ZM, Wang PL, Gong BC, Huang HW, Luo L, Wang X, Xing YN, Xu HM, Liu FN. Rare upper gastrointestinal hemorrhage of cetuximab: a case report. Medicine (Baltimore). 2017;96:e9391.

    Article  Google Scholar 

  20. Fidler MJ, Argiris A, Patel JD, Johnson DH, Sandler A, Villaflor VM, Coon J, Buckingham L, Kaiser K, Basu S, et al. The potential predictive value of cyclooxygenase-2 expression and increased risk of gastrointestinal hemorrhage in advanced non-small cell lung cancer patients treated with erlotinib and celecoxib. Clin Cancer Res. 2008;14:2088–94.

    Article  CAS  Google Scholar 

  21. Fujihara S, Mori H, Kobara H, Nishiyama N, Ayaki M, Ohata R, Ueda N, Sugimoto M, Kakehi Y, Masaki T. Uncommon gastrointestinal bleeding during targeted therapy for advanced renal cell carcinoma: a report of four cases. Oncol Lett. 2015;10:2895–8.

    Article  CAS  Google Scholar 

  22. Fujihara S, Mori H, Kobara H, Suenaga T, Hayashida Y, Sugimoto M, Kakehi Y, Masaki T. Life-threatening gastrointestinal bleeding during targeted therapy for advanced renal cell carcinoma: a case report. BMC Nephrol. 2013;14:141.

    Article  Google Scholar 

  23. Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American association for the study of liver diseases. Hepatology. 2017;65:310–35.

    Article  Google Scholar 

  24. Ghassemi KA, Kovacs TO, Jensen DM. Gastric acid inhibition in the treatment of peptic ulcer hemorrhage. Curr Gastroenterol Rep. 2009;11:462–9.

    Article  Google Scholar 

  25. Gonzales P, Klusewitz S, Marowske J, Gancayco J, Osswald MB, Setlik R. Everolimus implicated in case of severe gastrointestinal hemorrhage. Case Rep Oncol Med. 2017;2017:3657812.

    PubMed  PubMed Central  Google Scholar 

  26. Gralnek IM, Dumonceau JM, Kuipers EJ, Lanas A, Sanders DS, Kurien M, Rotondano G, Hucl T, Dinis-Ribeiro M, Marmo R, et al. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy. 2015;47:a1–46.

    Article  Google Scholar 

  27. Hearnshaw SA, Logan RF, Lowe D, Travis SP, Murphy MF, Palmer KR. Acute upper gastrointestinal bleeding in the UK: patient characteristics, diagnoses and outcomes in the 2007 UK audit. Gut. 2011;60:1327–35.

    Article  Google Scholar 

  28. Heller SJ, Tokar JL, Nguyen MT, Haluszka O, Weinberg DS. Management of bleeding GI tumors. Gastrointest Endosc. 2010;72:817–24.

    Article  Google Scholar 

  29. Honda T, Kobayashi H, Saiki M, Sogami Y, Miyashita Y, Inase N. Gastroesphageal variceal hemorrhage induced by metastatic liver tumor of lung cancer. Case Rep Oncol. 2012;5:644–50.

    Article  Google Scholar 

  30. Imperiale TF, Birgisson S. Somatostatin or octreotide compared with H2 antagonists and placebo in the management of acute nonvariceal upper gastrointestinal hemorrhage: a meta-analysis. Ann Intern Med. 1997;127:1062–71.

    Article  CAS  Google Scholar 

  31. Jairath V, Kahan BC, Gray A, Dore CJ, Mora A, James MW, Stanley AJ, Everett SM, Bailey AA, Dallal H, et al. Restrictive versus liberal blood transfusion for acute upper gastrointestinal bleeding (TRIGGER): a pragmatic, open-label, cluster randomised feasibility trial. Lancet. 2015;386:137–44.

    Article  Google Scholar 

  32. Kouanda AM, Somsouk M, Sewell JL, Day LW. Urgent colonoscopy in patients with lower GI bleeding: a systematic review and meta-analysis. Gastrointest Endosc. 2017;86:107–117 e101.

