Presentation on theme: "Angel Qin, MD PGY 3 GI BLEEDING. Objectives Define GI bleed Common presentations Initial assessment Common causes of UGIB and LGIB Different diagnostic."— Presentation transcript:
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
Definitions Acute GI bleed < 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)
Ligament of Treitz UGIB: proximal to the ligament of Treitz LGIB: distal to the ligament of Treitz
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
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?
Is the patient stable? Appearance In distress? Pale? Actively bleeding in front of you? Vital signs Tachycardic? Hypotensive? Hypoxic?
ABCs Airway 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
Resuscitation IVF Normal saline boluses PRBCs 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)
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)
On physical exam… VITAL SIGNS 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?
How to proceed Labs (STAT) 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
Floor or MICU Consider ICU admission 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
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
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
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
From a national database of 7822 patients between 1999 and 2001
Wilkins T, Khan N, Nabh A, et al. Diagnosis and Management of Upper Gastrointestinal Bleeding. Am Fam Physician 2012; 85(5): 468- 76
Medical therapy for UGIB IV PPI Bolus with 80mg IV and then start drip at 8mg/hour PPIs decrease the risk of rebleeding 1, reduces the need for endoscopy 2, and decreases the stigmata of recent hemorrhage 2 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 rebleed 3 1.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 2.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): CD005415. 3.Gotzche PC, Hrobjartsson A. Somatostatin analogues for acute bleeding oesophageal varices. Cochrane Database Syst Rev 2010; (9): CD002907
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
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
VARIABLE* SCORE 0123 AgeYounger than 60 years 60 to 79 years80 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 — ComorbiditiesNo 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 gastrointestina l tract — Stigmata of recent hemorrhage None or dark spot only —Blood in upper gastrointestina l tract, adherent clot, visible or spurting vessel — RISK OF REBLEEDING AND MORTALITY BASED ON ROCKALL RISK SCORE RISK SCORE 01234567≥ 8 Rebleeding (%) 188.8.131.52184.108.40.206.943.841.8 Mortality (%)0 0.200.22.95.310.817.327.041.1 Rockall Risk Scoring System for Assessment After an Episode of Acute Upper Gastrointestinal Bleeding
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
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
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)
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
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
One last word…UGIB transfusion goals In a recent study published in the NEJM 1, 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
Questions? Thank you for your time and welcome to UH and Cleveland!