2 GI BleedingBackgroundAcute Upper GI BleedAcute Lower GI Bleed
3 Clinical Presentation Definitions Hematemesis: bloody vomitus (bright red or coffee-grounds)Melena: black, tarry, foul-smelling stoolHematochezia: bright red or maroon blood per rectumOccult: positive guaiac testSymptoms of anemia: angina, dyspnea, or lightheadedness
4 Clinical Presentation Reflection of bleeding:SiteEtiologyRate
7 History Prior history of bleeding Previous gastrointestinal illnesses Previous surgeryOther medical conditions (ie, cirrhosis)MedicationsAspirin, NSAIDs, & anti-platelet agentsAnticoagulants? SSRIsAbdominal pain, weight loss
8 Physical Exam & Labs Focused but thorough Laboratory studies Look for markers of liver diseaseLaboratory studiesCBCINRElectrolytesType and crossmatch RBCs
9 Acute Bleeding Changes Before and After 2 Liter Bleed 45%45%27%
10 Location of Bleeding Upper Lower Proximal to Ligament of Treitz Melena ( cc of blood)AzotemiaNasogastric aspirateLowerDistal to Ligament of TreitzHematochezia
11 Acute UGIB Demographics Annual incidence of hospitalization: 100/100,000 persons80% self-limitedMortality stable at 10%Continued or recurrent bleeding - mortality 30-40%
12 Acute UGIB Prognostic Indicators Cause of bleedingSeverity of initial bleedAge of the patientComorbid conditionsOnset of bleeding during hospitalization
16 Acute UGIB Final Diagnoses of the Cause in 2225 Patients Tedesco et al. ASGE Bleeding Survey. Gastro Endo
17 Acute UGIB Causes in CURE Hemostasis Studies (n=948) Savides et al. Endoscopy 1996;28:244-8.
18 Acute UGIB CORI Database: 7822 EGDs b/n 1999-2001 73 practices in 24 states: private, academic & VA; wide-range of practices; more reflective of real care; less selection biasBoonpongmanee S. et al. Gastrointest Endosc 2004;59:
19 Peptic Ulcers Stigmata of Recent Hemorrhage (SRH)
20 Acute Peptic Ulcer Bleeding Prognosis by SRH Laine and Peterson. New Eng J Med 1994;331:
22 Endoscopic Therapy of PUD Laine and Peterson New Eng J Med 1994;331:
23 Peptic Ulcer Bleeding Adjuvant Medical Therapy Erythromycin250 mg IV 30 minutes before endoscopy decreases blood in stomachProton pump inhibitor therapy80 mg IV bolus followed by 8 mg/hr continuous infusion for 72 hrsReduced risk:Rebleeding (NNT 12)Surgery (NNT 20)3 European studies have shown that IV Emycin prior to EGD increases view and ability to localize bleeding siteLeontiadis, G. et al. BMJ 2005;330:568
40 Urgent Colonoscopy for the Diagnosis and Treatment of Severe Diverticular Hemorrhage 121 pts with severe bleeding (>4 hrs after hospitalization)1st 73 pts: no colonoscopic txLast 48 pts eligible for colonoscopic txColonoscopy w/in 6-12 hrs
41 Urgent Colonoscopy for the Diagnosis and Treatment of Severe Diverticular Hemorrhage Jensen DM, et al. New Eng J Med 2000:342:78-82.
42 Ischemic Colitis Most common form of intestinal ischemia Transient and reversibleAbdominal painWatershed areasSplenic flexureRectosigmoid junction
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