Presentation is loading. Please wait.

Presentation is loading. Please wait.

© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. * For Best Viewing: Open in Slide Show Mode Click on icon or From the View.

Similar presentations


Presentation on theme: "© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. * For Best Viewing: Open in Slide Show Mode Click on icon or From the View."— Presentation transcript:

1 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. * For Best Viewing: Open in Slide Show Mode Click on icon or From the View menu, select the Slide Show option * To help you as you prepare a talk, we have included the relevant text from ITC in the notes pages of each slide

2 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. Terms of Use  The In the Clinic ® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for- profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets constitutes copyright infringement.

3 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. in the clinic Acute Gastrointestinal Bleeding

4 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. Who is at risk for acute GI bleeding? Risks factors vary by site and cause  Upper GI bleeding  Peptic ulcer disease (risk factors: NSAIDs, H. pylori)  Increased gastric acid production  Smoking  Severe physiologic stress  Host factors (genetic polymorphisms affecting cyclo- oxygenase and prostaglandin production)  Varices, esophagitis, vascular abnormalities, Mallory-Weiss tear, benign or malignant neoplasms  ? Spicy foods (no convincing data they increase risk)

5 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. Risks factors vary by site and cause  Lower GI bleeding  Diverticulosis (most common cause of hematochezia)  Inflammatory bowel disease  Infectious colitis  Neoplasia  Angioectasias  Benign anorectal disease  Upper GI sources Who is at risk for acute GI bleeding?

6 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. “Obscure” bleeding: 10-20% of GI bleeding  Unknown cause despite evaluation, tests, imaging  Recurrent or persistent bleeding (≈50%)  Obscure-overt (visible blood w/ melena / hematochezia)  Obscure-occult (recurrent iron-deficiency / positive FOBT)  Many from small intestine: “Mid-GI bleeding” (mostly from angioectasia)

7 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. Can acute GI bleeding be prevented?  Peptic ulcer disease  Reduce NSAID use  Administer antacid Rx with H2-inhibitors or PPIs  At-risk hospitalized pts  Coagulopathy or thrombocytopenia  Mechanical ventilation  Traumatic brain or spinal cord injury, burns  Prophylactic H2-inhibitors or PPIs

8 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. Can acute GI bleeding be prevented?  Chronic liver disease and portal hypertension  Nonselective β-blockers + endoscopic interventions  Diverticulitis or angioectasias  High-fiber diets may help  Surgical intervention (diverticulosis) after ≥1major episode

9 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. CLINICAL BOTTOM LINE: Prevention…  Upper GI bleeding  Minimize use and appropriately prescribe NSAIDs, antiplatelet agents, anticoagulants  Primary and secondary prophylactic acid suppression  Variceal bleeding  Nonselective beta-blockers and endoscopic therapy  Lower GI bleeding  Reduce exposure to NSAIDS, antiplatelet agents, anticoagulants  Few measures help in prevention

10 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. What are symptoms of acute GI bleeding?  Hematemesis  Upper GI bleeding  Nausea, dyspepsia  Lower GI bleeding  Altered bowel habits, lower abdominal pain, rectal discomfort  Melena  Bloody diarrhea  Presyncope or syncope  Fatigue; dizziness; pallor (anemia)

11 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. What are the signs of acute GI bleeding?  Hypotension (systolic BP < 90 mmHg)  Tachycardia (>120 bpm)  Orthostatic changes in BP (≥10mmHg), HR (≥30/min)  Blood or coffee-grounds-like material in nasogastric aspirate: upper GI source  Pallor: poor indicator without corroborative evidence  Perioral telangiectasias: hereditary hemorrhagic telangiectasia syndrome  Skin abnormalities: stigmata of cirrhosis, pigmented lip lesions, acanthosis nigricans, vascular anomalies

12 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. What are the common causes of upper and lower GI bleeding?  Inflammatory  PUD; esophagitis or esophageal ulceration  Diaphragmatic hernia; diverticular disease; IBD  Benign and malignant neoplasms  Vascular anomalies  Gastroesophageal varices, angioectasias  Dieulafoy lesion  gastric antral vascular ectasia  Radiation proctopathy  Drug-induced (aspirin; NSAIDs)  Miscellaneous  Post-polypectomy; Mallory–Weiss tear; Meckel diverticulum