    Article  Google Scholar 

  33. Krishna SG, Rao BB, Thirumurthi S, Lee JH, Ramireddy S, Guindani M, Ross WA. Safety of endoscopic interventions in patients with thrombocytopenia. Gastrointest Endosc. 2014;80:425–34.

    Article  Google Scholar 

  34. Kroschinsky F, Stolzel F, von Bonin S, Beutel G, Kochanek M, Kiehl M, Schellongowski P, Intensive Care in Hematological, Oncological Patients Collaborative Group. New drugs, new toxicities: severe side effects of modern targeted and immunotherapy of cancer and their management. Crit Care. 2017;21:89.

    Article  Google Scholar 

  35. Kyaw M, Tse Y, Ang D, Ang TL, Lau J. Embolization versus surgery for peptic ulcer bleeding after failed endoscopic hemostasis: a meta-analysis. Endosc Int Open. 2014;2:E6–E14.

    Article  Google Scholar 

  36. Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012;107:345–60; quiz 361

    Article  CAS  Google Scholar 

  37. Laine L, Yang H, Chang SC, Datto C. Trends for incidence of hospitalization and death due to GI complications in the United States from 2001 to 2009. Am J Gastroenterol. 2012;107:1190–5; quiz 1196

    Article  Google Scholar 

  38. Lalla RV, Bowen J, Barasch A, Elting L, Epstein J, Keefe DM, McGuire DB, Migliorati C, Nicolatou-Galitis O, Peterson DE, et al. MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer. 2014;120:1453–61.

    Article  Google Scholar 

  39. Lanas A, Garcia-Rodriguez LA, Polo-Tomas M, Ponce M, Quintero E, Perez-Aisa MA, Gisbert JP, Bujanda L, Castro M, Munoz M, et al. The changing face of hospitalisation due to gastrointestinal bleeding and perforation. Aliment Pharmacol Ther. 2011;33:585–91.

    Article  CAS  Google Scholar 

  40. Lawal TO, Farris AB, El-Rayes BF, Subramanian RM, Kim HS. Oxaliplatin-induced hepatoportal sclerosis, portal hypertension, and variceal bleeding successfully treated with transjugular intrahepatic portosystemic shunt. Clin Colorectal Cancer. 2012;11:224–7.

    Article  CAS  Google Scholar 

  41. Marmo R, Del Piano M, Rotondano G, Koch M, Bianco MA, Zambelli A, Di Matteo G, Grossi E, Cipolletta L, Investigators P, et al. Mortality from nonulcer bleeding is similar to that of ulcer bleeding in high-risk patients with nonvariceal hemorrhage: a prospective database study in Italy. Gastrointest Endosc. 2012;75:263–72, 272 e261

    Article  Google Scholar 

  42. Marmo R, Koch M, Cipolletta L, Bianco MA, Grossi E, Rotondano G, PNED 1 and PNED 2 Investigators. Predicting mortality in patients with in-hospital nonvariceal upper GI bleeding: a prospective, multicenter database study. Gastrointest Endosc. 2014;79:741–749 e741.

    Article  Google Scholar 

  43. Matsumoto H, Kawazoe A, Shimada K, Fukuoka S, Kuboki Y, Bando H, Kojima T, Ohtsu A, Yoshino T, Doi T, et al. A retrospective study of the safety and efficacy of paclitaxel plus ramucirumab in patients with advanced or recurrent gastric cancer with ascites. BMC Cancer. 2018;18:120.

    Article  Google Scholar 

  44. Murakami N, Yoshimoto S, Matsumoto F, Ueno T, Ito Y, Watanabe S, Kobayashi K, Harada K, Kitaguchi M, Sekii S, et al. Severe gastrointestinal bleeding in patients with locally advanced head and neck squamous cell carcinoma treated by concurrent radiotherapy and Cetuximab. J Cancer Res Clin Oncol. 2015;141:177–84.

    Article  CAS  Google Scholar 

  45. Myers RP, Papay KD, Shaheen AA, Kaplan GG. Relationship between hospital volume and outcomes of esophageal variceal bleeding in the United States. Clin Gastroenterol Hepatol. 2008;6:789–98.

    Article  Google Scholar 

  46. Namikawa T, Hanazaki K. Clinicopathological features and treatment outcomes of metastatic tumors in the stomach. Surg Today. 2014;44:1392–9.

