1. Gi bleeding
Angel Qin, MD
PGY 3

2. Objectives Define GI bleed Common presentations Initial assessment
Common causes of UGIB and LGIB
Different diagnostic tests and therapeutic options
Updates in GI bleeding
Practical tidbits along the way

3. Definitions Acute GI bleed Overt vs occult < 3 days duration
Hemodynamic instability
Requires blood transfusion
Overt vs occult
Overt: visible blood (melena, hematochezia, bright red blood per rectum, coffee ground emesis)
Occult: detected only on lab tests (ie stool cards)

4. UGIB: proximal to the ligament of Treitz
LGIB: distal to the ligament of Treitz
Ligament of Treitz

5. Common presentations…
“I am vomiting blood”
“When I wipe, there is blood on the toilet paper”
“My stools have changed color”
New finding of anemia on routine labwork

7. Initial assessment Is the patient stable?
ABCs (airway, breathing, circulation)
Home vs Floor vs MICU
What are the likely sources of the bleed?
What are patient’s underlying medical issues?
Any history of bleed in the past?
Any EGDs/colonoscopies?

8. Is the patient stable? Appearance Vital signs In distress? Pale?
Actively bleeding in front of you?
Vital signs
Tachycardic?
Hypotensive?
Hypoxic?

9. ABCs Airway Breathing Circulation
Can the patient protect his/her airway
Breathing
Is the patient tachypneic? Hypoxic?
Supplemental O2
Circulation
Establish 2 large bore IVs
Type and screen stat

10. Resuscitation IVF PRBCs FFPs/Platelets Normal saline boluses
Transfusion likely will be required if there is active bleed or there is a significant drop in hemoglobin
(More on transfusion goals later…)
FFPs/Platelets
May be needed depending on etiology of bleed (most commonly in patients with significant liver disease)

11. Now to the history… Has this ever happened before? Medical problems
Peptic ulcer disease, esophageal varices, diverticulosis
Medications: chronic NSAID use, aspirin, plavix, warfarin (other anticoagulants)
Trauma
Quality, quantity, frequency, onset
UGIB: bright red blood vs coffee ground emesis
LGIB: bright red blood vs melena (dark, TARRY stools)
Associated symptoms
Retching/vomiting (Mallory Weiss tears)
Abdominal pain (association with food? Ulcer vs mesenteric ischemia)
Weight loss, malaise (cancer)

12. On physical exam… VITAL SIGNS General: AAOX3? Distress?
Including orthostatic vital signs
General: AAOX3? Distress?
HEENT: blood in oropharynx? Pale conjunctiva?
Heart: tachycardic?
Abdomen: Soft? Distended? Tenderness to palpation?
RECTAL EXAM!
Melenic? (NOT melanotic!) Bright red?
Hemorrhoids?
Masses?

14. How to proceed Labs (STAT) Prior procedures/surgeries
CBC, RFP, coags, type and screen
What is baseline hemoglobin?
BUN:Cr ratio frequently >20:1 in UGIB
Also consider LFTs and iron studies
Prior procedures/surgeries
Last endoscopy or colonoscopy: findings, recommended treatment and followup, pathology results
Home vs Floor vs MICU
Home: misunderstanding of tarry stools, hemorrhoidal bleeding

15. Floor or MICU Consider ICU admission if: Be concerned if:
Despite aggressive fluid resuscitation, patient continues to be hypotensive, tachycardic
Continued active bleeding (NG lavage not clear after 2L, BRBPR)
History of cirrhosis and variceal bleeding
Any airway compromise
Be concerned if:
Elderly with multiple comorbidities
Use of anticoagulants
Prior abdominal surgeries

16. Practical tidbit: how to perform a NG lavage
Supplies:
NG tube, lubricant, normal saline, 50cc syringe, chucks, basin, gloves, stethoscope
1. Sit patient upright, cover with chucks, basin ready
2. Lubricate the NG tube well
3. Insert while having patient sip on water
4. Confirm placement by air insufflation via syringe or KUB (takes time)
5. Inject up to 250cc NS at a time into NG tube and withdraw aspirate via syringe or wall suction
Is there data regarding how much fluid can be pumped in at one time for lavage?

17. What does the aspirate look like?
Bright red clots: active upper GI bleed
Coffee grounds: slow UGIB, may have stopped
Clear: indeterminate
Bilious: bleeding has stopped
An indication for MICU admission is if after 2L, the NG aspirate is still bright red blood

19. Common causes of UGIB Gastric and/or duodenal ulcers
Esophageal varices w/wo portal gastropathy
Esophagitis
Erosive gastritis/duodenitis
More rare causes:
Mallory-Weiss syndrome
Angiodysplasia
Mass lesions (polyps/malignancy)
Dieulafoy’s lesions

20. From a national database of 7822 patients between 1999 and 2001

21. Wilkins T, Khan N, Nabh A, et al
Wilkins T, Khan N, Nabh A, et al. Diagnosis and Management of Upper Gastrointestinal Bleeding. Am Fam Physician 2012; 85(5):

22. Medical therapy for UGIB
IV PPI
Bolus with 80mg IV and then start drip at 8mg/hour
PPIs decrease the risk of rebleeding1, reduces the need for endoscopy2, and decreases the stigmata of recent hemorrhage2
H2 blockers are not recommended
Octreotide (for suspected variceal bleeding)
Long acting analogue of somatostatin; reduces splachnic blood flow, inhibit acid secretion
50-100mcg followed by drip at 25-50mcg/hr
Use is actually controversial; large meta -analysis did not find any significant reductions in mortality or risk of rebleed3
If ascites, then needs SBP prophylaxis x 7 days
Sung JJ, Barkun A, Kuipers EJ, et al. Intravenous esomeprazole for prevention of recurrent peptic ulcer bleeding: a randomized trial. Ann Intern Med 2009; 150(7):455-64
Sreedharan A, Martin J, Leontiadis GI et al. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane Database Syst Rev 2010; (7): CD
Gotzche PC, Hrobjartsson A. Somatostatin analogues for acute bleeding oesophageal varices. Cochrane Database Syst Rev 2010; (9): CD002907

