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Acute Gastrointestinal Bleeding Rajeev Jain, M.D..

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Presentation on theme: "Acute Gastrointestinal Bleeding Rajeev Jain, M.D.."— Presentation transcript:

1 Acute Gastrointestinal Bleeding Rajeev Jain, M.D.

2 GI Bleeding Clinical Presentation Acute Upper GI Bleed Acute Lower GI Bleed

3 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

4 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

5 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

6 Resuscitation 2 large bore peripheral IV’s Normal saline or LR Packed RBCs Correct coagulopathy

7 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

8 Acute UGIB Demographics 10,000 - 20,000 deaths annually Mortality stable at 10% 80% self-limited Continued or recurrent bleeding - mortality 30-40%

9 Cause of bleeding Severity of initial bleed Age of the patient Comorbid conditions Onset of bleeding during hospitalization Acute UGIB Prognostic Indicators

10 Tedesco et al. ASGE Bleeding Survey. Gastro Endo. 1981.

11 Acute UGIB Differential Diagnosis

12 Peptic ulcer disease –Gastric ulcer –Duodenal ulcer Mallory-Weiss tear Portal hypertension –Esophagogastric varices –Gastropathy Esophagitis Dieulafoy’s lesion Vascular anomalies Hemobilia Hemorrhagic gastropathy Aortoenteric fistula Neoplasms –Gastric cancer –Kaposi’s sarcoma Acute UGIB Differential Diagnosis

13 Acute UGIB Final Diagnoses of the Cause in 2225 Patients Tedesco et al. ASGE Bleeding Survey. Gastro Endo. 1981.

14 Acute UGIB Causes in CURE Hemostasis Studies (n=948) Savides et al. Endoscopy 1996;28:244-8.

15 Acute UGIB CORI Database University, VA, & private practices 20 months (12/99-7/01) 7822 EGDs for UGIB BoonpongmaneeS. et al. Gastrointest Endosc 2004;59:788-94.

16 Endoscopic Appearance of Ulcers

17 Prognostic Features at Endoscopy in Acute Ulcer Bleeding Laine and Peterson New Eng J Med 1994;331:717-27.

18 Thermal –Bipolar probe –Monopolar probe –Argon plasma coagulator –Heater probe Mechanical –Hemoclips –Band ligation Injection –Epinephrine –Alcohol –Ethanolamine –Polidocal Endoscopic Therapy of PUD

19 Laine and Peterson New Eng J Med 1994;331:717-27.

20 Adjuvant Medical Therapy of PUD Acid suppression (intragastric pH > 4) –Histamine 2 Receptor Antagonists (H2RAs) Ranitidine (Zantac) Famotidine (Pepcid) –Proton Pump Inhibitors (PPIs) Pantoprazole (Protonix) Lansoprazole (Prevacid) Esomeprazole (Nexium)

21 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.

22 472 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

23 Lau et al. New Eng J Med 2000;343:310-316.

24 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.

25 Mallory-Weiss Tear

26 Esophageal Varices

27 Variceal Band Ligation


29 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

30 TIPS IVC Portal Vein Splenic Vein Coronary Vein

31 Aortoduodenal Fistula Aorta Duodenum Graft Fistula

32 Acute Bleeding Changes Before and After 2 Liter Bleed 27% 45%

33 Acute UGIB Surgery Recurrent bleeding despite endoscopic therapy > 6-8 units pRBCs

34 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

35 Acute LGIB Differential Diagnosis

36 Diverticulosis Colitis –IBD (UC>>CD) –Ischemia –Infection Vascular anomalies Neoplasia Anorectal –Hemorrhoids –Fissure Dieulafoy’s lesion Varices –Small bowel –Rectal Aortoenteric fistula Kaposi’s sarcoma UPPER GI BLEED Acute LGIB Differential Diagnosis

37 Acute LGIB Diagnoses in pts with hemodynamic compromise. Zuccaro. ASGE Clinical Update. 1999.

38 Diverticulosis

39 Diverticular Bleeding

40 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

41 Urgent Colonoscopy for the Diagnosis and Treatment of Severe Diverticular Hemorrhage Jensen DM, et al. New Eng J Med 2000:342:78-82.

42 Hemorrhoids

43 Bleeding AVM

44 Radiation Proctitis

45 Incidence 0.3 - 3.0 % EtiologyIncomplete obliteration of the vitelline duct. Pathology50% ileal, 50% gastric, pancreatic, colonic mucosa Complications –Painless bleeding (children, currant jelly) –Intussusception Acute LGIB Meckel’s Diverticulum

46 Acute LGIB Evaluation Zuccaro. ASGE Clinical Update. 1999.

47 Resuscitation UGI source Most bleeding ceases Colonscopy - early No role for barium studies 5% Mortality Acute LGIB Key Points

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