Treatment of Acute Lower Gastrointestinal Bleeding Experience of a Specialized Management Team Eric J. Dozois, MD Division of Colon & Rectal Surgery Mayo Clinic Rochester, Minnesota

Acute GI Bleeding Significant health problem : Morbidity Mortality Cost Disease of the Elderly : By 2050, 78 million Americans will be 65 years or older

Lower Gastrointestinal Bleeding (LGIB) Background Distinct entity from upper GI bleeding Spectrum of disease is broad Trivial hematochezia to massive hemorrhage and shock

Lower GI Bleed Background – Management Pathway Assessment of severity Establishment of diagnosis Appropriate use of resources Control of bleeding Prevention of rebleeding Lower morbidity, mortality, cost

Acute Gastrointestinal Bleeding Management - Advances Growth of Therapeutic Endoscopy:* – Decrease length of hospitalization – Decrease transfusion requirements – Lowers need for surgical intervention – Reduced mortality *Sacks et al JAMA 1990;264:494-9

Gastrointestinal Bleeding Team Mayo Clinic - Background Surgeons ER Physicians Radiologists Pharmacists ICU Physicians 1988 Mayo Clinic Gastrointestinal Bleeding Team (GIBT)

Management of Acute GI Bleeding Mayo Clinic - Background Designed to satisfy the need for rapid and specialized endoscopic management of acute GI conditions, primarily GI bleeding

Mayo Clinic GI Bleed Team Rapid response, 24/7 service Response time for emergent endoscopy is < 30 minutes Involved until patient stabilized or surgery intervention

Members of Team 1 Staff Endoscopist (1 - wk rotation) 1-2 GI Fellows (1 - mo rotation) 1 Endoscopy nurse (1 - wk rotation) 1-2 full-time study coordinators Colorectal or General Surgeon

Mayo Clinic GI Bleed Team Scope of Practice : ER, clinic, hospital, OR All endoscopic emergencies – Food impaction – Foreign body removal – Colonic decompression (stents)

Early Assessment – High Risk Screening Criteria Historical Criteria: – Age > 65 years – Previous bleeding; identified site(s) – Major organ system disease, aortic graft Clinical Criteria: – SBP 20, HR > 100 – Transfusion of > 4U/24hrs, 8U hospital stay – Re-bleed event > 2U

GIBT - Bowel Prep GoLYTELY: – 4 oz. Q 5 min. until effluent clear OR – 4 liter down NG tube over 2 hours

GIBT - Equipment Motorized, mobile unit State-of-the-art: DVD recording Accessories Scopes

GIBT - Database Prospectively collected data on all patients Indications, findings, therapeutic modality, complications and outcome Enhances research productivity related to GI bleeding and other GI emergencies

Year-end 2005 > 42,000 Procedures

Extra procedures include PEG/PEJ, bedside NG-NJ tube placement, etc.

All GI Bleeding Etiologies PUD 29% Gastroesophageal varices 7% Vascular ectasias 6% Diverticular bleeding 6% Postpolypectomy 4% Colonic ulcers 4% Ischemia 3% Mallory-Weiss tear 3% Malignancy 0.8% Anastomotic site 0.7% Dieulafoy 0.1%

Causes of LGI Bleeding Diverticular21% Ulcers/erosions 15% NSAID, infection, idiopathic Ischemic colitis12% Post-polypectomy11% Vascular ectasias 8% Malignancy 2% Anastomotic site 2%

Lower GI Bleed Risk Factors for Mortality* Age > 70 years Vital organ disease (*heart, liver, lungs) History of Cancer Shock Re-bleeding (> 4 units/event) Hospitalized patients *With permission from CJ Gostout, MD

Lower GI Bleed Risk Factors for Re-bleeding Bleeding > 24 hours Hemodynamic instability Hemoglobin, 10 g/dL Anticoagulation/coagulation disorder Cirrhosis Transfusion > 4 U per resuscitation event Undiagnosed prior major bleeding *With permission from CJ Gostout, MD

GIBT – Complications Study Period No. of Cases10,520 Complications 230 Gostout et al. AJG 2001;96:3452 Complication Rate 2.19%

GIBT – Complications Gostout et al. AJG 2001;96:3452 Iatrogenic bleeding24.3% Perforation20.0% Hypoxia 9.6% Hypotension 9.6% Mucosal tears 8.0% Arrhythmias 6.1% Aspiration 3.0% Death 2.0%

GIBT - Technical Expertise Injection: Epi, sclerosants, cyanoacrylate glue Thermal : Heat probe, Bipolar electrocoagulation Mechanical : Clipping, Banding, Cryotherapy

Endoscopic Management LGIB Principles: – If active bleeding, inject epinephrine (1:10,000) to slow or stop bleeding – Epinephrine is generally a temporary solution and used as an adjunct to definitive therapy (e.g., clipping or thermal coagulation)

Endoscopic Management LGIB Principles: – If feasible, clipping generally preferred in the colon due to perceived increased safety relative to thermal techniques – Clipping and thermal coagulation techniques are equally effective for most bleeding colonic lesions

Indications for Clips Mallory-Weiss Tear Peptic Ulcer Disease Dieulafoy lesion Post-polypectomy bleeding Diverticular bleeding Angioectasias* (*APC or contact thermal modality preferred) Raju GS et al. Gastrointest Endosc 2004;59:267

Vascular Ectasia Non-BleedingBleeding Coaptive Coagulation APC (preferred) Epinephrine Injection Coaptive Coagulation APC (preferred) Clipping not optimal for vascular ectasias

Diverticular & Postpolypectomy Bleeding Angiographic Embolization Coaptive Coagulation Clipping (preferred) Epinephrine Injection Coaptive Coagulation Clipping failed

Anastomotic Site Bleed StigmataActive Bleed Coaptive Coagulation Clipping (preferred) Epinephrine Injection Coaptive Coagulation Clipping (preferred)

Conclusions Mayo Clinic GI Bleed Team Organized, highly skilled team Delivers immediate and advanced endoscopic therapy to patients with acute GI bleeding Should improved outcomes

Mayo GIBT – Future Research How will the presence of the GIBT effected: Mortality, Morbidity, Cost Transfusion requirements Need for surgical intervention Length of hospital stay