Presentation on theme: "Basics of GI Bleeding Ron Thomas, MD Fellow Division of Gastroenterology and Hepatology."— Presentation transcript:
Basics of GI Bleeding Ron Thomas, MD Fellow Division of Gastroenterology and Hepatology
Early July on ART 6W… Overnight admit – 69 yo male with recent melena and Hgb to 5 g/dl – Prior perforated gastric ulcer with Graham patch – Recent hemicolectomy for colonic signet ring adenoCA – EGD two days prior with large nonbleeding ulcer extending from lesser curvature to incisura – Was in rehab for a few hours before hematemesis
During Rounds “This patient was admitted for hematemesis” [Pause, quick glance at patient in room] “And he’s having active hematemesis now!!”
What do you do now? Assess hemodynamics Ensure large bore IV access Consider PPI infusion Could we be dealing with varices? Key labs: CBC, INR, BUN Think about NG lavage Don’t think about Fecal Occult
Magnitude Acute UGIB estimated to be 400,000 U.S. hospital admissions per year 1 80-90% of UGIB is nonvariceal 2 Peptic ulcer bleeding – Affects patients > 60 years old 3 – 5-10% mortality 2,4 – $2B in U.S. health care spending per year 5 1 Lewis JD et al. Am J Gastroenterol 2002; 97. 2 Barkun A et al. Am J Gastroenterol 2004;99. 3 Ohmann C et al. Scand J Gastroenterol 2005; 40. 4 Lim CH et al. Endoscopy 2006;38. 5 Viviane A et al. Value Health 2008;11.
Initial Steps Estimate hemodynamics Volume resuscitate Rectal exam Identify high risk patients Early endoscopy is key – Within 24 hours – High risk window 72 hours from presentation
Initial Steps Understand anti-coagulation history Assess level of care and airway Make a differential diagnosis Find old endoscopy reports
Risk Stratification Important way to predict who might do poorly Rockall Score – Age – Shock (HR, BP) – Coexisting illness – Add endoscopic component Diagnosis High risk stigmata
Gralnek IM et al. NEJM 2008; 359.
Endoscopic Stigmata of Bleeding Peptic Ulcer, Classified as High Risk or Low Risk. Gralnek IM et al. N Engl J Med 2008;359:928-937. Gralnek IM et al. NEJM 2008; 359.
Basic Endoscopic Therapy Injection AND – Thermal (e.g. heater probe, APC) OR – Mechanical (e.g. clip) Thermal or mechanical alone For varices, – Band ligation
Why PPI’s? Goal of PPI therapy is to raise the gastric PH High dose PPI infusion decreases basal and stimulated acid secretion by parietal cells Cochrane meta-analysis that included 6 RCT from 1992- 2007 found that IV PPI prior to endoscopy did NOT experience any statistically significant differences in outcomes of mortality, rebleeding, or progression to surgery. However, analysis did show that PPI therapy resulted in significantly reduced rates of high risk stigmata identified on endoscopy and need for endoscopic therapy. Courtesy of Joseph Thomas, MD
Post-Endoscopy High risk lesions – PPI infusion for 72 hours after endoscopic hemostasis – Technically Can advance diet to clears after 6 hours (if hemodynamic instability) Can go to oral PPI after infusion complete Discuss with GI consultant – No role for repeat endoscopy in 24 hours; relook if rebleed
Post-Endoscopy Varices – Octreotide infusion for up to 5 days in conjunction with band ligation 1 Result of meta-analysis 5 day period highest for re-bleed – Antibiotics for 1 week For non-variceal bleeding – H pylori testing (preferably from mucosal biopsy) 1 Banales R et al. Hepatology 2002; 305.
What if Endoscopy Fails? IR – Tagged RBC scan Bleeding > 0.1 ml/min – Angiography Need localization Renal contrast load Bleeding 0.5-1.5 ml/min (CT angiography) Can be therapeutic – Embolization
What if Endoscopy Fails? Surgery – Uncontrolled bleeding – Recurrent diverticular bleeding – Get on board early
GastroHep Slide Atlas, www.gastrohep.com
Summary While “all bleeding eventually stops…” Assess Resuscitate Risk-stratify Form a differential diagnosis Be particularly vigilant in the first 24 hours