GASTROINTESTINAL BLEEDING Ajay Jain, MD, FACG, FRCPC Gastroenterologist Meridian Medical Group INSGNA March 5, 2011

Objectives Introduction Lower Gastrointestinal Bleeding (LGIB) etiology presentation diagnostic testing management Upper Gastrointestinal Bleeding (UGIB) evaluation endoscopy

Introduction gastrointestinal bleeding (GIB) common clinical problem source of GIB traditionally divided into either upper or lower upper gastrointestinal bleeding (UGIB): bleeding from any source proximal to ligament of Treitz lower gastrointestinal bleeding (LGIB): bleeding from any source distal to ligament of Treitz

Lower Gastrointestinal Bleeding one-fifth to one-third as common as UGIB less severe course compared with UGIB annual incidence rate: 25 cases per 100,000 adult population at risk (UGIB rate : 150 cases per 100,000) incidence increases with age greater than 200-fold increase from 20s to 80s mean age of patients with LGIB: 63 - 77 mortality rate 2 - 4%

LGIB - Etiology Age, Mortality Rates, and Causes of Acute Lower Gastrointestinal Bleeding in the Elderly Study Mean Age (yrs) Mortality (%) Divertic-ulosis Angio- dysplasia Cancer/ Polyp Colitis/ Ulcer* Ano- rectal Other Boley (1979) n = 183 >65 2 40 11 14 12 NA Jensen (1988) n = 80 65 20 37 5 Leitman (1989) n = 65 63 27 24 15 10 Richter (1995) n = 107 70 48 6 3 Jensen (2003)Ψ n = 291 77 30 21 23 NA Not available * Includes Inflammatory bowel disease, infectious colitis, radiation colitis, vasculitis and inflammation of unknown origin Ψ Expressed as % of colonic causes of bleeding

LGIB - Presentation Chief complaint may vary passage of occasional bright red blood per rectum associated with formed, brown stool patient usually hemodynamically stable passage of relatively higher volumes of bright red blood (“hematochezia”) patient may be hemodynamically unstable passage of black, tarry stools (“melena”) first evaluate for UGIB if evaluation shows no upper GI source then consider bleeding from right colon or small bowel

LGIB Monitoring patients may be critically ill at presentation not only at risk for direct consequences of GI tract pathology, but also for cardiac, pulmonary, renal and neurologic complications of acute blood loss identify symptoms of hemodynamic compromise: postural symptoms/fatigue/palpitations/chest pain/dyspnea monitor vital signs (including postural vitals) increase of > 10 beats/min or drop in BPs > 10mmHg indicative of at least a 15% acute blood loss volume Ebert et al, Arch Int Med 1941; Am Coll Surg 1993

LGIB Initial resuscitation restore euvolemia, prevent complications of acute blood loss MI, CHF, CVA, etc. transfuse packed red blood cells as necessary correct coagulopathy fresh frozen plasma & vitamin K obtain relevant history while resuscitation is underway duration of bleeding/presence or absence of abdominal pain/chest pain /fever history of ulcer disease/IBD/radiation therapy to abdomen or pelvis cardiopulmonary, renal, hepatic disease current medications (ASA, NSAIDS, anticoagulants)

LGIB Initial resuscitation (cont’d) Physical examination cardiac/pulmonary/abdominal and rectal examinations Laboratory studies CBC/electrolytes/BUN/CR/PT/PTT type and cross EKG

LGIB Not All Hematochezia is Due to a Colonic Source first think of a colonic source of bleeding but remember that UGIB source may present with hematochezia, if the bleeding is brisk in one series 11% of patients with hematochezia and hemodynamic compromise had an UGI source Jensen et al, Gastroenterology 1988

LGIB Not All Hematochezia is Due to a Colonic Source (cont’d) nasogastric (NG) tube is reasonable to use to evaluate for possible UGIB note presence or absence of both blood and bile if significant blood seen on NG tube, consider performing upper endoscopy presence of bile confirms that duodenal contents sampled; if bile absent an upper GI endoscopy should be considered NG tube has been shown to be useful test in this regard with accuracy of 94-98% no role for upper GI barium x-ray Luk et al, JAMA 1979; Cuellar et al, Arch Intern Med, 1990

LGIB Sources of Colonic Bleeding Diverticulosis arterial bleeding, painless, ceases spontaneously in most cases

LGIB Sources of Colonic Bleeding Diverticular Bleeding 87 year-old woman who presented with lower gastrointestinal bleeding. The bleeding was finally localized to a single diverticulum, shown here

LGIB Sources of Colonic Bleeding Angiodysplasia vascular malformations frequently involves proximal colon Arrow indicates point of bleeding

LGIB Sources of Colonic Bleeding Colonic Neoplasia (large adenoma or adenocarcinoma) may present with blood per rectum but more often present with change in bowel habits, abdominal pain or other related symptom Sessile (flat) polyp Bleeding polyp Colon cancer

