Transcript Gi bleeding - School of Medicine

GI BLEEDING
Angel Qin, MD
PGY 3
Objectives
• Define GI bleed
• Common presentations
• Initial assessment
• Common causes of UGIB and LGIB
• Different diagnostic tests and therapeutic options
• Updates in GI bleeding
• Practical tidbits along the way
Definitions
• Acute GI bleed
• < 3 days duration
• Hemodynamic instability
• Requires blood transfusion
• Overt vs occult
• Overt: visible blood (melena, hematochezia, bright red blood per rectum,
coffee ground emesis)
• Occult: detected only on lab tests (ie stool cards)
UGIB: proximal to the
ligament of Treitz
LGIB: distal to the
ligament of Treitz
Ligament of Treitz
Common presentations…
• “I am vomiting blood”
• “When I wipe, there is blood on the toilet paper”
• “My stools have changed color”
• New finding of anemia on routine labwork
Initial assessment
• Is the patient stable?
• ABCs (airway, breathing, circulation)
• Home vs Floor vs MICU
• What are the likely sources of the bleed?
• What are patient’s underlying medical issues?
• Any history of bleed in the past?
• Any EGDs/colonoscopies?
Is the patient stable?
• Appearance
• In distress?
• Pale?
• Actively bleeding in front of you?
• Vital signs
• Tachycardic?
• Hypotensive?
• Hypoxic?
ABCs
• Airway
• Can the patient protect his/her airway
• Breathing
• Is the patient tachypneic? Hypoxic?
• Supplemental O2
• Circulation
• Establish 2 large bore IVs
• Type and screen stat
Resuscitation
• IVF
• Normal saline boluses
• PRBCs
• Transfusion likely will be required if there is active bleed or there is a
significant drop in hemoglobin
• (More on transfusion goals later…)
• FFPs/Platelets
• May be needed depending on etiology of bleed (most commonly in
patients with significant liver disease)
Now to the history…
• Has this ever happened before?
• Medical problems
• Peptic ulcer disease, esophageal varices, diverticulosis
• Medications: chronic NSAID use, aspirin, plavix, warfarin (other
anticoagulants)
• Trauma
• Quality, quantity, frequency, onset
• UGIB: bright red blood vs coffee ground emesis
• LGIB: bright red blood vs melena (dark, TARRY stools)
• Associated symptoms
• Retching/vomiting (Mallory Weiss tears)
• Abdominal pain (association with food? Ulcer vs mesenteric ischemia)
• Weight loss, malaise (cancer)
On physical exam…
• VITAL SIGNS
• Including orthostatic vital signs
• General: AAOX3? Distress?
• HEENT: blood in oropharynx? Pale conjunctiva?
• Heart: tachycardic?
• Abdomen: Soft? Distended? Tenderness to palpation?
• RECTAL EXAM!
• Melenic? (NOT melanotic!) Bright red?
• Hemorrhoids?
• Masses?
How to proceed
• Labs (STAT)
• CBC, RFP, coags, type and screen
• What is baseline hemoglobin?
• BUN:Cr ratio frequently >20:1 in UGIB
• Also consider LFTs and iron studies
• Prior procedures/surgeries
• Last endoscopy or colonoscopy: findings, recommended treatment and
followup, pathology results
• Home vs Floor vs MICU
• Home: misunderstanding of tarry stools, hemorrhoidal bleeding
Floor or MICU
• Consider ICU admission if:
• Despite aggressive fluid resuscitation, patient continues to be hypotensive,
tachycardic
• Continued active bleeding (NG lavage not clear after 2L, BRBPR)
• History of cirrhosis and variceal bleeding
• Any airway compromise
• Be concerned if:
• Elderly with multiple comorbidities
• Use of anticoagulants
• Prior abdominal surgeries
Practical tidbit: how to perform a NG lavage
• Supplies:
• NG tube, lubricant, normal saline, 50cc syringe, chucks, basin, gloves,
stethoscope
• 1. Sit patient upright, cover with chucks, basin ready
• 2. Lubricate the NG tube well
• 3. Insert while having patient sip on water
• 4. Confirm placement by air insufflation via syringe or KUB (takes
time)
• 5. Inject up to 250cc NS at a time into NG tube and withdraw
aspirate via syringe or wall suction
• What does the aspirate look like?
