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Gi bleeding Angel Qin, MD PGY 3.

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Presentation on theme: "Gi bleeding Angel Qin, MD PGY 3."— Presentation transcript:

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!

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