Transcript GI BLEED - PBworks

UPPER GI BLEED
Presentation designed by Wendy Gerstein,
MD
Department of Medicine
NMVAHCS
OBJECTIVES
Recognize bleeding and level of severity.
 Have a differential diagnosis for the bleeding.
 Know how to stabilize the patient and stop the
bleeding.
 Decrease risk of future bleeding.

MR. J
 HPI:
Pt is a 43 yo male with h/o etoh abuse
who presented with 3 day h/o vomiting blood
(3-4x each day), about ½ cup each time. Pt
fainted after vomiting on morning of
admission, and friend brought him to the ER.
No food or drink for last 2-3 days. Never
happened before. Also with dark tarry stools x
2 days and sharp epigastric abdominal pain.
 Pmhx:



Alcoholism, (6-30 beers/day x 25 years).
Low back pain secondary to military accident 1980.
Heart burn x 5 years – uses Tums.
 Meds:
methocarbamol 750 mg po tid, etodolac
400mg po bid**. No known drug allergies
 Shx: etoh, current tobacco, lives on Isleta Pueblo,
partial disability.
 PE: AF, p 80-86, bp 146/92, nl o2 sat
 Exam remarkable for no jaundice or signs of
liver disease **, nl abd exam.
 Labs: wbc wnl, hct 37.3 with mcv 85, rdw 16.9,
platelets 74. Bun 21, creat .8, potassium 2.9,
chloride 99**. Liver enzymes – sgot 88, sgpt 70,
Tbili 1.4 (direct .2). Inr 1.2
 CXR wnl

In ER – nasogastric tube placed – removed 400 cc
dark red liquid, lavaged to clear with 500cc of
normal saline.
DIFFERENTIAL

Upper GI bleed:
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Peptic ulcer disease (majority of cases)
Esophageal varices (14%)
Mallory-Weiss tear
Gastric erosions
Esophagitis/ulceration
Neoplasm
AVM malformations
EPIDEMIOLOGY
100 cases of UGI bleed per 100,000 adults.
 Incidence increases with advancing age.
 150,000 hospitalizations per year in the US.
 $2 billion per year in costs.
 Mean length of stay 5.7 days.
 Mortality ranges from 3.5%-7% (death usually
from co-morbid conditions).
 Bleeding stops spontaneously in 80%.

TRIAGE
INITIAL EVALUATION/MANAGEMENT
Assess hemodynamic stability **.
 Assess for active bleeding **.
 2 large bore IV’s, fluid resuscitation.
 Tranfusion based on hct and co-morbidities.
 Correct coagulopathies (FFP, platelets).
 NGT lavage.
 Evaluate need for airway protection.

Notify GI consultants, surgeons if severe and
acute.
 Consider octreotide (somatostatin).
 Endoscopy.
 For complicated cases, can also use angiography,
tagged rbc scan.

VERY LOW RISK
Normal hemodynamics, no bleeding within last
48 hours, negative NGT aspirate (bilious w/ no
blood)**, normal labs.
 Outpatient evaluation acceptable.
 Follow up within one week.
 Oral PPI.

LOW RISK
Hemodynamics return to normal within 1 hour of
resuscitation.
 No evidence of active bleeding **.
 No active cardiopulmonary or liver disease.
 No co-morbid conditions requiring
hospitalization.
 Immediate endoscopy with discharge from
endoscopy suite.

MODERATE RISK
Tachycardia continues despite resuscitation.
 Requires more than 2 units PRBC’s.
 Advanced age, cardiopulmonary disease, liver
disease.
 Admit to hospital bed.
 Early EGD when patient stable.

HIGH RISK
Active bleeding.
 Persistent hypotension.
 Severe co-morbidities.
 Needs airway protection.
 ICU admission.
 Endoscopy when stable.

TRIAGE FOR MR. J…

Actively bleeding, low hct, probable liver disease,
vitals normal on admission (although h/o
syncope).
Where would you place him?
He was admited to MICU, 2 peripheral IV’s
secured, started on IV octreotide, IV pepcid,
IVF’s, vitals and hct monitored.
 GI performed EGD that afternoon:

No varices, large hiatal hernia, hemorrhagic gastritis
in fundus.
 They injected 3cc epinephrine, and then used cautery
on lesions in fundus.


Patient stared on IV protonix, switched to oral
omeprazole 40 mg po bid next day. Hematocrit
reached nadir of 29.5 (required no transfusions).
Discharged with substance abuse follow up, and
recommendations for repeat EGD in 3 months
time.
ENDOSCOPY
Should be performed within 12 hours of
admission.
 Reduces rebleeding rates, number of surgeries,
number of units transfused.
 Mortality has not yet been shown to be reduced
based on meta-analysis.
 Non-thermal and thermal methods used for
hemostasis.


