Upper GI Bleed Leigh Vaughan, MD Division of Hospital Medicine General Internal Medicine and Geriatrics, MUSC

Objectives Identify common causes for acute gastrointestinal bleeding in the hospitalized patient Describe clinical presentation and appropriate evaluation of patients with an acute upper GI bleed Outline appropriate resuscitative measures for the patient with consideration given to co- morbid illnesses Delineate high risk patients who may need more aggressive intervention or level of care

Key Messages The history and physical are essential to identifying the cause of an acute GI bleed Physical exam and laboratory data can assess the severity of illness and the likelihood of clinical decompensation Initial and rapid stabilization with IV fluids and blood products followed by intensive monitoring are the mainstays of resuscitation efforts

Causes Upper GI Bleed Peptic ulcer disease Gastritis Esophagogastric varices Arteriovenous malformation Tumor Mallory-Weiss (esophageal) tears

Initial evaluation History Physical examination Laboratory tests Assess the severity of the bleed Identify potential sources of the bleed

History – Pertinent points HPI Inquire about hematemesis Coffee ground emesis suggests limited bleed BRBPR  suggests faster bleed Melena- tarry black stools* Clots in stool less likely upper GI bleed PMHx Prior GI bleed- 60 % patients with a history of prior GI bleed, rebleed from same cause H. pylori status Relevant comorbidities Prior surgeries that may have affected anatomy Social history Prior smoking Alcohol use *Only takes a small amount of blood to get melena (50cc) Coffee ground emesis & melena- both suggest bleed is proximal to ligament of Treitz.

History -continued Family history Medications Coagulopathy Congenital disorders with AV malformation Medications ASA, NSAID Pill esophagitis- bisphosphonates, doxycycline, KCl, quinidine, iron Anticoagulants Bismuth, iron- darken stool

Physical Exam – Pertinent findings Assessing clinical stability Resting tachycardia suggests mild to moderate volume loss Orthostatic hypotension  suggests blood volume loss of at least 15% Supine hypotension  indicates blood volume loss of at least 40% Involuntary guarding consider perforation Stigmata of liver disease Skin manifestations of systemic disorders (such as petechiae or telangiectasia) that may predispose to gastrointestinal bleeding Rectal exam

Finding that may correlate with etiology RUQ pain, epigastric discomfortPUD Dysphagia, odynophagia, GERD esophageal ulcer Retching, cough that precedes emesis Mallory Weiss tear Weight loss, early satiety, cachexia cancer

Workup & laboratory, Nasogastric lavage- not uniformly recommended Assess ongoing bleeding Confirm upper GI bleed as source Identify those who might benefit from an early endoscopy Type and cross CBC, serum chemistries, liver tests, and coagulation studies Elevated BUN: linear correlation with likelihood of source of bleed being upper GI Other labs depending on clinical scenario (LFT, alb) Serial EKG’s and cardiac enzymes Once stable, all patients should undergo H. Pylori testing

Interpretation of data Initial Hgb in acute bleed- likely reflects baseline (no time to drop) Check Hgb q 2-8 depending on clinical scenario Over resuscitation can falsely dilute Hgb Normocytic anemia most expected type in acute GI bleed; microcytic anemia suggests chronic bleed

Risk stratification tools Multiple validated models -Blatchford and Rockall Many include endoscopic data (which not available at presentation) Poor prognostic indicators: age, shock, comorbidities, Hgb, need for blood, sepsis, BUN, Cr., AST, high APACHE score AIM 65 - each risk factor gets a point, endpoints mortality & hospital stay Album <3.0, INR >1.5, altered mental status, SBP < 90mmHg, age > 65 Zero risk factors conveys 0.3% chance of death during hospitalization. 5 risk factors 31.8 % chance of death during hospitalization Saltzman JR, Tabak YP,. Gastrointest Endosc. 2011;74(6):1215. Always look at tools’ endpoints and purpose. Is it to establish who could safely be discharged? Likelihood of mortality? Who needs higher level of care?

