Transcript Upper GI bleed History - Vanderbilt University Medical Center

Gastrointestinal Bleeding
Lisa N. Flemmons, ACNP-BC
Vanderbilt University Medical Center
Medical Intensive Care Unit
Objectives
• Learn how to effectively evaluate and manage gastrointestinal
bleeding in the critically ill patient
• Distinguish upper gastrointestinal bleeding from lower and
discuss possible etiologies
• Understand diagnostic testing and therapeutic interventions
• Review and discuss transfusion strategies in the
gastrointestinal bleeding patient
Epidemiology
• Common and potentially fatal diagnosis
accounting for ~30,000 admissions/year
• Upper GIB accounts for 20,000 deaths/year
• In our MICU, it is the 3rd most common
diagnosis
Distinguishing upper vs lower
Upper GI bleed
– History
• Previous PUD
• Alcoholism/liver dz varices
• Retching/vomiting  Mallory
Weiss tear
• Medications such as
anticoagulants, antiplatelets,
NSAIDS → ulcers
– Symptoms
• Nausea/vomiting
• Hematemesis
• Melena
• Rarely hematochezia (massive
bleed)
Lower GI bleed
– History
• Previous colon cancer
• Previous colon surgery
• Known diverticulosis
• Known hemorrhoids
– Symptoms
• Abdominal pain or can be
painless
• Hematochezia
• Melena (less common)
Evaluation and Assessment
• ABCs of GIB
1. Airway and Access
2. Blood products
3. Correct Coagulopathy and
Consultation
4. Drugs and Diagnostic testing
Airway and Access
• Ensure adequate airway
–Hematemesis
–Altered mental status
–Shock
–Needed for endoscopy
• Adequate access
–2 large bore PIV vs CVC
Blood Products
• Crystalloid infusion while waiting on
PRBC
• Vasopressors are not a substitute for
volume resuscitation
• Each PRBC should increase PCV by ~3%
per unit
Transfusion goal
• Randomized 921 patients to either liberal or restrictive
strategy
• Liberal strategy transfusion trigger was Hgb <9 and restrictive
strategy was 7
• The probability of survival at 6 weeks was higher in the
restrictive-strategy group than in the liberal-strategy group
(95% vs. 91%).
• Further bleeding occurred in 10% of the patients in the
restrictive-strategy group as compared with 16% of the
patients in the liberal-strategy group and adverse events
occurred in 40% as compared with 48%.
6 week survival rate in the 2 groups
Correction of Coagulopathy
• FFP transfusion
– Synthetic liver dysfunction
– Warfarin
• Consider Vitamin K
– Dilutional coagulopathy
– Goal INR <1.5
• Platelet transfusion
– in bleeding pt if less than 50K
– Platelet dysfunction
• Anti-platelet agents or uremia
– Goal platelets >50, 000/mm³
Correction of Coagulopathy
• Transexamic acid
– Synthetic derivative of aminoacid lysine that
inhibits fibrinolysis or dissolution of the clot
– Given as 1 gm loading dose followed by 1 gm IV
infusion over 8 hrs
Correction of Coagulopathy
• Prothrombin Complex Concentrate
– Non-activated concentrate of Vitamin K
dependent factors (II, VII, IX, X)
– Advantages compared to FFP:
1. small volume with rapid infusion time
2. no time delays for ABO blood typing and thawing
3. less risk of pathogen transmission, transfusion related
ALI, add circulatory volume overload
4. less time to correct coagulopathy
Consultation
• Urgent gastroenterology consult
• Consider surgical consult
– Massive transfusion
– Abdominal pain associated with GIB
– Recurrent bleeding
Diagnostics
• Upper GIB→EGD
(esophagogastroduodenoscopy)
– Definitive test for diagnosis and treatment
– Safe to perform once the airway is secure and pt is
reasonably hemodynamically stable
– Interventional options: epinephrine injection,
cauterization, clipping, or banding of varices
– May give 1 time dose of erythromycin 250 mg IV or Reglan
10 mg IVP to promote gastric emptying prior to procedure
Large ulcer
Status post cauterization
Submucosal duodenal tumor
1.5 cm lesion
s/p resection
Site of resection: friable and
oozing with visible vessel
S/p epinephrine and
cauterization
Diagnostics continued
• Lower GIB→colonoscopy
– If slow bleed consider bowel prep overnight to
allow for maximum visualization
– If brisk bleed consider STAT colonscopy, tagged
RBC scan, or angiography
• Tagged RBC scan vs angiography
• If upper and lower endoscopy fail to ID source
then can consider video capsule or push
enteroscopy
Drugs
• Proton pump inhibitor BID
Am J Health-Syst Pharm—Vol 62 Jun 1, 2005 1165
Drugs
• If hx of liver disease or ascites give SBP
prophylaxis (quinolone, CTX, or bactrim)
• Octreotide gtt for hx of liver disease or known
varices
• Hold beta blocker in the acute setting which
will prevent/block reflex tachycardia
Minnesota/Blakemore Tube
A flexible tube consisting
of an esophageal and
gastric balloon that is
inflated and is used as a
temporizing measure to
tamponade gastric and/or
esophageal varices.
Minnesota/Blakemore Tube
Uses
Cautions
• Should have experienced
personnel assist with insertion
• Maximum amt of time 24-72
hrs
• Must be to traction (usually a
football helmet)
• KUB and CXR for confirmation
of placement (keep in mind
after transfer from OSH)
• Necrosis if inflated too much
or too long
• Nasal insertion can cause nose
bleeds and sinusitis
• Can migrate upwards and
compress trachea especially in
shorter stature patients
• Perforate or tear esophagus
during insertion
Large esophageal varices with
red wales sign
Status post banding
Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Increased pressure in PV forces blood to
flow into smaller branches coming from
abdominal organs that normally drain into
the PV. These veins then enlarge and are
referred to as varices
• 63 patients with cirrhosis and acute variceal bleeding
randomly assigned within 24 hours after admission
– 32 patients assigned to early TIPS group (within 72
hours)
– 31 patients assigned to continuation of vasoactive
drugs, NS- beta blockade, and long term EBL with
insertion of a TIPS as rescue therapy if needed.
• Results
– rebleeding or failure to control bleeding occurred in 14
patients in the pharmacotherapy–EBL group as compared
with 1 patient in the early-TIPS group (P=0.001).
– The number of days in the intensive care unit and the
percentage of time in the hospital during follow-up were
significantly higher in the pharmacotherapy–EBL group
than in the early-TIPS group.
– The 1-year actuarial survival was 61% in the
pharmacotherapy–EBL group versus 86% in the early-TIPS
group (P<0.001).
References
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CRASH-2 trial collaborators, Lancet 2010; 376; 23-32
Garcia-Pagan et al, NEJM 2010; 362: 2370-9
Lau JY, Sung JJ, Lee KKC, et al, NEJM 2000; 343: 310–316
Marini, J.J., Wheeler, A.W. (2010). Critical care medicine: The
essentials (4th ed.). Philadelphia, PA: Lippincott Williams &
Wilkins.
• Rivkins, K., Lyakhovetskiy, A AJHP 2005; 62: 1164-1165
• Sarode, R., et al, Circulation 2013; 128: 1234-1243
• Villaneuva, C et al NEJM 2013; 368: 11-21