Gastrointestinal Bleeding Rajeev Jain, M.D.

GI Bleeding Background Acute Upper GI Bleed Acute Lower GI Bleed

Clinical Presentation Definitions Hematemesis: bloody vomitus (bright red or coffee-grounds) Melena: black, tarry, foul-smelling stool Hematochezia: bright red or maroon blood per rectum Occult: positive guaiac test Symptoms of anemia: angina, dyspnea, or lightheadedness

Clinical Presentation Reflection of bleeding: Site Etiology Rate

Initial Patient Assessment Hemodynamic Status

Resuscitation 2 large bore peripheral IV’s Colloid (normal saline or lactated Ringer’s) Transfuse packed RBCs In elderly, goal Hct 30% In young, goal Hct 20-25% In cirrhotics, goal Hct 25-28% Correct coagulopathy Reassess hemodynamics

History Prior history of bleeding Previous gastrointestinal illnesses Previous surgery Other medical conditions (ie, cirrhosis) Medications Aspirin, NSAIDs, & anti-platelet agents Anticoagulants ? SSRIs Abdominal pain, weight loss

Physical Exam & Labs Focused but thorough Laboratory studies Look for markers of liver disease Laboratory studies CBC INR Electrolytes Type and crossmatch RBCs

Acute Bleeding Changes Before and After 2 Liter Bleed 45% 45% 27%

Location of Bleeding Upper Lower Proximal to Ligament of Treitz Melena (100-200 cc of blood) Azotemia Nasogastric aspirate Lower Distal to Ligament of Treitz Hematochezia

Acute UGIB Demographics Annual incidence of hospitalization: 100/100,000 persons 80% self-limited Mortality stable at 10% Continued or recurrent bleeding - mortality 30-40%

Acute UGIB Prognostic Indicators Cause of bleeding Severity of initial bleed Age of the patient Comorbid conditions Onset of bleeding during hospitalization

Acute UGIB Prognostic Indicators Tedesco et al. ASGE Bleeding Survey. Gastro Endo. 1981.

Acute UGIB Differential Diagnosis

Acute UGIB Differential Diagnosis Peptic ulcer disease Gastric ulcer Duodenal ulcer Mallory-Weiss tear Portal hypertension Esophagogastric varices Gastropathy Esophagitis Dieulafoy’s lesion Vascular anomalies Hemobilia Hemorrhagic gastropathy Aortoenteric fistula Neoplasms Gastric cancer Kaposi’s sarcoma

Acute UGIB Final Diagnoses of the Cause in 2225 Patients Tedesco et al. ASGE Bleeding Survey. Gastro Endo. 1981.

Acute UGIB Causes in CURE Hemostasis Studies (n=948) Savides et al. Endoscopy 1996;28:244-8.

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 bias Boonpongmanee S. et al. Gastrointest Endosc 2004;59:788-94.

Peptic Ulcers Stigmata of Recent Hemorrhage (SRH)

Acute Peptic Ulcer Bleeding Prognosis by SRH Laine and Peterson. New Eng J Med 1994;331:717-27.

Endoscopic Therapy of PUD Thermal Bipolar probe Monopolar probe Argon plasma coagulator Heater probe Mechanical Hemoclips Band ligation Injection Epinephrine Alcohol Ethanolamine Polidocal

Endoscopic Therapy of PUD Laine and Peterson New Eng J Med 1994;331:717-27.

Peptic Ulcer Bleeding Adjuvant Medical Therapy Erythromycin 250 mg IV 30 minutes before endoscopy decreases blood in stomach Proton pump inhibitor therapy 80 mg IV bolus followed by 8 mg/hr continuous infusion for 72 hrs Reduced 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 site Leontiadis, G. et al. BMJ 2005;330:568

Mallory-Weiss Tear

Esophageal Varices

Variceal Band Ligation

Variceal Band Ligation

Variceal Band Ligation

MEDICAL THERAPY Acute Variceal Bleeding Octreotide Cyclic octapeptide analog of somatostatin Longer acting than somatostatin Equivalent to sclerotherapy and improves endoscopic results

Transjugular Intrahepatic Portosystemic Shunt (TIPS) Coronary Vein IVC Splenic Vein Portal Vein

Aortoduodenal Fistula Aorta Duodenum Fistula Graft

Acute UGIB Surgery Recurrent bleeding despite endoscopic therapy > 6-8 units pRBCs

Acute LGIB Differential Diagnosis

Acute LGIB Differential Diagnosis Diverticulosis Colitis IBD (UC>>CD) Ischemia Infection Vascular anomalies Neoplasia Anorectal Hemorrhoids Fissure Dieulafoy’s lesion Varices Small bowel Rectal Aortoenteric fistula Kaposi’s sarcoma UPPER GI BLEED

Acute LGIB Diagnoses in pts with hemodynamic compromise. Zuccaro. ASGE Clinical Update. 1999.

Etiology of Acute LGIB Strate LL. Gastroenterol Clin North Am. 2005 Dec;34(4):643-64.

Outcomes of Acute LGIB Strate LL. Gastroenterol Clin North Am. 2005 Dec;34(4):643-64.

Diverticulosis

Diverticular Bleeding

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 tx Last 48 pts eligible for colonoscopic tx Colonoscopy w/in 6-12 hrs

Urgent Colonoscopy for the Diagnosis and Treatment of Severe Diverticular Hemorrhage Jensen DM, et al. New Eng J Med 2000:342:78-82.

Ischemic Colitis Most common form of intestinal ischemia Transient and reversible Abdominal pain Watershed areas Splenic flexure Rectosigmoid junction

Hemorrhoids

Bleeding AVM

Radiation Proctitis

Acute LGIB Meckel’s Diverticulum Incidence 0.3 - 3.0 % Etiology Incomplete obliteration of the vitelline duct. Pathology 50% ileal, 50% gastric, pancreatic, colonic mucosa Complications Painless bleeding (children, currant jelly) Intussusception

Acute LGIB Evaluation Zuccaro. ASGE Clinical Update. 1999.

Acute LGIB Key Points Annual incidence of hospitalization: 20-30/100,000 persons Resuscitation Exclude an UGI source Most bleeding ceases Colonoscopy No role for barium studies