GI Bleeding Clinical Presentation Acute Upper GI Bleed Acute Lower GI Bleed
Case Presentation CC: Melena HPI: 54 yo man taking ibuprofen 200 mg po tid for the past 2 wks b/o acute LBP after lifting presents with 2 day h/o melena PMHx: negAll: NKDA SHx/FHx: neg Vitals: BP 105/75 P 90 PE: normal
Clinical Presentation Hematemesis: bloody vomitus (bright red or coffee-grounds) Melena: black, tarry, foul-smelling stool Hematochezia: bright red or maroon blood per rectum Occult: positive guaiac test Symptoms of anemia: angina, dyspnea, or lightheadedness
Patient Assessment Hemodynamic status Localization of bleeding source CBC, PT, and T & C Risk factors –Prior h/o PUD or bleeding –Cirrhosis –Coagulopathy –ASA or NSAID’s
Resuscitation 2 large bore peripheral IV’s Normal saline or LR Packed RBCs Correct coagulopathy
Location of Bleeding Upper –Proximal to Ligament of Treitz –Melena (100-200 cc of blood) –Azotemia –Nasogatric aspirate Lower –Distal to Ligament of Treitz –Hematochezia
Acute UGIB Demographics 10,000 - 20,000 deaths annually Mortality stable at 10% 80% self-limited Continued or recurrent bleeding - mortality 30-40%
Cause of bleeding Severity of initial bleed Age of the patient Comorbid conditions Onset of bleeding during hospitalization Acute UGIB Prognostic Indicators
Tedesco et al. ASGE Bleeding Survey. Gastro Endo. 1981.
Bleeding PUD: IV H2RAs Meta-Analysis Duodenal ulcer: no benefit Gastric ulcer: mild benefit –Mortality ARR 3%; NNT 33 –Surgery ARR 7%; NNT 14 –Rebleeding ARR 7%; NNT 14 Caveats –Tolerance develops within 24 hrs –More potent acid suppression available Levine JE et al. Aliment Pharmacol Ther 2002;16:1137-42.
472 patients required no endoscopic treatment 27 patients not included: comorbid or no consent 120 patients received IV omeprazole 80 mg bolus then 8 mg/hr for 72 hours 120 patients received placebo 267 received endoscopic treatment 739 patients admitted with GI bleeding Lau et al. New Eng J Med 2000;343:310-316. Adjuvant Medical Therapy of PUD
Lau et al. New Eng J Med 2000;343:310-316.
Bleeding PUD: PO/IV PPIs Meta-Analysis Reduction in: –RebleedingNNT* 4-17 –SurgeryNNT* 6-25 No change in mortality PPIs add to endoscopic therapy but do not supplant endoscopic therapy * Estimates from pooled ORs Leontiadis, GI et al. BMJ 2005;330:568-75.
Variceal Band Ligation
Vasopressin/Glypressin Nonselective vasoconstrictor 50% efficacy in controlling bleeding 25% vasospastic side effects Octreotide Cyclic octapeptide analog of somatostatin Longer acting than somatostatin Equivalent to sclerotherapy and improves endoscopic results MEDICAL THERAPY Acute Variceal Bleeding
Acute Bleeding Changes Before and After 2 Liter Bleed 27% 45%
Acute UGIB Surgery Recurrent bleeding despite endoscopic therapy > 6-8 units pRBCs
Case Presentation CC: Hematochezia HPI: 74 yo woman presents with 6 hour history of painless maroon blood per rectum PMHx: CAD, Chol, AFib, CABG, L-CEA Meds: ASA, coumadin, digoxin, lovastatin Vitals: BP 105/75 P 90 PE: irreg rhythm, maroon blood on DRE
Acute LGIB Diagnoses in pts with hemodynamic compromise. Zuccaro. ASGE Clinical Update. 1999.
Urgent Colonoscopy for the Diagnosis and Treatment of Severe Diverticular Hemorrhage 121 pts with severe bleeding (>4 hrs after hospitalization) 1 st 73 pts: no colonoscopic tx Last 48 pts eligible for colonoscopic tx Colonoscopy w/in 6- 12 hrs
Urgent Colonoscopy for the Diagnosis and Treatment of Severe Diverticular Hemorrhage Jensen DM, et al. New Eng J Med 2000:342:78-82.