Sections

Medication

Medication Summary

Vasoconstrictive agents reduce the blood flow and facilitate hemostatic plug formation in the bleeding vessel. However, the results are less than satisfactory in patients with severe atherosclerosis and coagulopathy.

In patients on anticoagulant agents, a multidisciplinary team approach is indicated for decision making regarding discontinuing these agents or using reversal agents to weigh the risks of ongoing hemorrhage with the potential for thromboembolic events.^[5] In patients on dual antiplatelet therapy or monotherapy with nonaspirin antiplatelet agents (thienopyridine), resume non-aspirin antiplatelet therapy as soon as possible and at least within 7 days following multidisciplinary assessment of cardiovascular and GI risk and the adequacy of endoscopic therapy. Do not discontinue dual antiplatelet therapy in individuals with an acute coronary syndrome within the past 90 days or coronary stenting within the past 30 days.^[5]

Avoid the use of nonsteroidal anti-inflammatory agents in patients with a history of acute lower gastrointestinal (GI) bleeding (LGIB), such as from diverticular disease or angioectasia.^[5]Do not discontinue aspirin as secondary prophylaxis in those who have high-risk cardiovascular disease and a history of LGIB; however, avoid the use of aspirin for primary prevention of cardiovascular events in most patients with LGIB.^[5]

Class Summary

Agents with vasopressor and antidiuretic hormone (ADH) activity may reduce lower gastrointestinal bleeding.

Vasopressin (Pitressin Injection)

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Vasopressin is a pituitary hormone that causes severe vasoconstriction in the splanchnic bed. This agent has vasopressor and ADH activity: Vasopressin increases water resorption at the distal renal tubular epithelium (ADH effect) and promotes smooth muscle contraction throughout the vascular bed of the renal tubular epithelium (vasopressor effects). However, vasoconstriction also increases in the splanchnic, portal, coronary, cerebral, peripheral, pulmonary, and intrahepatic vessels.

Vasopressin decreases the portal pressure in portal hypertension. A notable undesirable effect is coronary artery constriction that may dispose patients with coronary artery disease to cardiac ischemia. This can be prevented with concurrent use of nitrates.

Class Summary

Epinephrine can be used in lower gastrointestinal bleeding, causing vasoconstriction and physical compression of the vessel. Epinephrine may be used in cases of diverticular bleeding or postpolypectomy hemorrhage.

Epinephrine

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Epinephrine has alpha-agonist effects that include increased peripheral vascular resistance, reversed peripheral vasodilatation, systemic hypotension, and vascular permeability. Beta2-agonist effects include bronchodilatation, chronotropic cardiac activity, and positive inotropic effects. Epinephrine solution (1/10,000 ) can be injected into the bleeding site at the time of the endoscopic evaluation.

Questions

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Media Gallery

Types of lower gastrointestinal bleeding (LGIB).
Methods used to treat lower gastrointestinal (GI) bleeding. CBC = complete blood cell count, coags = coagulation studies, EGD = esophagogastroduodenoscopy, NG = nasogastric, RBC = red blood cell, TRBC = tagged RBC, UGIB = upper GI bleeding.
Types of lower gastrointestinal (GI) bleeding. HR = heart rate, SBP = systolic blood pressure.
Algorithm for massive lower gastrointestinal (GI) bleeding, surgical perspective. EGD = esophagogastroduodenoscopy; NG = nasogastric; 99mTc RBC = technetium-99m pertechnetate–labeled autologous RBC.

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Author

Burt Cagir, MD, FACS Associate Regional Dean and Professor of Surgery, Geisinger Commonwealth School of Medicine; Director, General Surgery Residency Program, Executive Director, Donald Guthrie Foundation for Research and Education, Guthrie Robert Packer Hospital; Medical Director, Guthrie/RPH Skills and Simulation Lab; Associate in Surgery, Guthrie Robert Packer Hospital and Corning Hospital

Burt Cagir, MD, FACS is a member of the following medical societies: American College of Surgeons, Association of Program Directors in Surgery, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Coauthor(s)

Gabriel O Ologun, MD Resident Physician, Department of Surgery, Guthrie Robert Packer Hospital

Disclosure: Nothing to disclose.

Gavin F Chico, MD Consulting Staff, CHRISTUS Coushatta Rural Health Clinic

Disclosure: Nothing to disclose.

Elizabeth Cirincione, MD Director of Colon and Rectal Surgery, Department of Surgery, Nassau University Medical Center

Elizabeth Cirincione, MD is a member of the following medical societies: American College of Surgeons, American Society of Colon and Rectal Surgeons

Disclosure: Nothing to disclose.

Kenneth J Manas, MD Assistant Professor, Department of Medicine, Section of Gastroenterology and Hepatology, Louisiana State University Health Sciences Center

Kenneth J Manas, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Marc D Basson, MD, PhD, MBA, FACS Senior Associate Dean for Medicine and Research, Professor of Surgery, Pathology, and Biomedical Sciences, University of North Dakota School of Medicine and Health Sciences

Marc D Basson, MD, PhD, MBA, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Gastroenterological Association, Phi Beta Kappa, Sigma Xi, The Scientific Research Honor Society

Disclosure: Nothing to disclose.

Chief Editor

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Additional Contributors

David Greenwald, MD Professor of Clinical Medicine, Fellowship Program Director, Department of Medicine, Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine

David Greenwald, MD is a member of the following medical societies: Alpha Omega Alpha, New York Society for Gastrointestinal Endoscopy, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Acknowledgements

Michael A Grosso, MD Consulting Staff, Department of Cardiothoracic Surgery, St Francis Hospital

Michael A Grosso, MD is a member of the following medical societies: American College of Surgeons, Society of Thoracic Surgeons, and Society of University Surgeons

Disclosure: Nothing to disclose.

Lower Gastrointestinal Bleeding in Adults	Patients (%)
Diverticular disease Diverticulosis/diverticulitis of small intestine Diverticulosis/diverticulitis of colon	60%
Inflammatory bowel disease Crohn disease of small bowel, colon, or both Ulcerative colitis Noninfectious gastroenteritis and colitis	13%
Benign anorectal diseases Hemorrhoids Anal fissure Fistula-in-ano	11%
Neoplasia Malignant neoplasia of small intestine Malignant neoplasia of colon, rectum, and anus	9%
Coagulopathy	4%
Arteriovenous malformations (AVMs)	3%
TOTAL	100%
Source: Vernava AM, Longo WE, Virgo KS. A nationwide study of the incidence and etiology of lower gastrointestinal bleeding. Surg Res Commun. 1996;18:113-20.^[13]

Lower Gastrointestinal Bleeding Medication

Medication Summary

Posterior Pituitary Hormones

Class Summary

Vasopressin (Pitressin Injection)

Vasopressin (Pitressin Injection)

Adrenergic Agonists

Class Summary

Epinephrine

Epinephrine

Lower Gastrointestinal Bleeding Medication

Medication Summary

Posterior Pituitary Hormones

Class Summary

Vasopressin (Pitressin Injection)

Vasopressin (Pitressin Injection)

Adrenergic Agonists

Class Summary

Epinephrine

Epinephrine

References

Tables

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