    Article  Google Scholar 

  47. Niikura R, Nagata N, Shimbo T, Sakurai T, Aoki T, Moriyasu S, Sekine K, Okubo H, Watanabe K, Yokoi C, et al. Adverse events during bowel preparation and colonoscopy in patients with acute lower gastrointestinal bleeding compared with elective non-gastrointestinal bleeding. PLoS One. 2015;10:e0138000.

    Article  Google Scholar 

  48. Oakland K, Guy R, Uberoi R, Hogg R, Mortensen N, Murphy MF, Jairath V, Collaborative UKLGB. Acute lower GI bleeding in the UK: patient characteristics, interventions and outcomes in the first nationwide audit. Gut. 2018;67:654–62.

    PubMed  Google Scholar 

  49. Oakland K, Jairath V, Uberoi R, Guy R, Ayaru L, Mortensen N, Murphy MF, Collins GS. Derivation and validation of a novel risk score for safe discharge after acute lower gastrointestinal bleeding: a modelling study. Lancet Gastroenterol Hepatol. 2017;2:635–43.

    Article  Google Scholar 

  50. Patel SD, Desai R, Patel U, Singh S, Patel Z, Patel N, Zhang A, Panwala AH, Khan VN, Singh G, et al. Thirty-day readmissions after upper and lower gastrointestinal hemorrhage: a national perspective in the United States. J Clin Gastroenterol. epub March 20 2018.

    Google Scholar 

  51. Pittayanon R, Rerknimitr R, Barkun A. Prognostic factors affecting outcomes in patients with malignant GI bleeding treated with a novel endoscopically delivered hemostatic powder. Gastrointest Endosc. 2018;87:994–1002.

    Article  Google Scholar 

  52. Ramos GP, Binder M, Hampel P, Braga Neto MB, Sunjaya D, Al Bawardy B, Abu Dayyeh BK, Buttar NS, Bruining DH, Prabhu-Coelho N, et al. Outcomes of endoscopic intervention for overt GI bleeding in severe thrombocytopenia. Gastrointest Endosc. 2018;88(1):55–61.

    Article  Google Scholar 

  53. Razzaghi A, Barkun AN. Platelet transfusion threshold in patients with upper gastrointestinal bleeding: a systematic review. J Clin Gastroenterol. 2012;46:482–6.

    Article  Google Scholar 

  54. Richter-Schrag HJ, Glatz T, Walker C, Fischer A, Thimme R. First-line endoscopic treatment with over-the-scope clips significantly improves the primary failure and rebleeding rates in high-risk gastrointestinal bleeding: a single-center experience with 100 cases. World J Gastroenterol. 2016;22:9162–71.

    Article  CAS  Google Scholar 

  55. Robertson M, Majumdar A, Boyapati R, Chung W, Worland T, Terbah R, Wei J, Lontos S, Angus P, Vaughan R. Risk stratification in acute upper GI bleeding: comparison of the AIMS65 score with the Glasgow-Blatchford and Rockall scoring systems. Gastrointest Endosc. 2016;83:1151–60.

    Article  Google Scholar 

  56. Roshan Afshar I, Sadr MS, Strate LL, Martel M, Menard C, Barkun AN. The role of early colonoscopy in patients presenting with acute lower gastrointestinal bleeding: a systematic review and meta-analysis. Therap Adv Gastroenterol. 2018;11:1756283X18757184.

    Article  Google Scholar 

  57. Schatz RA, Rockey DC. Gastrointestinal bleeding due to gastrointestinal tract malignancy: natural history, management, and outcomes. Dig Dis Sci. 2017;62:491–501.

    Article  Google Scholar 

  58. Sengupta N, Tapper EB. Derivation and internal validation of a clinical prediction tool for 30-day mortality in lower gastrointestinal bleeding. Am J Med. 2017;130:601 e601–8.

    Article  Google Scholar 

  59. Shafi MA, Bresalier RS. The gastrointestinal complications of oncologic therapy. Gastroenterol Clin N Am. 2010;39:629–47.