LGIB Sources of Colonic Bleeding Inflammatory Colitides/Ulceration inflammatory bowel disease, infectious colitis, radiation colitis, vasculitis 33 year-old man with Crohn’s colitis involving the proximal colon, with severe inflammation, edema and ulcers Normal vascular pattern Normal transverse colon

LGIB Sources of Colonic Bleeding Anorectal hemorrhoids, anal fissure, idiopathic rectal ulcer

LGIB Diagnostic Testing Colonoscopy clearly test of choice no evidence that colonic purge will increase the rate of bleeding or cause renewed bleeding if it has ceased overall diagnostic yield of colonoscopy 70-80% not only allows identification of bleeding source but also can apply therapy to stop bleeding endoscopic therapies (discussed in greater detail with UGIB) Thermal (heater probe, argon plasma coagulation) Injection (epinephrine, ethanolamine etc.) Mechanical (band ligation, hemoclips, endoloops) Forde et al, Gastrointest Endosc 1981

LGIB Diagnostic Testing (cont’d) Angiogram use if unable to find bleeding site diagnostic yield: 40-80% usually need to have a bleeding rate of >0.5mL/min to identify extravasation of contrast into bowel risk of complications greater than colonoscopy contrast-induced renal failure, contrast allergy, bleeding after arterial puncture, embolism from dislodged thrombus therapy can be applied (embolization or intra-arterial injection) Nuclear Medicine Red Blood Cell (RBC) Scan can potentially identify slower rate of bleeding diagnostic yield 26-72% Gomes et al, AJR 1986; Suzman et al, Ann Surg 1996

LGIB Role of Surgery Evaluation of Small Intestine if bleeding does not cease, and site of bleeding known, directed surgery (ie. limited colonic resection) can be performed with better outcomes compared with subtotal colectomy or “blind” right hemicolectomy Evaluation of Small Intestine LGIB but no colonic source identified rule-out UGIB first if absent upper and lower GI source, exam small intestine: video capsule endoscopy enteroclysis Meckels scan

ALGORITHM TO ACUTE LGIB (Part 1) SEE NEXT SLIDE

ALGORITHM TO ACUTE LGIB

Upper Gastrointestinal Bleeding can divide causes into variceal and non-variceal UGIB (focus on non-variceal UGIB) Healthcare burden/cost of UGIB from peptic ulcer disease 250,000 to 300,000 hospital admissions $2.5 billion in US each year despite advances in diagnosis and treatment, mortality of UGIB remains from 5 – 14% mortality higher in patients > 60 yrs and in patients with multiple comorbid conditions Rockall et al, Lancet 1995; Rockall et al, Gut 1996

UGIB Natural History majority of patients with UGIB will spontaneously cease 70-80% will stop within first 48 hrs of onset; of those 10-20% will have recurrence of UGIB at initial presentation ~20% will continue to bleed mortality greatest in these patients and also patients that have recurrent bleeding

UGIB - Etiology Etiology % Peptic ulcer disease 50+ Esophageal varices 10 Mallory-Weiss tear 5-10 Esophagitis 8-10 Neoplasm 2-5 Angiodysplasia Miscellaneous

UGIB - Etiology 20-30% of patients will have two or more diagnoses of UGIB no disease entity is found in 10-15% of patients (prognosis is excellent) bleeding peptic ulcer disease most common etiology and is also the most widely studied excellent randomized control trials regarding best treatment modalities, outcomes, risk of rebleeding and natural progression

UGIB Initial evaluation monitor hemodynamic status IV access; vigorous volume replacement confirm UGI source of bleeding by history (hematemesis – fresh blood or coffee ground emesis, melena) nasogastric aspiration is 80% sensitive for actively bleeding UGI source False negative aspirates occur when the tube is improperly positioned or when reflux of blood from a duodenal source prevented by pylorospasm or obstruction Cuellar et al, Arch Intern Med 1990

UGIB Endoscopy when UGIB suspected, test of choice for identifying and treating the bleeding lesion is upper endoscopy no role for barium studies in acute UGIB greatest benefit in the ~20% of patients with continued or recurrent bleeding endoscopy can improve morbidity and mortality endoscopic therapy with coagulation and/or injection therapy effective in the setting of actively bleeding ulcers active bleeding can be controlled in 85-90% of patients, with less than 3% complication rate mortality decreased by nearly one third concurrent use of proton pump inhibitors (eg. IV prevacid or protonix) of significant benefit in decreasing recurrent bleeding Sacks et al, JAMA 1990; Laine et al, Gastro 1990

UGIB Endoscopy management decision for other 80% who will not have further bleeding can be altered by aggressive diagnosis requires ability to separate high-risk patients from low-risk patients clinical indicators of higher mortality from UGIB variceal bleeding advanced age comorbid illnesses large volume bleeding persistent or recurrent bleeding despite medical therapy

Risk of Recurrent Bleeding UGIB Endoscopy best predictor of recurrent bleeding in peptic ulcer disease is the endoscopic appearance of the ulcer Risk of Recurrent Bleeding By Endoscopic Criteria Endoscopic Finding Risk of Recurrent Bleeding Mortality Active Bleeding 55% 11% Visible Vessel 43% Adherent Clot 22% 7% Flat Spot 10% 3% Clean Base 5% 2% Freeman et al, Gastrointest Endosc 1993

