2Objectives Define GI bleed Common presentations Initial assessment Common causes of UGIB and LGIBDifferent diagnostic tests and therapeutic optionsUpdates in GI bleedingPractical tidbits along the way
3Definitions Acute GI bleed Overt vs occult < 3 days duration Hemodynamic instabilityRequires blood transfusionOvert vs occultOvert: visible blood (melena, hematochezia, bright red blood per rectum, coffee ground emesis)Occult: detected only on lab tests (ie stool cards)
4UGIB: proximal to the ligament of Treitz LGIB: distal to the ligament of TreitzLigament of Treitz
5Common 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
7Initial assessment Is the patient stable? ABCs (airway, breathing, circulation)Home vs Floor vs MICUWhat are the likely sources of the bleed?What are patient’s underlying medical issues?Any history of bleed in the past?Any EGDs/colonoscopies?
8Is the patient stable? Appearance Vital signs In distress? Pale? Actively bleeding in front of you?Vital signsTachycardic?Hypotensive?Hypoxic?
9ABCs Airway Breathing Circulation Can the patient protect his/her airwayBreathingIs the patient tachypneic? Hypoxic?Supplemental O2CirculationEstablish 2 large bore IVsType and screen stat
10Resuscitation 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/PlateletsMay be needed depending on etiology of bleed (most commonly in patients with significant liver disease)
11Now to the history… Has this ever happened before? Medical problems Peptic ulcer disease, esophageal varices, diverticulosisMedications: chronic NSAID use, aspirin, plavix, warfarin (other anticoagulants)TraumaQuality, quantity, frequency, onsetUGIB: bright red blood vs coffee ground emesisLGIB: bright red blood vs melena (dark, TARRY stools)Associated symptomsRetching/vomiting (Mallory Weiss tears)Abdominal pain (association with food? Ulcer vs mesenteric ischemia)Weight loss, malaise (cancer)
12On physical exam… VITAL SIGNS General: AAOX3? Distress? Including orthostatic vital signsGeneral: 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?
14How to proceed Labs (STAT) Prior procedures/surgeries CBC, RFP, coags, type and screenWhat is baseline hemoglobin?BUN:Cr ratio frequently >20:1 in UGIBAlso consider LFTs and iron studiesPrior procedures/surgeriesLast endoscopy or colonoscopy: findings, recommended treatment and followup, pathology resultsHome vs Floor vs MICUHome: misunderstanding of tarry stools, hemorrhoidal bleeding
15Floor or MICU Consider ICU admission if: Be concerned if: Despite aggressive fluid resuscitation, patient continues to be hypotensive, tachycardicContinued active bleeding (NG lavage not clear after 2L, BRBPR)History of cirrhosis and variceal bleedingAny airway compromiseBe concerned if:Elderly with multiple comorbiditiesUse of anticoagulantsPrior abdominal surgeries
16Practical tidbit: how to perform a NG lavage Supplies:NG tube, lubricant, normal saline, 50cc syringe, chucks, basin, gloves, stethoscope1. Sit patient upright, cover with chucks, basin ready2. Lubricate the NG tube well3. Insert while having patient sip on water4. 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 suctionIs there data regarding how much fluid can be pumped in at one time for lavage?