23. If patient has ascites, then SBP prophylaxis w/antibiotics for 7 days is indicated
Inpatient: ceftriaxone 1g IV
Outpatient: norfloxacin 400mg PO BID or Bactrim DS BID

24. Endoscopic intervention
PUD
epinephrine injection
bipolar cautery
hemoclip
Varices
endoscopic band ligation
>90% success
30% rebleeding rate
TIPS for hemorrhage refractory to banding
also used for gastric varices
TIPS increases the risk for hepatic encephalopathy

25. VARIABLE*
SCORE 1 2 3
Age
Younger than 60 years
60 to 79 years
80 years or older —
Shock symptoms, systolic blood pressure, and heart rate
Shock absent, blood pressure 100 mm Hg or greater, heart rate less than 100 bpm
Tachycardia, blood pressure 100 mm Hg or greater, heart rate100 bpm or greater
Hypotension, blood pressure less than 100 mm Hg
Comorbidities
No major comorbidity
Heart failure, coronary artery disease, any major comorbidity
Renal failure, liver failure, disseminated malignancy
Endoscopic diagnosis
Mallory-Weiss tear or no lesion identified, and no stigmata of recent hemorrhage
All other diagnoses
Malignancy of upper gastrointestinal tract
Stigmata of recent hemorrhage
None or dark spot only
Blood in upper gastrointestinal tract, adherent clot, visible or spurting vessel
Rockall Risk Scoring System for Assessment After an Episode of Acute Upper Gastrointestinal Bleeding
RISK OF REBLEEDING AND MORTALITY BASED ON ROCKALL RISK SCORE
RISK
SCORE 1 2 3 4 5 6 7
≥ 8
Rebleeding (%)
4.9
3.4
5.3
11.2
14.1
24.1
32.9
43.8
41.8
Mortality (%)
0 0.2
0.2
2.9
10.8
17.3
27.0
41.1

27. Common causes of LGIB Diverticulosis Ischemia
Anorectal disease (hemorrhoids, fissures, ulcers)
Neoplasm (benign and malignant)
Inflammatory bowel disease
More rare causes
Angiodysplasia
Radiation colitis
Colitis NOS

29. Therapy for LGIB No medical therapies
Bleeding 2/2 to diverticulosis stops spontaneously about 75% of the time
Bleeding 2/2 to angiodysplasia stops spontaneously about 85% of the time
If the patient continues to bleed…
Angiography can be used to localize source of bleed and intravascular embolization can be delivered; requires >0.5cc/min of blood loss
Can be useful when determining surgical intervention
For those with contraindications to angiography, can consider tagged RBC scan , which requires bleeding at >0.1cc/min
Highly false positive rate; localization unreliable

30. Colonoscopy Rarely an emergent procedure
Standard prep is 4L of GoLytely (miralax + electrolytes) starting the evening PRIOR to colonoscopy
Patient must be passing CLEARS
A “rapid prep” can be done with GoLytely proceed to colonoscopy in 6-12 hours
Discovers the source of bleeding in >70% cases
Therapeutic interventions include epinephrine injection, cautery, and clipping

31. More advanced modalities
Limit of EGD is proximal duodenum and limit of colonscopy is cecum…leaving a significant portion of the small intestine left unvisualized
Though obscure GI bleeding accounts for only about 5% of GIB, in 75% of those cases, the source is the small intestine
Video capsule endoscopy
Enteroscopy (push, double balloon, intraoperative)
Push enteroscopy: long upper endoscope that are in the range of 220cm-250cm, but realistically due to coiling can reach about 150cm into the proximal small bowel
Intraoperative enterosocopy: insertion of endoscope through an enterotomy site during surgery
Double balloon enteroscopy: anterograde or retrograde; using two balloons that alternately inflate and deflate

33. Practical tidbit: what to order in the EMR
Basic admission orders
Remember to OMIT pharmacologic DVT prophylaxis ; use TEDs/SCDs
NPO (now or after midnight) depending on urgency of GI consult; for colonoscopies, clear liquid diet the day before
Check CBC q6
Always remember to check a post-transfusion CBC
IVF until blood arrives
Need new type and screen Q72 hours
Daily RFP
Assess electrolytes , BUN/Cr
IV PPI bolus followed by drip
Pantoprazole is the formulary IV PPI at both UH and VA
Octreotide drip for variceal bleeding
When does hemoglobin equilibrate

34. Practical tidbit: how to call a GI consult
Don’t be intimidated
Patients name, MRN, and location
Question you are asking
Be specific
Patient’s pertinent past medical history
What was the chief complaint?
Pertinent vitals, physical exam (RECTAL!), labs (include trends), and prior endoscopies/procedures (and when)
If patient has been seen in the GI department before

35. One last word…UGIB transfusion goals
In a recent study published in the NEJM1, patients with acute UGIB were randomly assigned to restrictive transfusion group vs liberal transfusion group
Restrictive: transfuse only when Hgb <7g/dL with target Hgb 7-9g/dL
Liberal: transfuse when Hgb <9g/dL with target Hgb 9-11g/dL
The jist: patients in the restrictive group had higher survival, decreased rates of rebleed, and decreased adverse events
Did not apply to patients with Child-Pugh class 3 cirrhosis
1. Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. NEJM 2013; 368:11-21

36. Questions?
Thank you for your time and welcome to UH and Cleveland!