Complications of endoscopy include:
Aspiration
 Hypotension/hypoventilation (due to sedation)
 Perforation

OCTREOTIDE
Long-acting analog of somatostatin.
 Inhibits release of vasodilator hormones such as
glucagon – indirectly causes splanchnic vasoconstriction
which decreases portal inflow.
 Has not yet been shown to have a clearly established
benefit on mortality.
 Used as infusion for up to 5 days in variceal bleeds.

ACID SUPPRESSION
Essential for preventing re-bleeding in the initial
72-hour period after index bleed.
 HCL and pepsin in UGI tract appear to be
antihemostatic.
 Want to maintain intragastric pH at 7 or higher
(pepsin destruction occurs at 8).
 H2 blockers: block histamine H2 receptors on the
parietal cell.

Proton Pump Inhibitors: inhibit production of H+/K+
adenosine triphosphate (final step in acid production).
 In high risk lesions, certain studies have shown that
omeprazole significantly decreases risk of rebleeding.
Another study showed omeprazole infusion after
endoscopic treatment reduced risk of re-bleed, reduced
length of stay, and transfusion requirements.

Break point: continue for specific discussions on
PUD, H. pylori, varices, and Mallory-Weiss tears,
if time permits.
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Otherwise skip to slide 45 for final slides.
PUD (PEPTIC ULCER DISEASE)
Major causes include H. pylori, NSAID’s, stress,
gastric acid (and various combinations).
 Tobacco and alcohol can exacerbate existing
lesions.
 Initial symptoms can be vague – only 50% of
patients with PUD present with typical
symptoms, which include:

- burning/gnawing pain
- post-prandial pain 2-5 hours after eating.
- relief with antiacids.
- bloating, nausea, early satiety.
 If ulcer is bleeding, typically presents with epigastric
abdominal pain, hematemesis/coffee ground emesis,
melena.

Complications (other than bleeding) include
obstruction, penetration (pancreas, duodenum) or
perforation.
H. PYLORI
No data to support routine testing in patients
without ulcer disease.
 Test patients with active or documented PUD or
gastric MALT (biopsy urease test: 95% sensitive,
95% specific).
 H. pylori infection doubles the risk of GI bleed in
patients taking NSAID’s.

One study from Hong Kong in 2002 showed that the
prevalence of ulcers was significantly decreased in
patients who had H. pylori eradicated (prior to starting
NSAID’s).
 Other tests for H. pylori:

Stool antigen (4 weeks post therapy).
 Urease breath test.
 H. pylori serum antibody.

Treatment is with various combinations of a PPI
and two antibiotics for 2 weeks.
 Test for cure.

VARICES (GASTRIC AND ESOPHAGEAL)
Secondary to systemic or portal hypertension.
 Associated with alcoholic liver disease and
chronic active hepatitis (25-40% of patients with
cirrhosis will have a variceal hemorrhage).
 30% mortality with each bleeding episode.
 Risk of rebleed 60-70% in one year.
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Risks factors predictive of bleed:
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Location (GE junction highest risk).
Size (diameter – related to Laplace’s law).
Appearance (red wale marks).
Clinical picture (Childs classification).
Variceal pressure (essentially 0% risk of bleeding
over 12 months if pressure ≤ 13mmHg. 72% chance if
>16mmHg).
Acute therapy: band ligation and sclerotherapy.
 Primary prophylaxis:

Propranolol (shown to reduce risk of hemorrhage at
two years).
 Variceal ligation (for high risk patients).
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Secondary prophylaxis – TIPS procedure.
MALLORY-WEISS TEARS
Longitudinal intramural dissection in distal
esophagus/proximal stomach (submucosal artery
bleed).
 Usually associated with retching.
 Described in 1929 by Mallory and Weiss in 15
alcoholic patients.
 Predisposing conditions:
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Hiatal hernia (seen in 40-100%)
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Chronic alcohol (40%-80%).
Amount of blood loss usually small and self-limited.
 Heal within 24-48 hours.
 Treat actively bleeding lesions with endoscopy.
 PPI’s/H2 blockers promote healing.

KEY POINTS
Triage and resuscitate patient quickly and
appropriately.
 Obtain quick endoscopy.
 Test for H. pylori if ulcers present, and treat if
positive.
 Use PPI’s to reduce risk of rebleeding.
 Remove medications that increase risk of
bleeding.

THE END
RESOURCES
www.uptodate.com
 Lung E. “Evaluation and Management of
Gastrointestinal bleeding Part 1: Nonvariceal
Upper GI Bleeding.” Advanced Studies in
Medicine. Vol 4 (4) April 2004. 186-190.
 Papatheodoridis GV et al. “Effect of Helicobacter
pylori infection on the risk of upper GI bleeding
in users of NSAID’s.” Am J Med. 2004 May 1:
116(9) 601-5.
 Exon DJ, Sydney Chung SC. “Endoscopic therapy
for upper GI Bleed.” Best Pract Res Clin
Gastroenterol. 2004 Feb; 18(1):77-98.
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