Transcript GI Bleeds - Calgary Emergency Medicine

GI Bleeds
Rebecca Burton-MacLeod
Feb 15th, 2007
Emerg Med Resident
Rounds
Overview
Anatomy
 Upper GI bleeds
 Lower GI bleeds
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Anatomy
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UGI vs. LGI defined by Ligament of
Treitz…located in 4th section of
duodenum
UGI vs. LGI ?
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Melena and hematemesis means
UGI bleed, right?
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Hematochezia—10-15% of pts will be
UGI presentation
Ddx in adults
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UGI:
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PUD
Gastric erosions 75%
Varices
Mallory-Weiss tear
Esophagitis
Duodenitis
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LGI:
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UGI bleed
Diverticulosis
Angiodysplasia 80%
Ca/polyps
Rectal disease
(hemorrhoids,
fistulas, fissures)
IBD
Infectious
Ddx in adults
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No identifiable source found for GIB
in 10% of patients
Elderly and LGIB
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Tips from EMR…
Don’t rely on the color of stool to determine the bleeding site.
Colors change as transit times vary and blood products break
down.
• All that bleeds bright red is not a hemorrhoid. Unless it’s
bleeding before your eyes, look for another diagnosis.
• Elderly patients may not manifest orthostatic changes from
blood loss as readily as their younger counterparts.
• The initial hemoglobin may not be a reliable indicator of the
volume of blood lost, as the volume may be contracted.
• Look for other systemic causes if your investigation of the
abdominal structures turns up negative and the patient still has
abnormal vitals, especially if the rectal bleeding has ceased.
• Order typed blood products.
• Peritoneal signs may take up to 20 hours to manifest.
• Perform a digital exam and anoscopy on a patient with
anorectal bleeding.
Case
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78M presents with hematemesis and
hematochezia x 2hrs. States he has had
increasing episodes over last 30min.
Feeling presyncopal.
PMHx: HTN, CAD, AAA repair 3mos ago
O/e: HR 110, BP 100/70; pale, clammy
Any thoughts?
Ddx in peds
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UGI:
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Esophagitis
Gastritis
Ulcer
Varices
Mallory-Weiss tear
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LGI:
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Anal fissure
Infectious colitis
IBD
Polyps
Intussusception
Case
47M brought in with
hematemesis…EMS reports just
vomited 1-2L of BRB. He reports
this is his third episode in last 1hr
 Feeling weak, pale. Says he thinks
he’s going to vomit again…
 HR 132, BP 86/62
 Plan?
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Case cont’d
Monitors, supplemental O2
 2 x 18G IVs
 CBC, INR/PTT, T+S
 2L bolus IV N/S with monitoring
vitals
 Consider PRBC if ongoing vomiting,
vitals fail to improve
 Consult GI ASAP
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Diagnosis
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History:
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Hematemesis, melena, hematochezia
Duration/amount of bleeding, previous
episodes, recent meds/Etoh/surgeries
s/s of blood loss
Physical:
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Vitals—sustained tachycardia is most
sensitive
Don’t forget the DRE…and good ol’ FOB
testing!
Case
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56F who presents c/o abdo pain and
“black stool”. Epigastric pain x1day. No
emesis. 1x episode of black stool this
a.m. No previous hx
PMHx: HTN
Meds: HCTZ, pepto-bismol (used last
nite for epigastric pain)
O/E: HR 82, BP 140/80. exam
unremarkable except black stool on DRE
(FOB negative)
Any thoughts?
Ddx bleeding
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Melena:
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Requires >150ml
blood digested
over prolonged
period (~8h)
Pepto-bismol
Iron
Blueberries
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Hematochezia:
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Only 5ml of blood
required to turn
“toilet water bright
red”
Beets
FOB testing
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False positives:
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Red fruits/meats
Methylene blue
Chlorophyll
Iodide
Cupric sulfate
Bromide
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False negatives:
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Rare!
Bile
Ingestion of Mgcontaining antacids
Ascorbic acid
HOB testing
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What about pt with “coffee ground
emesis” appearing vomitus…any role
for HOB testing?
Case
2day-old post SVD, no
complications. Discharged home
earlier today. At home, had a
bloody BM (parents bring the diaper
just to show you!)
