2. A Bloody Mess Upper GI Bleeding Tim Pfanner, MD, COL, USAR(ret) Asst Professor of Medicine Chief, Section of IBD & Nutrition

3. Case 85 year old male –Presents with Melena & Dizziness –PMHx: CHF CADz Etoh –PE: passes the eyeball test Vital signs all look good Is NOT tilt positive, Hbg 8, INR 1, Plts 300k

4. Case Now that you have done an initial survey, what other questions might you want to ask? –Any history of prior gi bleeding? –Any history of liver disease? –What meds is the patient on?

5. The following questions enter your mind(or should) What should I do to manage the pt now? Where should the pt go & how do I decide? –Home, ward, icu –Are there admission/home Criteria??? What are the causes of his GI bleed?

6. More Questions enter your inquisitive mind How good is the therapy? –What medical Rx should I order? How good is it? When should it begin? –How good is endoscopy? Risk stratification Therapeutic mgmt –When should I get others involved? Surgery &/or interventional radiology?

7. So Here is what we are talking about Duodenal ulcer Gastric Ulcer with bleeding Visible vessel

8. NOW HERE’S A HAPPY CROWD VISITING FRIENDS

9. So Why Focus on Peptic Ulcer Bleeding? Majority of all gi bleeds are from upper gi source 90% of all ugi bleeds are non-variceal 400,000 admissions yearly In-hospital direct medical costs = 2.5 billion Mortality is still high –5-10% mortality from peptic ulcer bleeding More common in Men by 3:2 ratio Mortality in UK –3% in pts <60 –20% in pts >80

10. So what are you thinking about the source of bleeding here? Esophageal varicies –Maybe he is a drinker gastric varicies

11. So what are you thinking about the source of bleeding here? Mallory-weiss tear Horrible ulcer(guess) Syphilitic Ulcer

12. So what are you thinking about the source of bleeding here? AVMs Polyps

13. So what are you thinking about the source of bleeding here? Gastric Ulcer Duodenal ulcer

14. Clinical Presentation Most commonly with: –Melena –Hematemesis Think about serious signs of intravascular volume status: –Hypotension & resting tachycardia 100bpm –Orthostatic changes(tilts)-20mmHg/20bpm

15. Clinical Presentation Initial Tx: What is it? –Restore hemodynamic stability Place 2 large bore iv & fluids –Supplemental oxygen esp in elderly –Consider: blood/correcting coagulopathy Place an NG tube-does this really help –15% with negative ng aspirate have high risk leisons on endoscopy

16. Clinical Presentation Helping the patient & Gastroenterologist? –Orogastric tube placement –Do not guiac –Erythromycin 250mg iv 30 to 60 min prior to egd –?iv ppi 80mg bolus followed by 8mg/hour Has not definitely been shown to help prior to egd

17. how might I determine where they go? Clinical Risk Stratification Pre-endoscopic scoring systems –Blatchford Score-Neural network –Rockall Score General components –Systolic BP-heart rate –Hemoglobin-melena –Co-morbid conditions –Age-?etoh

18. Forrest Classification Endoscopic Stigmata of Bleeding Peptic Ulcer, Classified as High Risk or Low Risk Gralnek I et al. N Engl J Med 2008;359:928-937 Grade 1aGrade 1b 2a 2b 2c 3

19. Clinical Risk Stratification Systems combining clinical and endoscopic parameters –Rockall –Baylor bleeding score –Cedar Sinai

20. Clinical Risk Stratification So How should I use all this stuff? Look at the patient and use your common sense –How did the pt present syncope, orthostatic –Are they elderly –Do they have other serious diseases –What meds are they on(coumadin, NSAIDs) –Is the hemoglobin <10 –Is the BUN >25 –If you use scoring, Rockall>5 is high risk, <2 is low risk

21. Clinical Risk Stratification So How should I use all this stuff? High Clinical Risk –To the MICU & resuscitate –Call GI to scope within 24 hours –Does early endoscopy(before admit) change what the managing provider does? –Does early endoscopy save money? GI Endoscopy 2004;60:1-8 NO Low Risk in the United Kingdom can go home with no endoscopy

22. Low Risk patients Gralnek I et al. N Engl J Med 2008;359:928-937

23. Clinical Risk Stratification So How should I use all this stuff? If endoscopy has been performed and low risk leisons seen may consider outpatient Rx Intermediate risk & low risk can go to ward Usually keep high & intermediate for 72 hours –This is when risk for rebleed is highest Octreotide if with cirrhosis/etoh ppi

24. Clinical Risk Stratification So, What do I do? In general do endoscopy within 24 hours If we see: –high risk Rx & 24 h MICU, then 48h hospitalization –Ulcer >2cm, vessel > 2mm are high risk –Low risk Rx & consider home/early discharge

25. Oh!, those places you will go!

26. Management Medical –octreotide –Goal-pH >6.0 –H2RA- not effective –PPIs-very effective Endoscopic Surgical RX-much less common Interventional Radiology

27. Management Medical – PPIs Decrease: rebleed risk(odds ratio =.40) surgery risk(odds ratio =.50) Death (odds ratio=.53) –PPI Dosing Iv- 80mg bolus and 8mg/hour for 72 hours(most effective dosing method) High dose oral effective in Asian populations

28. Effect of Proton-Pump Inhibition in Peptic-Ulcer Bleeding From Leontiadis GI, etal. Cochrane Database Syst Rev 2006;1 Gralnek I et al. N Engl J Med 2008;359:928-937