•
•
•
•
Bright red clots: active upper GI bleed
Coffee grounds: slow UGIB, may have stopped
Clear: indeterminate
Bilious: bleeding has stopped
• An indication for MICU admission is if after 2L, the NG aspirate is
still bright red blood
Common causes of UGIB
• Gastric and/or duodenal ulcers
• Esophageal varices w/wo portal gastropathy
• Esophagitis
• Erosive gastritis/duodenitis
• More rare causes:
•
•
•
•
Mallory-Weiss syndrome
Angiodysplasia
Mass lesions (polyps/malignancy)
Dieulafoy’s lesions
other
5%
varices
13%
nonspecific
mucosal
abnormalities
44%
esophagitis
16%
peptic ulcers
22%
From a national database of 7822 patients between 1999 and 2001
Wilkins T, Khan N, Nabh A, et al. Diagnosis and Management of Upper Gastrointestinal Bleeding. Am Fam Physician 2012; 85(5): 46876
Medical therapy for UGIB
• IV PPI
• Bolus with 80mg IV and then start drip at 8mg/hour
• PPIs decrease the risk of rebleeding1, reduces the need for endoscopy2, and
decreases the stigmata of recent hemorrhage2
• H2 blockers are not recommended
• Octreotide (for suspected variceal bleeding)
• Long acting analogue of somatostatin; reduces splachnic blood flow, inhibit
acid secretion
• 50-100mcg followed by drip at 25-50mcg/hr
• Use is actually controversial; large meta -analysis did not find any significant
reductions in mortality or risk of rebleed3
1. Sung JJ, Barkun A, Kuipers EJ, et al. Intravenous esomeprazole for prevention of recurrent peptic ulcer bleeding: a randomized
trial. Ann Intern Med 2009; 150(7):455-64
2. Sreedharan A, Martin J, Leontiadis GI et al. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper
gastrointestinal bleeding. Cochrane Database Syst Rev 2010; (7): CD005415.
3. Gotzche PC, Hrobjartsson A. Somatostatin analogues for acute bleeding oesophageal varices. Cochrane Database Syst Rev 2010;
(9): CD002907
• If patient has ascites, then SBP prophylaxis w/antibiotics for 7 days
is indicated
• Inpatient: ceftriaxone 1g IV
• Outpatient: norfloxacin 400mg PO BID or Bactrim DS BID
Endoscopic intervention
• PUD
• epinephrine injection
• bipolar cautery
• hemoclip
• Varices
• endoscopic band ligation
• >90% success
• 30% rebleeding rate
• TIPS for hemorrhage refractory to banding
• also used for gastric varices
• TIPS increases the risk for hepatic encephalopathy
SCORE
VARIABLE*
0
1
2
3
Rockall Risk Scoring System for Assessment
After an Episode of Acute Upper Gastrointestinal
Bleeding
Age
Younger than
60 years
60 to 79 years 80 years or
older
—
Shock
symptoms,
systolic blood
pressure, and
heart rate
Shock absent,
blood
pressure 100
mm Hg or
greater, heart
rate less than
100 bpm
Tachycardia,
blood
pressure 100
mm Hg or
greater, heart
rate100 bpm
or greater
Hypotension,
blood
pressure less
than 100 mm
Hg
—
Comorbidities
No major
comorbidity
—
Heart failure,
coronary
artery
disease, any
major
comorbidity
Renal failure,
liver failure,
disseminated
malignancy
Endoscopic
diagnosis
Mallory-Weiss
tear or no
lesion
identified, and
no stigmata of
recent
hemorrhage
All other
diagnoses
Malignancy of —
upper
gastrointestina
l tract
Stigmata of
recent
hemorrhage
None or dark
spot only
—
Blood in upper —
gastrointestina
l tract,
adherent clot,
visible or
spurting
vessel
RISK OF REBLEEDING AND MORTALITY BASED ON ROCKALL RISK SCORE
SCORE
RISK
0
1
2
3
4
5
6
≥8
7
Rebleeding
(%)
4.9
3.4
5.3
11.2
14.1
24.1