Who needs ICU? & Why?  All patients with hemodynamic instability (shock, orthostatic hypotension) All patients with active bleeding (hematemesis, BRB per nasogastric tube, or hematochezia) Resuscitation and close observation Monitoring blood pressure, pulse oximetry, urine output Electrocardiogram monitoring

Management – volume resuscitation Fluid resuscitation with 2 large bore IVs Bolus (not only hourly drip) of isotonic crystalloid Consideration for invasive hemodynamic monitoring Packed RBCs – revised transfusion criteria: Hemodynamic instability, despite fluid resuscitation Hgb < 8 high risk patient, intolerant to anemia (CAD, Pulmonary HTN, Pulmonary disease) Hgb < 7 in low risk patient Overall data supportive of restrictive transfusion if early endoscopy available Every 4 u PRBC’s necessitates unit of FFP Barkun AN, Bardou M, Kuipers EJ, et al., Ann Intern Med. 2010; 152(2):101 Carson JL, et al., Ann Intern Med 2012;157:49-58

Management NPO O2 supplement Correction of coagulopathy INR > 1.5  FFP (not vit K acutely) Platelets < 50,000 transfusion Recent use of ASA/ antiplatelet agent- indication for platelet transfusion in massive bleed 2/2 induced platelet dysfunction Empiric IV PPI (Omeprazole IV 80 bolus, plus hourly infusion)- until etiology established Provide appropriate nutritional support Assess aspiration risk, need for intubation Early GI/ IR/ surgery involvement

Confounding variables Beware of over zealous fluid resuscitation in CHF, renal disease Avoid over transfusion in variceal bleed- do not exceed Hgb >10g/dL Esophageal varices, cirrhosis IV somatostatin bolus, followed by hourly infusion Broad spectrum antibiotics* - 20% patients have concurrent infection, 50% develop infection during hospital course Various studies using flouroquinolones, cephalosporins. No consensus on duration or spectrum of pathogens covered.

Anticoagulation & active bleed Do NOT delay endoscopy-moderately anticoagulated (INRs of 1.3 -2.7) success rates are comparable to those not anticoagulated INR > 3.0 urgent reversal prior to endoscopy Attempt to lower below 2.5 -3.0 when possible No reversal agent for direct thrombin inhibitors or Factor Xa inhibitors

Invasive tests, studies Endoscopy- #1 tool, used early (24 hr) Can locate bleed Can achieve hemostasis Can prevent rebleed Requires hemodynamic stability Patients likely get erythromycin (as prokinetic) prior to procedure in severe bleed Tagged red cell Angiography NO GI barium- contraindicated

Who can be discharged quickly & safely? Reliable patient with good follow-up Favorable factors Few comorbidities Negative NG aspirate Hemodynamic stablility Normal labs (Hgb, BUN, Cr.) Likely source of bleed identified (from endoscopy or other modality) Absence of factors associated with rebleed (variceal bleeding, active bleeding, bleeding from a Dieulafoy's lesion, or ulcer bleeding with high-risk stigmata)

Discharge medications All decisions predicated on favorable risk benefit analysis Resumption of warfarin after bleed Many risk stratification tools (HAS-BLED, ATRIA) If risk/benefit ratio favors resuming, wait 4 days after bleed Patients who require NSAIDS - PPI with a cyclooxygenase-2 inhibitor can reduce, not prevent, rebleed Discharge in cardiac patients requiring ASA- ASA +PPI may be resumed in 7 days Most patients should receive a single Rx for daily dosing of PPI; duration should be determined by cause of bleed

References Barkun AN, Bardou M, Kuipers EJ. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010;152(2):101. The role of endoscopy in the management of acute non- variceal upper GI bleeding. Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy. Gastrointest Endosc. 2012;75(6):1132. Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012 Mar;107(3):345-60; quiz 361. Epub 2012 Feb 07. Carson JL, Grossman BJ, Kleinman S, et al. Red blood cell transfusion: a clinical practice guideline from the AABB. Ann Intern Med 2012;157:49-58