Bright Red Blood Per … ULCER!!

Dr. Sylvia Cardounell presented a case of H.pylori induced peptic ulcer disease with a few interesting twists.

One atypical feature of this patient’s case was that he presented with bright red bloody bowel movements initially despite having an upper GI bleed. Upper GI bleeds (upper meaning proximal to the ligament of Treitz or 4th portion of the duodenum) classically present with melena, but when brisk and accompanied by other systemic signs and symptoms such as presyncope, tachycardia, and hypotension, can manifest as hematochezia. The BUN:Cr ratio is sometimes used to aid in differentiating between upper and lower GI bleeding. Due to digestion of blood in the stomach, the BUN increases in upper GI bleed, however a significant portion of lower GI bleeds also have increased BUN due to hypovolemia-induced prerenal azotemia. Some authors suggest various ratios 36:1-100:1 as more specific for upper GI bleeds, but our take home message is that the higher the ratio, the more likely it is for your GI bleed to be upper.

The classic presentation of a patient with peptic ulcer disease is epigastric abdominal pain about 2 to 5 hours after a meal when acid is secreted in the absence of a food buffer. Pain may also manifest at night between 11pm and 2am when circadian stimulation of acid secretion is maximal. Other food-provoked symptoms may occur as well including pain worse with eating (due to visceral sensitization and gastroduodenal dysmotility), belching postprandially, early satiety, fatty food intolerance, nausea, and occasional vomiting. Alarm features for dyspepsia that should provoke further testing and looking for alternate diagnoses are unintentional weight loss, dysphagia, odynophagia, unexplained iron deficiency anemia, persistent vomiting, palpable mass or lymphadenopathy, and a family history of upper GI cancer. Our patient’s initial vital signs showed mild tachycardia and hypotension when laying supine, indicating a blood loss of about 40% of total blood volume. Tachycardia typically starts at <15% blood loss, orthostatic hypotension requires a blood loss of at least 15%, and supine hypotension indicates a minimum blood loss of 40%.

The following are good rules of thumb for initially stabilizing your patient bleeding from their upper GI tract:

  • Prioritize access: they should have at least 2 large bore (18 gauge or larger). You can look at the color of your IV catheter to ascertain the gauge. Green is 18g, grey is 16g, and orange is 14g. 14g are not usually used for IV access due to their large size. Smaller IVs are pink, blue, and yellow.
  • Monitor for airway protection, place patient NPO, type and cross, consent for blood transfusion
  • Resuscitate: 
    • Crystalloids should be started for resuscitation if blood products cannot be obtained initially. Be judicious due to the risk of volume overload with subsequent transfusions.
    • Blood products:
      • A transfusion goal of Hgb 7 is appropriate for most patients, but those with unstable coronary artery disease should aim for a hemoglobin of 9. Clinical judgement is necessary in these cases and those who are elderly or with many comorbidities may need a higher transfusion goal.
        • In patients with cirrhosis, overtransfusion has been shown to lead to worse outcomes, likely due to worsening of underlying portal hypertension
      • Transfuse platelets if platelet <50 
        • Platelet transfusion can also be considered in patients on chronic antiplatelet therapy. However, evidence is lacking and given the risks of transfusion, platelet transfusion should not be routine in these patients
      • Goal INR <2. If your patient requires significant PRBC transfusion, you may dilute the concentration of clotting factors in the serum, creating an iatrogenic coagulopathy. Therefore, for every 4u PRBCs transfused, you should give 1u FFP.
  •  Acid suppression: Increasing the gastric pH allows blood to form clots and hopefully stop active hemorrhage. Traditionally, PPI infusion was used for UGIB cases, but more recent evidence has shown no difference in outcomes when comparing continuous PPI infusion and PPI bolusing BID. In fact, there was a trend toward lower rates of rebleeding in the bolusing group. Because of this evidence, the decreased cost, less resource utilization, and increased patient comfort, intermittent bolusing of PPIs is recommended. A loading dose of 80mg IV should still be given before starting 40mg IV BID dosing. Protonix and Nexium are the only PPIs available IV, but there is increasing evidence that oral PPIs may be sufficient.
  • In cirrhotics: octreotide and antibiotics should be added
  • Consider prokinetic agents such as erythromycin or Reglan 30-90 minutes before EGD if your patient has severe bleeding or has recently eaten as these may help your gastroenterologist visualized the stomach

Once you diagnose peptic ulcer disease, your differential remains broad. 

Peptic ulcer disease accounts for >50% of upper GI bleeds. It has myriad causes and risk factors. H.pylori, NSAID-induced, steroid-induced, and stress ulcers are our most commonly considered components on the differential, but ulcers have been associated with other more rare disorders such as gastrinoma, IgG4 related infilrative gastropathy, polycythemia vera, and sarcoidosis. There is also an association with acetaminophen of 2-3g/day or higher, bisphosphonates, Sirolimus, and an increasing body of evidence indicating that SSRIs increase risk of PUD as well. Smoking also increases the risk of peptic ulcer disease through many mechanisms.

Our patient received testing for H.Pylori via stool antigen test, which returned positive. Another atypical aspect of his case was that he received biopsy of his gastric mucosa during his EGD as well, but this came back negative. Typically, biopsy has a sensitivity of 90-95%, but active GI bleeding, antibiotics, PPIs, and bismuth-containing compounds decrease the sensitivity of biopsy, stool antigen test, and urea breath testing. If biopsy is negative for H.Pylori and you are worried about the sensitivity of biopsy in your clinical case, doing noninvasive H.Pylori testing 2 weeks after cessation of PPIs and 4 weeks after cessation of bismuth compounds is indicated. If EGD is indicated for another reason, biopsy is always first line for H.Pylori diagnosis. If no EGD is indicated, stool antigen or urea breath test should be used. 

Serology is not used to diagnose H.pylori because it remains positive after H.pylori treatment or after exposure that is not causing clinical disease.

H.Pylori Treatment:

Triple therapy should be used unless there is significant local resistance to clarithromycin (15% or more) or the patient has risk of macrolide resistance (has received macrolides for any reason). 

Triple therapy: Clarithromycin, amoxicillin, and PPIx14d

Quadruple therapy: Tetracycline, Flagyl, PPI, and Bismuth Subsalicylate x14d

One month after treatment of H.pylori, you should confirm eradication with urea breath test or stool antigen.

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