32.9
43.8
41.8
Mortality (%)
0 0.2
0
0.2
2.9
5.3
10.8
17.3
27.0
41.1
Common causes of LGIB
• Diverticulosis
• Ischemia
• Anorectal disease (hemorrhoids, fissures, ulcers)
• Neoplasm (benign and malignant)
• Inflammatory bowel disease
• More rare causes
• Angiodysplasia
• Radiation colitis
• Colitis NOS
other/unknown
IBD
9%
4%
neoplasia
11%
diverticulosis
42%
anorectal disease
16%
ischemia
18%
Therapy for LGIB
• No medical therapies
• Bleeding 2/2 to diverticulosis stops spontaneously about 75% of the
time
• Bleeding 2/2 to angiodysplasia stops spontaneously about 85% of
the time
• If the patient continues to bleed…
• Angiography can be used to localize source of bleed and intravascular
embolization can be delivered; requires >0.5cc/min of blood loss
• Can be useful when determining surgical intervention
• For those with contraindications to angiography, can consider tagged RBC
scan , which requires bleeding at >0.1cc/min
• Highly false positive rate; localization unreliable
Colonoscopy
• Rarely an emergent procedure
• Standard prep is 4L of GoLytely (miralax + electrolytes) starting the
evening PRIOR to colonoscopy
• Patient must be passing CLEARS
• A “rapid prep” can be done with GoLytely proceed to colonoscopy
in 6-12 hours
• Discovers the source of bleeding in >70% cases
• Therapeutic interventions include epinephrine injection, cautery,
and clipping
More advanced modalities
• Limit of EGD is proximal duodenum and limit of colonscopy is
cecum…leaving a significant portion of the small intestine left
unvisualized
• Though obscure GI bleeding accounts for only about 5% of GIB, in
75% of those cases, the source is the small intestine
• Video capsule endoscopy
• Enteroscopy (push, double balloon, intraoperative)
Practical tidbit: what to order in the EMR
• Basic admission orders
• Remember to OMIT pharmacologic DVT prophylaxis ; use TEDs/SCDs
• NPO (now or after midnight) depending on urgency of GI consult; for
colonoscopies, clear liquid diet the day before
• Check CBC q6
• Always remember to check a post-transfusion CBC
• IVF until blood arrives
• Need new type and screen Q72 hours
• Daily RFP
• Assess electrolytes , BUN/Cr
• IV PPI bolus followed by drip
• Pantoprazole is the formulary IV PPI at both UH and VA
• Octreotide drip for variceal bleeding
Practical tidbit: how to call a GI consult
• Don’t be intimidated
• Patients name, MRN, and location
• Question you are asking
• Be specific
• Patient’s pertinent past medical history
• What was the chief complaint?
• Pertinent vitals, physical exam (RECTAL!), labs (include trends), and
prior endoscopies/procedures (and when)
• If patient has been seen in the GI department before
One last word…UGIB transfusion goals
• In a recent study published in the NEJM 1, patients with acute UGIB
were randomly assigned to restrictive transfusion group vs liberal
transfusion group
• Restrictive: transfuse only when Hgb <7g/dL with target Hgb 7-9g/dL
• Liberal: transfuse when Hgb <9g/dL with target Hgb 9-11g/dL
• The jist: patients in the restrictive group had higher survival,
decreased rates of rebleed, and decreased adverse events
• Did not apply to patients with Child-Pugh class 3 cirrhosis
1. Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding.
NEJM 2013; 368:11-21
Questions?
Thank you for your time and
welcome to UH and Cleveland!