    Article  Google Scholar 

  60. Sheibani S, Kim JJ, Chen B, Park S, Saberi B, Keyashian K, Buxbaum J, Laine L. Natural history of acute upper GI bleeding due to tumours: short-term success and long-term recurrence with or without endoscopic therapy. Aliment Pharmacol Ther. 2013;38:144–50.

    Article  CAS  Google Scholar 

  61. Shih AW, Crowther MA. Reversal of direct oral anticoagulants: a practical approach. Hematology Am Soc Hematol Educ Program. 2016;2016:612–9.

    Article  Google Scholar 

  62. Slade JH, Alattar ML, Fogelman DR, Overman MJ, Agarwal A, Maru DM, Coulson RL, Charnsangavej C, Vauthey JN, Wolff RA, et al. Portal hypertension associated with oxaliplatin administration: clinical manifestations of hepatic sinusoidal injury. Clin Colorectal Cancer. 2009;8:225–30.

    Article  CAS  Google Scholar 

  63. Strate LL, Ayanian JZ, Kotler G, Syngal S. Risk factors for mortality in lower intestinal bleeding. Clin Gastroenterol Hepatol. 2008;6:1004–10; quiz 1955-

    Article  Google Scholar 

  64. Strate LL, Gralnek IM. ACG clinical guideline: management of patients with acute lower gastrointestinal bleeding. Am J Gastroenterol. 2016;111:459–74.

    Article  CAS  Google Scholar 

  65. Streiff MB, Milentijevic D, McCrae K, Yannicelli D, Fortier J, Nelson WW, Laliberte F, Crivera C, Lefebvre P, Schein J, et al. Effectiveness and safety of anticoagulants for the treatment of venous thromboembolism in patients with cancer. Am J Hematol. 2018;93:664–71.

    Article  CAS  Google Scholar 

  66. Sung JJ, Chiu PC, Chan FKL, Lau JY, Goh KL, Ho LH, Jung HY, Sollano JD, Gotoda T, Reddy N, et al. Asia-Pacific working group consensus on non-variceal upper gastrointestinal bleeding: an update 2018. Gut. 2018;67(10):1757–68.

    Article  Google Scholar 

  67. Tey J, Soon YY, Koh WY, Leong CN, Choo BA, Ho F, Vellayappan B, Lim K, Tham IW. Palliative radiotherapy for gastric cancer: a systematic review and meta-analysis. Oncotarget. 2017;8:25797–805.

    Article  Google Scholar 

  68. Villanueva C, Colomo A, Bosch A, Concepcion M, Hernandez-Gea V, Aracil C, Graupera I, Poca M, Alvarez-Urturi C, Gordillo J, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013;368:11–21.

    Article  CAS  Google Scholar 

  69. Weber JS, Postow M, Lao CD, Schadendorf D. Management of adverse events following treatment with anti-programmed death-1 agents. Oncologist. 2016;21:1230–40.

    Article  Google Scholar 

  70. Wuerth BA, Rockey DC. Changing epidemiology of upper gastrointestinal hemorrhage in the last decade: a nationwide analysis. Dig Dis Sci. 2018;63:1286–93.

    Article  Google Scholar 

  71. Yarris JP, Warden CR. Gastrointestinal bleeding in the cancer patient. Emerg Med Clin North Am. 2009;27:363–79.

    Article  Google Scholar 

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Authors and Affiliations

  1. Gastroenterology Hepatology & Nutrition, University of Texas MD Anderson Cancer Center, Houston, TX, USA

    David M. Richards & William A. Ross

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  1. David M. Richards
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  2. William A. Ross
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Correspondence to William A. Ross .

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  1. Department of Critical Care, University of Texas MD Anderson Cancer C Department of Critical Care, Houston, TX, USA

    Joseph L. Nates

  2. Department of Critical Care, University of Texas MD Anderson Cancer C Department of Critical Care, Houston, TX, USA

    Kristen J. Price

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Richards, D.M., Ross, W.A. (2019). Gastrointestinal Bleeding in Critically Ill Cancer Patients. In: Nates, J., Price, K. (eds) Oncologic Critical Care. Springer, Cham. https://doi.org/10.1007/978-3-319-74698-2_72-1

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  • DOI: https://doi.org/10.1007/978-3-319-74698-2_72-1

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