 Pt exams well. Normal vitals.
 Any investigations?
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GIB investigations
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CBC, INR/PTT, T+S
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Remember, Hct lags behind clinical
picture, and is affected by hemodilution
Consider lytes, BUN, Cr
 EKG
 Upright CXR if suspect perf
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Case
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78M presents to ED with hx of melena
x3days…wife convinced him to come get
it checked. Slightly dizzy.
PMHx: Afib, diverticulosis
Meds: metoprolol, warfarin
O/e: HR 72 BP 118/69, obvious melena
stool on DRE. Exam otherwise
unremarkable.
Thoughts ?
Investigations ?
Case cont’d
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Blwk:
Hgb 117, Plt 450
 INR >9
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Reverse INR?
Vit K?
 FFP?
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Role of CT ?
Not indicated in UGIB cases
 Sensitivity for identifying
mesenteric ischemia is 64-82%
 Identification of other colonic
pathology is 75% sensitive
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specificity 96%
 NPV 96%
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Case
58M with hx of CAD. Presents with
2x episodes of melena yest and 1x
episode hematemesis after breakfast
this a.m. C/o epigastric pain which
radiates into his chest, SOB,
dizziness. No previous episodes
 O/E: HR 92 BP 120/80
 You order CBC, INR/PTT, T+S, EKG
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EKG
Case cont’d
His labs are still pending
 What do you want to do?
 One of your colleagues walks by and
eyeballs the EKG and says “wow,
that patient needs ASA, b-blocker,
heparin, cardiology consult
STAT”…what do you think?
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UGIB and NG tubes
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Any role for NG tube insertion?
May aid in ruling out LGIB in pt with
hematochezia
 Otherwise, 10% of established UGIB
will have negative NGT aspirates…so
NOT useful!
 Lots of false negatives (ex: bleeding in
duodenum or bleeding already stopped)
 Bottomline…not very useful…
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UGIB management
GI—endoscopy
 Gen Surg—operative
 Intervent Radiol—angio
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Melena, Cuba
UGIB and endoscopy
Most accurate diagnostic tool
 Identifies source in 78-95% of pts,
when performed within 12-24hrs
post-UGIB
 Allows for risk stratification
(rebleeding and mortality) as well as
treatment (banding or sclerosing of
varices)
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When to scope ?
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Most authors suggest within 12-24hrs
Lin et al (1996):
Large RCT (n=124pts) showed that
endoscopy within 12h is safe and
effective
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Leads to dec transfusion requirements
Dec length of hospital stay
Dec costs
UGIB and angiography
Detects location of UGIB in 2/3 of
pts
 Usually performed during active
bleeding
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Unstable vitals
 Ongoing transfusion requirements
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UGIB and surgery
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Mortality for pts undergoing surgery for
UGIB is 23%
Hemodynamically unstable pts, not
responsive to medical/transfusion mgmt,
endoscopy unavailable
Consider if >5U PRBC given over first 6h
or when 2U PRBC required q4h after
replacing initial losses—and still unstable!
UGIB medications
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PPI—pantoloc
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Bolus 80mg then run @ 8mg/h x 72hrs
Role in pts with PUD as cause
Is an adjunct, not therapy for UGIB…still need
endoscopy
Somatostatin analogues—octreotide
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Bolus 40ug then continuous infusion
Role in esophageal varices
Peptide analogue which causes splanchnic
vasoconstriction by direct effect on vascular
smooth muscle
Pantoloc ?
Octreotide ?
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Multicenter RCT of octreotide vs. injection
sclerotherapy for acute variceal
hemorrhage
N=150
No significant differences in control of
bleeding, re-bleeding, and mortality
Octreotide felt to be as effective as
injection sclerotherapy
Jenkins SA, et al. A multicentre randomised trial comparing octreotide and
injection sclerotherapy in the mgmt and outcome of acute variceal
hemorrhage. GUT. 1997.
Vasopressin ?