29. Management Helicobacter Pylori Yep, you wanna test For me.

30. Management testing for H. Pylori

31. Management of H. pylori + Initial Rx: –Clarithromycin 500mg bid –Amoxicillin 1000mg bid –PPI bid –All for 10-14 days, then PPI qd x4-8 wks’ Healing of DU takes 3-4 wks & GU 6-8 wks Salvage Rx: –Bismuth 120mg qid –Metronidazole 500mg tid –Tetracycline 500mg qid –PPI bid –All for 14 days

32. So does RX of H. Pylori work? Eradication of H. Pylori reduces the 1 year recurrence of ulcers from 75% to 15-20%. H. pylori has been strongly associated with gastric cancer –Japanese eradication trials = no gastric cancer Eradication in MALT lymphoma –Regression in 70-80% Eradication prior to NSAIDs can reduce ulcer risk

33. NSAID’s & PUD 33 million commonly use NSAIDs Ulcers found in 5-20% of chronic users Only a third of chronic NSAID users have normal EGD’s Gastric ulcers more common than duodenal NSAID’s increase risks of ulcer complication – bleeding, obstruction and perforation –.5%-4% per year risk –>50% May present as a “silent” hemorrhage Perforating gastric ulcer Bleeding gastric ulcer with visible vessel

34. AFTER ALL, don’t we all want to be LONGHORNS?

35. Endoscopic Management Most studies use emergent endoscopy with 12-24 hours of admission Identifies bleeding site & stigmata of recent hemorrhage Able to predict likelihood of continued or recurrent bleeding Early treatment reduces hospital costs and length of stay

36. We can burn it!

37. We can inject it!

38. We can clip it!

39. Endoscopic Tx for PUD bleeding So, How good are we? LesionRebleed RiskRisk after Tx clean base 3% pigmented spot7% Oozing10-27% Adherent clot12-33%5% visible vessel50%15-30% actively bleeding90%15-30% Repeat endoscopic therapy is effective in approximately 70% of recurrent bleeders

40. Management But, what does the literature say? Endoscopic –Overall Effectiveness Active bleeding-NNT=2 Visible vessel-NNT=5 –Injection of epi should not be done alone NNT=9 –Burn the vessel NNT=5 –Clip the vessel NNT = 4-5 –Combination appears most effective NNT = 4-5 –What about when rebleeding occurs? NNT 4-5 Laine, et al; Endoscopic Therapy for Bleeding Ulcers: An Evidence-Based Approach Based onn Meta-Analyses of Randomized Controlled Trials, Clinical Gastro & Hep 2009;7:33-47

41. Management Does endoscopic Rx lower rates of Surgery? –Surgical rates before and after Endoscopic Rx Before After Active Bleeding 35% 7% Visible Vessel 34% 6% Adherent Clot 10% 2% Flat Spot 6% <1% Laine L. Et al: Bleeding Peptic Ulcer NEJM;331:717, 1994

42. Honduras, 2007

43. Management Surgery –Surgical rates Prior to the 1980’s –operative rate 20-27% –Mortality 5%, 20% in recurrent bleeds Now the rate is 6.5- 7.5% What happened in the 1980’s?

44. Management Surgery –Indications: Bleeding continues after 2 nd Endoscopy Pt cannot be stabilized Pts who cannot tolerate recurrent or worsening bleeding After the first endoscopic RX –Pts with ulcers >2cm or large vessels(>2mm) –WHY? This is associated with endoscopic Tx failure

45. Management Surgery- Operations commonly used –Vagotomy with pyloroplasty & oversew –Vagotomy with Antrectomy & oversew Recent cohort studies indicate equivalency De la Fuente SG, et al: Comparative analysis of vagotomy and drainnage versus vagotomy and resection procedures for bleedinng peptic ulcer disease: results of 907 patients from the Dept of VA National Surgical QI Program Database. J Am Coll Surg 2006;202:78-86 Surgical success: –23% recurrent bleeding –31% additional surgery –20% mortality is possible

46. Honduran Jurassic Park

47. Management Interventional Radiology –Angiography with transcatheter embolization This uses: gelfoam, coils, super glue, polyvinyl alcohol –Usually reserved for high risk who –Failed endoscopic Tx –Too high risk for surgery –In other words: The sickest of the sick who failed all other attempts at treatment

48. Here is what the little springs look like

49. Management How good is Interventional Radiology –Technical success is 52-94% –Uncontrolled trials-reduces bleeding & death Recurrent bleeding rate=29% Mortality=26% Additional surgery=16.1% –Problems: –ischemic bowel –secondary duodenal stenosis –Infarct of liver, spleen or stomach

50. Since payments are decreasing, this is the future of GI

51. Summary PUDz accounts for most Acute significant UGI bleeds It is a very common and expensive problem Identify high risk clinical criteria: –Old age-hemoglobin <10-etoh –Syncope-elevated BUN –Tilt positive-comorbities

52. Summary After Endoscopy risk stratify –Active bleeding -visible vessel –Adherent clot –LOW RISK: clean based ulcer, pigmented spot Realize that endoscopic Tx is not always effective Use iv PPI for 72 hours in high risk patients

53. Summary Iv PPI do not work as well in the absence of endoscopic Tx If rebleed, call GI again for endoscopic treatment attempt Then if this fails, call the surgeon Get interventional involved if all else fails Test for H. Pylori and Rx if positive Avoid NSAIDs, etc

54. QUESTIONS????????? My cold happy crew At Granmda’s Home in Springville, New York