17What does the aspirate look like? Bright red clots: active upper GI bleedCoffee grounds: slow UGIB, may have stoppedClear: indeterminateBilious: bleeding has stoppedAn indication for MICU admission is if after 2L, the NG aspirate is still bright red blood
20From a national database of 7822 patients between 1999 and 2001
21Wilkins 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):
22Medical therapy for UGIB IV PPIBolus with 80mg IV and then start drip at 8mg/hourPPIs decrease the risk of rebleeding1, reduces the need for endoscopy2, and decreases the stigmata of recent hemorrhage2H2 blockers are not recommendedOctreotide (for suspected variceal bleeding)Long acting analogue of somatostatin; reduces splachnic blood flow, inhibit acid secretion50-100mcg followed by drip at 25-50mcg/hrUse is actually controversial; large meta -analysis did not find any significant reductions in mortality or risk of rebleed3If ascites, then needs SBP prophylaxis x 7 daysSung 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):455-64Sreedharan 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): CDGotzche PC, Hrobjartsson A. Somatostatin analogues for acute bleeding oesophageal varices. Cochrane Database Syst Rev 2010; (9): CD002907
23If patient has ascites, then SBP prophylaxis w/antibiotics for 7 days is indicated Inpatient: ceftriaxone 1g IVOutpatient: norfloxacin 400mg PO BID or Bactrim DS BID
24Endoscopic intervention PUDepinephrine injectionbipolar cauteryhemoclipVaricesendoscopic band ligation>90% success30% rebleeding rateTIPS for hemorrhage refractory to bandingalso used for gastric varicesTIPS increases the risk for hepatic encephalopathy
25VARIABLE*SCORE123AgeYounger than 60 years60 to 79 years80 years or older—Shock symptoms, systolic blood pressure, and heart rateShock absent, blood pressure 100 mm Hg or greater, heart rate less than 100 bpmTachycardia, blood pressure 100 mm Hg or greater, heart rate100 bpm or greaterHypotension, blood pressure less than 100 mm HgComorbiditiesNo major comorbidityHeart failure, coronary artery disease, any major comorbidityRenal failure, liver failure, disseminated malignancyEndoscopic diagnosisMallory-Weiss tear or no lesion identified, and no stigmata of recent hemorrhageAll other diagnosesMalignancy of upper gastrointestinal tractStigmata of recent hemorrhageNone or dark spot onlyBlood in upper gastrointestinal tract, adherent clot, visible or spurting vesselRockall Risk Scoring System for Assessment After an Episode of Acute Upper Gastrointestinal BleedingRISK OF REBLEEDING AND MORTALITY BASED ON ROCKALL RISK SCORERISKSCORE1234567≥ 8Rebleeding (%)220.127.116.1118.104.22.168.943.841.8Mortality (%)0 0.20.22.910.817.327.041.1
29Therapy for LGIB No medical therapies Bleeding 2/2 to diverticulosis stops spontaneously about 75% of the timeBleeding 2/2 to angiodysplasia stops spontaneously about 85% of the timeIf 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 lossCan be useful when determining surgical interventionFor those with contraindications to angiography, can consider tagged RBC scan , which requires bleeding at >0.1cc/minHighly false positive rate; localization unreliable
30Colonoscopy Rarely an emergent procedure Standard prep is 4L of GoLytely (miralax + electrolytes) starting the evening PRIOR to colonoscopyPatient must be passing CLEARSA “rapid prep” can be done with GoLytely proceed to colonoscopy in 6-12 hoursDiscovers the source of bleeding in >70% casesTherapeutic interventions include epinephrine injection, cautery, and clipping
31More advanced modalities Limit of EGD is proximal duodenum and limit of colonscopy is cecum…leaving a significant portion of the small intestine left unvisualizedThough obscure GI bleeding accounts for only about 5% of GIB, in 75% of those cases, the source is the small intestineVideo capsule endoscopyEnteroscopy (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 bowelIntraoperative enterosocopy: insertion of endoscope through an enterotomy site during surgeryDouble balloon enteroscopy: anterograde or retrograde; using two balloons that alternately inflate and deflate
33Practical tidbit: what to order in the EMR Basic admission ordersRemember to OMIT pharmacologic DVT prophylaxis ; use TEDs/SCDsNPO (now or after midnight) depending on urgency of GI consult; for colonoscopies, clear liquid diet the day beforeCheck CBC q6Always remember to check a post-transfusion CBCIVF until blood arrivesNeed new type and screen Q72 hoursDaily RFPAssess electrolytes , BUN/CrIV PPI bolus followed by dripPantoprazole is the formulary IV PPI at both UH and VAOctreotide drip for variceal bleedingWhen does hemoglobin equilibrate
34Practical tidbit: how to call a GI consult Don’t be intimidatedPatients name, MRN, and locationQuestion you are askingBe specificPatient’s pertinent past medical historyWhat 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
35One 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 groupRestrictive: transfuse only when Hgb <7g/dL with target Hgb 7-9g/dLLiberal: transfuse when Hgb <9g/dL with target Hgb 9-11g/dLThe jist: patients in the restrictive group had higher survival, decreased rates of rebleed, and decreased adverse eventsDid not apply to patients with Child-Pugh class 3 cirrhosis1. Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. NEJM 2013; 368:11-21
36Questions?Thank you for your time and welcome to UH and Cleveland!