Has been used in pts with
esophageal variceal hemorrhages
 No effect on overall mortality
 High rate of complications (9%
major, 3% fatal)
 Only role would be in
exsanguinating pt, with endoscopy
or other measures unavailable
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Sengstaken-Blakemore
tubes
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Useful if esophageal
variceal bleeding
source
Linton tube if gastric
varices
High risk of
complications (14%
major, 3% fatal)
One of those lastditch efforts!
Insertion techniques…
SB tubes…
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Equipment:
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Sterile SengstakenBlakemore tube
Pair of scissors
50ml syringe
2 x rubber tipped
artery forceps
Water soluble
lubricant
3 metres of white
linen tape
Pressure gauge
Weight for traction
Pulley
PPE
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Precautions:
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Balloon pressure should
always be <45mmHg
Pt should be intubated
prior to procedure
Keep scissors near bed
at all times (to cut tube
prn if migrates and
causes resp distress)
Check tube placement
by:
• Aspirate and check pH
• Inject air and
auscultate over
stomach
• XR
Insertion…
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Any takers ?
SB tube
Sengstaken vs. Linton tubes
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RCT of SB vs. LN tubes in pts with known
esophageal/gastric varices
N=79
Primary hemostasis in 86% of pts
If esophageal varices as cause, SB more
effective at permanent hemostasis (52
vs. 30%)
If gastric varices as cause, LN tube much
more effective (50 vs. 0%)
Teres J et al. Esophageal tamponade for bleeding varices. Controlled
trial between the Sengstaken-Blakemore tube and the LintonNachlas tube. Gastro 1978.
LGIB and scopes
Must r/o UGIB source first usually
 If mild LGIB with no evidence of
hemorrhoids, then anoscopy /
proctosigmoidoscopy recommended
 Absence of blood above rectum
indicates rectal source; however,
blood above rectum does not r/o
rectal source
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LGIB and angiography
Does not usually diagnose cause of
bleeding, but identifies source in
40% of pts
 Arterial embolization may be useful
if ongoing bleeding
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Disposition
Very-low risk
 Low risk
 Medium risk
 High risk
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D/c home if:
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No comorbid disease
Normal vitals
Normal or trace FOB positive
+/- neg gastric aspirate
Normal (or near) Hgb/Hct
Good social situation
F/u within 24hrs
Understanding as to when to return…
Initial ED stratification
Low Risk
Moderate Risk
High Risk
Age <60
Age >60
Initial SBP ≥100 mm Hg
Initial SBP <100 mm Hg
Persistent SBP <100 mm Hg
Normal vitals for 1 hr
Mild ongoing tachycardia for
1 hr
Persistent moderate/severe tachycardia
No transfusion requirement
Transfusions required ≤4 U
Transfusion required >4 U
No active major comorbid
diseases
Stable major comorbid
diseases
Unstable major comorbid diseases
No liver disease
Mild liver disease—PT
normal or near-normal
Decompensated liver disease—i.e.,
coagulopathy, ascites, encephalopathy
No moderate-risk or highrisk clinical features
No high-risk clinical features
Stratification with initial and
endoscopy findings
Clinical Risk Stratification
Endoscopy
Low Risk
Moderate Risk
Low risk
hospitalizatio
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Immediate discharge[*]
24-hr inpatient stay (floor)[†]
24-hr patient stay[†]
24–48 hr inpatient stay
(floor)[†]
Close monitoring for 24 hr;
≥48-hr hospitalization
Close monitoring for 24 hr;
48–72 hr hospitalization
Close monitoring for 24 hr;
48–72 hr hospitalization
Close monitoring ≥72-hr
hospitalization
Moderate
risk
High risk
High Risk
Close monitoring for 24
hr[‡]; ≥48-hr
So what does this mean at
FMC for UGIB pts…
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Low-risk pts:
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Hold o/n in ED until
scoped
Consider admission
to Hospitalist until
scoped (depending
on GI suggestions)
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Med risk pts:
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Admit to
Hospitalist/Medicin
e until scoped
Scope immediately
High risk pts:
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Scope immediately
Admit to
Medicine/ICU
Disposition LGIB pts
If not clearly due to hemorrhoids,
fissures, proctitis then should admit
 Low risk: admit to Hospitalist with
scoping
 Med/High risk: admit to
Medicine/ICU with scoping +/- angio
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