UGIB Endoscopy Clean based ulcer Adherent clot

UGIB Endoscopy Small ulcer with a prominent visible vessel 2 cm ulcer with pulsatile, arterial bleed

UGIB Endoscopy Laine et al (Gastro 1992) showed that patients with a clean based ulcer had only a 2% risk of recurrent bleeding and could be safely fed and immediately discharged from hospital reduces hospital stay → reduces healthcare costs Lee et al (Gastrointest Endosc 1999) showed that “endoscopic triage” significantly decreased costs and resulted in median savings of $2068

UGIB Endoscopic Management several endoscopic therapeutic techniques available to attempt hemostasis in patients with UGIB Thermal Heater Probe Multipolar electrocautery (MPEC)/bipolar electrocautery Argon plasma coagulation Injection Epinephrine Alcohol Ethanolamine Other Mechanical Band Ligation Hemoclips (Endoclip) Detachable Snare (Endoloop)

UGIB Endoscopic Management several endoscopic therapeutic techniques available to attempt hemostasis in patients with UGIB Thermal Heater Probe Multipolar electrocautery (MPEC)/bipolar electrocautery Argon plasma coagulation (APC) Injection Epinephrine Alcohol Ethanolamine Other Mechanical Band Ligation Hemoclips (Endoclip) Detachable Snare (Endoloop)

UGIB Endoscopic Management – Thermal all thermal devices generate heat directly (heater probe) or indirectly by tissue absorption of light energy (laser) or passage of electrical current through tissue (multipolar probes, APC) heating leads to edema, coagulation of tissue protein, contraction of vessels, resulting in hemostatic bond multipolar electrocautery (MPEC) has been compared with sham treatment in patients with active bleeding or nonbleeding visible vessel shown to reduce re-bleeding, emergency surgery, mean hospital stay and cost of hospitalization

Thermal small ulcer with a prominent visible vessel site after eradication of the vessel using heater probe

UGIB Endoscopic Management several endoscopic therapeutic techniques available to attempt hemostasis in patients with UGIB Thermal Heater Probe Multipolar electrocautery (MPEC)/bipolar electrocautery Argon plasma coagulation Injection Epinephrine Alcohol Ethanolamine Other Mechanical Band Ligation Hemoclips (Endoclip) Detachable Snare (Endoloop)

UGIB Endoscopic Management – Injection devices passed through working channel of endoscope that allow injection of liquid agents into target site of interest injection of various solutions achieves hemostasis by mechanical tamponade in sham controlled trials, injection therapy reduced rebleeding, transfusion requirement, emergency surgery and hospital stay Nelson et al, Gastointest Endosc 1999; Chung et al, Br Med J 1988

UGIB Endoscopic Management several endoscopic therapeutic techniques available to attempt hemostasis in patients with UGIB Thermal Heater Probe Multipolar electrocautery (MPEC)/bipolar electrocautery Argon plasma coagulation Injection Epinephrine Alcohol Ethanolamine Other Mechanical Band Ligation Hemoclips (Endoclip) Detachable Snare (Endoloop)

UGIB Endoscopic Management – Mechanical Band ligation Hemoclips preloaded elastic band(s) with a release mechanism affixed to tip of endoscope esophageal variceal band ligation effective in control of active hemorrhage in 86 to 91% Hemoclips preloaded metal clips deployed through biopsy channel of scope (mechanism of hemostasis is mechanical compression) achieved hemostasis in 84 to 100% of patients with variety of UGIB sources Detachable Snares loop placed around target tissue and loop tightened and then released were developed to prevent and treat post-polypectomy bleeding Laine et al, Ann Intern Med 1995; Binmoeller et al, Endoscopy 1993

Band ligation Esophageal varices in a 74 year-old man with alcoholic cirrhosis Two neighboring esophageal varices which have been successfully banded In another day or two the banded areas will sloughed off

Detachable Snares

Detachable Snares

Hemoclips Erythematous ulcer base with a visible vessel Two hemostatic clips were successful applied to the vessel, and there was no further bleeding

ALGORITHM TO UGIB

ALGORITHM TO UGIB

Summary LGIB resuscitation, hemodynamic stability a priority colonoscopy procedure of choice for evaluation of acute LGIB upper endoscopy should be performed when an upper source is suspected or when evaluation of colon is negative if colonoscopy and upper endoscopy are negative, evaluation of small bowel should be considered angiogram and/or a bleeding scan may be appropriate in the setting of massive bleeding pre-operative localization of bleeding attempted prior to surgical intervention

Summary UGIB resuscitation, hemodynamic stability a priority determine if (based on available information), if variceal vs non-variceal UGIB upper endoscopy procedure of choice for evaluation of UGIB “endoscopic triage” endoscopic therapeutic options (thermal, injection, mechanical) use of IV proton pump inhibitors (eg. Prevacid or protonix) in the high risk group of significant benefit in reducing recurrent bleeding