1. Basics of GI Bleeding Ron Thomas, MD Fellow Division of Gastroenterology and Hepatology

2. 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

3. During Rounds “This patient was admitted for hematemesis” [Pause, quick glance at patient in room] “And he’s having active hematemesis now!!”

4. 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

5. His EGD

10. Definitions Inpatient – Overt Outpatient – Occult – Obscure UGIB LGIB

11. 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.

12. 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

13. Initial Steps Understand anti-coagulation history Assess level of care and airway Make a differential diagnosis Find old endoscopy reports

14. Melena Courtesy of Joseph Thomas, MD

15. Hematochezia Courtesy of Joseph Thomas, MD

16. Maroon Stools Courtesy of Joseph Thomas, MD

17. UGIB: Brief DDx Peptic ulcer disease – H. pylori – NSAIDs – Malignancy Mallory-Weiss tear Erosive esophagitis Erosive gastritis Esophageal ulcers

18. UGIB: Brief DDx Vascular malformations – Angiodysplasia in CRI – Dieulafoy’s lesion (submucosal arteriole) – GAVE – PHG Miscellaneous – AE fistula – Pancreatic pseudoaneurysm – Hemobilia

19. Varices Some adjustments to protocol – Octreotide drip Decrease splanchnic blood flow Reduce portal pressure – Antibiotics – Lower transfusion requirement – Correcting coagulopathy if appropriate – Intubate

20. LGIB: Brief DDx Diverticulosis Angiodysplasia Neoplastic disease Colitis – Ischemia, infection, XRT, IBD Internal hemorrhoids Solitary rectal ulcer UGIB

21. 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

22. Gralnek IM et al. NEJM 2008; 359.

23. 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.

24. Basic Endoscopic Therapy Injection AND – Thermal (e.g. heater probe, APC) OR – Mechanical (e.g. clip) Thermal or mechanical alone For varices, – Band ligation

25. 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

26. 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

27. 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.

28. 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

29. What if Endoscopy Fails? Surgery – Uncontrolled bleeding – Recurrent diverticular bleeding – Get on board early

30. GastroHep Slide Atlas, www.gastrohep.com

37. Summary While “all bleeding eventually stops…” Assess Resuscitate Risk-stratify Form a differential diagnosis Be particularly vigilant in the first 24 hours