13 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. Can risk for adverse outcomes be predicted in patients with acute GI bleeding?  Factors that portend a poorer prognosis  Chronic alcoholism  Active cancer  Risk-stratification tools facilitate triage  Rockall scoring system  Glasgow–Blatchford Scale  Incorporate clinical, lab, and/or endoscopic parameters  Predict need for hospitalization or further intervention

14 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. Which patients may be evaluated as outpatients, and which require the emergency department or hospitalization?  Outpatient management if low-risk for rebleeding:  Rockall score 0–2  Glasgow–Blatchford score 0  Inpatient management & consider admission to ICU:  Brisk, active bleeding  Other parameters for high risk for rebleeding, mortality  Chronic alcoholism  Higher Rockall or Glasgow–Blatchford score

15 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. What should the initial diagnostic evaluation for possible acute GI bleeding include?  History  Associated signs and symptoms  Use of NSAIDs, antiplatelet agents, anticoagulants, SSRIs, β-blockers  Prior GI bleeding episodes and comorbid conditions  Physical exam  Routine exam + assess vital signs on postural changes  Examine stool  Check for resting hypotension or tachycardia  Check for increase in pulse (≥30/min) or severe lightheadedness when rising from supine position

16 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1.  Lab tests  CBC, prothrombin and partial thromboplastin times  Platelet count, blood type and crossmatch, and routine chemistry panel  Ratio of blood urea nitrogen to creatinine  Increased ratio suggests upper GI source  Nasogastric or orogastric aspiration  May confirm upper GI bleeding  May provide prognostic information on severity  False negative in ~15%  No proof of altered outcomes

17 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. When should a gastroenterologist be consulted in the evaluation of acute GI bleeding?  Consult early  To consider prompt endoscopy and facilitate triage  Initial diagnostic tests of choice: EGD &/or colonoscopy  EGD  For melena and hematemesis  For subset with hematochezia from upper GI source  Early endoscopy (≤24h admission)  For upper GI bleeding  Ensure volume resuscitation + hemodynamic stabilization  Urgent endoscopy (<12h admission)  For suspected variceal bleeding  Provides valuable information for appropriate triage

18 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. What is the role of prokinetic medications before upper endoscopy in patients with acute GI bleeding?  Facilitate clearance of blood and clots from stomach  Erythromycin, metoclopramide  Administered IV 20-120 mins before upper endoscopy  Improve endoscopic visualization  Does not appear to alter important clinical outcomes  Reserve for patients with red blood hematemesis or blood in nasogastric aspirate

19 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. What adjunctive tests help evaluate or treat patients with acute GI bleeding without an identified source on EGD or colonoscopy?  Small-bowel barium radiography (historically)  Wireless video capsule endoscopy (VCE)  Higher diagnostic yield (35%–76%)  Can’t provide hemostatic interventions  Many institutions can’t perform urgent VCE inpatient  Angiography  Allows intervention if lesion localized  Requires active bleeding at time of study  CTA or CT/MR enterography  Enables visualization + therapeutics deep in small intestine  Low-risk; no need for high-risk intraoperative enteroscopy

20 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. CLINICAL BOTTOM LINE: Presentation and Diagnosis…  Presents with myriad signs and symptoms  Asymptomatic to overt hematemesis or hematochezia  Due to causes virtually anywhere along the GI tract  Initial evaluation helps narrow differential diagnosis  Including history and physical examination  Routine laboratory tests

21 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1.  Aggressive volume resuscitation  Large-bore peripheral IV catheters to give fluids and blood products rapidly  Emesis  Intubate if unable to protect airway from aspiration  Isotonic IV fluids to replenish intravascular volume  Blood transfusions may be harmful in hypovolemic anemia What interventions should be started immediately for acute GI bleeding?  Treat coagulopathy in patients receiving anticoagulants  Don’t delay therapeutic endoscopy unless INR >2.5  Except in cirrhosis (INR can’t predict bleeding risk)  Target platelets > 50,000/μL if no platelet dysfunction  > 100,000/μL if suspected dysfunction

22 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. How should acute upper GI bleeding due to peptic ulcer disease be managed?  Endoscopy – allows biopsy / assess cause  ≈100% specific (rare false-+ result); >90% sensitive  Consider pre-endoscopic PPIs (but don’t delay endoscopy or replace resuscitation)  Forrest classification: describes ulcers, predicts risk  Clean ulcer base or flat pigmented spot in ulcer base: low rebleeding risk  pharmacologic Rx only  Adherent clots, nonbleeding visible vessels, or active bleeding: high-risk continued or recurrent bleeding  endoscopic interventions + pharmacologic Rx  High-risk lesions having endoscopic therapy: 3 days in- hospital IV PPI required, then once-daily oral PPI; H2 blockers not as effective  Low-risk lesions, hemodynamically stable, no serious comorbidities: consider early D/C on daily PPI

