#53 Non-Variceal GI Bleeds

Written By Nick Mark

Join us on this week's episode of Critical Care Time as we embrace blood-and-guts with Dr. David T. Dulaney, gastroenterologist-extraordinaire! Nick & Cyrus host David for a pearl-laden discussion on non-variceal GI bleeds where we talk guidelines, expert opinion and so much more. Who needs a scope? When do you scope them? Why is stabilizing your patient SO important before GI comes in to save the day? How can we work together effectively with our colleagues in GI to ensure the best outcomes for our patient? We tackle a ton of content on this episode so you'll definitely want to tune in... and maybe even take some notes! Make sure to leave us feedback and let us know what you think! Oh... and spoiler alert: cirrhosis and variceal bleeds is on deck for our next installment so keep your eyes peeled for that one too!

Why Focus on Non-Variceal GI Bleeds (NVGIB)?

  • NVGIB vs. Variceal Bleeds:

    • NVGIB: arterial source, often abrupt onset

    • Variceal: venous origin, linked to cirrhosis and portal hypertension

  • Upper vs. Lower GI Bleeds:

    • UGIB: esophagus to duodenum (proximal to Ligament of Treitz)

    • LGIB: jejunum onward (with small bowel bleeds newly termed "obscure")

  • Why It Matters to the ICU:

    • Over 500,000 hospitalizations annually in the US for GI bleeds

    • Team-based care: ED, hospitalists, critical care, GI, radiology

📚 References:

  • ACG Clinical Guidelines on Upper GI Bleeding

  • ACG 2023 Lower GI Bleeding Guidelines

  • ESGE Upper GI Bleed Guidelines

Pathophysiology and Etiologies

  • Common Causes of UGIB:

    • Peptic ulcer disease (PUD)

    • Dieulafoy lesion

    • Gastritis, Mallory-Weiss tear

    • Aortoenteric fistula

  • Common Causes of LGIB:

    • Diverticulosis

    • Angiodysplasia (e.g. Heyde’s Syndrome)

    • AVMs

    • Post-polypectomy

  • Clinical Clues:

Risk Factors & Clinical Scoring Tools

  • Risk Factors:

    • NSAIDs

    • H. pylori

    • Age, vascular lesions

    • Anticoagulants (DOACs, warfarin), antiplatelets

  • Decision Tools:

    • ✅ Glasgow-Blatchford Score (GBS): Best sensitivity for ruling out severe bleeds
      🔗 GBS on MDCalc

    • ❌ AIM65: No longer recommended for triage

    • 🚨 Rockall: Limited utility pre-endoscopy

    • ⚖️ Oakland Score: For LGIB, though evidence is limited

Case Discussion – Upper GI Bleed

Discussion Points:

  • Immediate stabilization: IVs, blood, PPI drip (80 mg IV bolus + 8 mg/hr)

  • PPI benefits: downstaging Forrest class, not mortality

  • Endoscopy timing: <24 hrs; no benefit for <12 hrs in most cases

  • Intubation before EGD in massive hematemesis

  • Transfusion threshold: 7 g/dL unless CVD history

  • Caution: Normal Hgb does not rule out severe blood loss

📌 Visual Placeholder: Forrest Classification of Ulcer Bleeding
📌 Visual Placeholder: EGD Interventions (clips, epi injection, powder)

Team-Based Resuscitation & Peri-Endoscopy Communication

  • Definition of “stabilized” varies; base excess can be useful trend

  • Multidisciplinary team engagement (GI, ICU, IR, Anesthesia)

  • Time-out with role declaration improves communication

  • Tools of the trade:

    • Standard vs. large-channel scopes

    • Hemostatic powder

    • Bipolar cautery, through-the-scope clips

📌 Visual Placeholder: Endoscopic tools & their functions

Case 2 – Lower GI Bleed

Discussion Points:

  • Most likely cause: Diverticular bleed

  • First-line test: CT angiogram (if active bleeding)

  • No need to reverse apixaban in stable patients

  • Colonoscopy prep: PEG solution, high-quality prep essential

  • Unprepped flex sig considered in known diverticulosis (controversial)

🧠 Pearl: Pulsatile stents from prior vascular surgery = think aortoenteric fistula

📌 Visual Placeholder: Algorithm for LGIB diagnosis

Anticoagulation and Hemostatic Interventions

  • Anticoagulant reversal:

    • Apixaban: No routine reversal (ACG/Canadian Guidelines)

    • Reverse only in life-threatening bleed within 24h of last dose

  • TXA: No mortality benefit in HALT-IT trial
    🔗 HALT-IT RCT – The Lancet, 2020

    • ACG: No recommendation

    • ESGE: Recommends against use

📌 Visual Placeholder: Summary table of anticoagulation reversal strategies

What If the Scope Is Negative?

  • Dieulafoy lesions may hide between bleeds

  • Timing is critical for radiology: Active bleeding needed

  • Consider tagged RBC scan, Meckel’s, vascular history (aortoenteric fistula)

📌 Visual Placeholder: Algorithm for workup of negative scope + ongoing bleeding

Conclusion: Key Takeaways

  • NVGIBs are common, dangerous, and demand a multidisciplinary approach

  • Risk stratification and appropriate timing of endoscopy are key

  • GI and ICU teams must communicate clearly and early

  • Not all GI bleeds need emergent scope—but all need thoughtful triage

Nick Mark
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#52 Lactate & Lactic Acidosis