23 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. How should acute esophageal variceal bleeding be treated?  Result of significant portal hypertension  Bleeding occurs under high pressure and often brisk  Monitor closely for adverse effects of volume replacement  Target hemoglobin: 7–8 g/dL  Antibiotic prophylaxis reduces infectious complications  Medical Rx (infusion octreotide, somatostatin analogue)  Endoscopic therapy (for known or suspected varices)  Refractory to medical and endoscopic therapy?  Balloon tamponade: temporizing measure  TIPS placement: within 72 hours (recommended)  Surgery: portosystemic shunting, esophageal transection, liver transplant

24 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. How should acute lower GI bleeding from colonic diverticulosis be treated?  Initially: Fluid resuscitation, blood transfusion, testing  Colonoscopy: to localize (difficult if brisk hemorrhage)  Within 12-24 h of presentation with rapid colonic prep  Allows exclusion of other causes (cancer)  Can be therapeutic if visible vessel or adherent clot noted  Nuclear imaging  Angiography  Surgical resection: if bleeding doesn’t resolve (≈20%)  Segmental colectomy: if bleeding can be localized  Subtotal colectomy: if bleeding can’t be localized source

25 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. What is the role of angiography?  Local administration of vasopressin  Controls bleeding in up to 80% of patients  Rebleeding often occurs when infusion stopped  Temporizing measure, allows for more controlled procedure  Use with caution if CAD or PVD present  Embolization of the source  Injection of sealant materials or mechanical devices  Alternative if vasopressin has failed or too risky  More definitive means to control bleeding  Contraindication: poor collateral blood supply  More effective in absence of coagulopathy

26 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. How should therapy for acute GI bleeding be monitored?  Tachycardia  Early warning recurrent bleeding, followed by hypotension  Hemoglobin levels  Check at least every several hours initially  Possible ongoing blood loss if levels don’t increase by ≈1 g/unit of transfused packed RBCs  Additional blood transfusions and diagnostic testing  Consider if evidence of ongoing blood loss  Platelet count and coagulation  Measure serially to assess need for repeated transfusions  If multiple transfusions of RBCs: monitor for hypocalcemia

27 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. When should a surgeon be consulted for the management of acute GI bleeding?  Early in evaluation and management  For severe or hemodynamically significant bleeding  Consult shouldn’t delay initial interventions  Surgery indicated when…  Life-threatening bleeding continues  Hemodynamic compromise despite resuscitation  Bleeding can’t be stopped by endoscopy / angiography  Localization of site of bleeding critical for surgical planning  Surgery type also depends on presence of comorbidities

28 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. What instructions do patients require following acute GI bleeding?  Signs and symptoms of recurrent bleeding  Benefit and duration of targeted therapies  Bleeding from…  H. pylori: complete therapy; test for eradication  d/c PPI if eradicated unless NSAID or antiplatelet Rx needed  NSAID: discontinue NSAID if feasible  Low-dose aspirin Rx: resume after bleeding stops for secondary prevention of established CV disease  Aspirin or clopidogrel for primary prevention of CV events: weigh risks & benefits on individual basis  Dual antiplatelet Rx: PPI prophylaxis as long as antiplatelet Rx indicated  Bleeding not associated with H. pylori, NSAID, or antiplatelet agents: continue daily PPI indefinitely – no good data

29 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. CLINICAL BOTTOM LINE: Treatment…  Depends on cause and severity of bleeding  Initial evaluation and management in all cases should include:  History and physical examination  Stabilization interventions  Placement of IV access & IV fluid resuscitation  Emergent endoscopy (within 6 h) rarely indicated  Urgent endoscopy if variceal bleeding suspected  PPI for suspected PUD (but don’t delay endoscopy)  Transfusion: target hemoglobin of 7-8 g/dL  Base outpatient follow-up on:  Establish etiology of bleeding  Estimated risk of re-bleeding


Download ppt "© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (3): ITC2-1. * For Best Viewing: Open in Slide Show Mode Click on icon or From the View."

Similar presentations


Ads by Google