Acute Gastrointestinal Bleeding

Rajeev Jain, M.D.

GI Bleeding

• Clinical Presentation

• Acute Upper GI Bleed

• Acute Lower GI Bleed

Case Presentation

• CC: Melena• HPI: 54 yo man taking ibuprofen 200 mg

po tid for the past 2 wks b/o acute LBP after lifting presents with 2 day h/o melena

• PMHx: neg All: NKDA SHx/FHx: neg• Vitals: BP 105/75 P 90• PE: normal

Clinical Presentation

Hematemesis: bloody vomitus (bright red or coffee-grounds)

Melena: black, tarry, foul-smelling stool

Hematochezia: bright red or maroon blood per rectum

Occult: positive guaiac test

Symptoms of anemia: angina, dyspnea, or lightheadedness

Patient Assessment• Hemodynamic status• Localization of bleeding source• CBC, PT, and T & C• Risk factors

– Prior h/o PUD or bleeding– Cirrhosis– Coagulopathy– ASA or NSAID’s

Resuscitation

• 2 large bore peripheral IV’s

• Normal saline or LR

• Packed RBCs

• Correct coagulopathy

Location of Bleeding

• Upper– Proximal to Ligament of Treitz– Melena (100-200 cc of blood)– Azotemia– Nasogatric aspirate

• Lower– Distal to Ligament of Treitz– Hematochezia

Acute UGIBDemographics

• 10,000 - 20,000 deaths annually

• Mortality stable at 10%

• 80% self-limited

• Continued or recurrent bleeding - mortality 30-40%

• Cause of bleeding

• Severity of initial bleed

• Age of the patient

• Comorbid conditions

• Onset of bleeding during hospitalization

Acute UGIBPrognostic Indicators

NASOGASTRIC ASPIRATE

STOOL COLOR

MORTALITY RATE (%)

Clear Red, brown, or black 10

Coffee Grounds Brown or black 10

Red 20

Red Blood Black 10

Brown 20

Red 30

Acute UGIBPrognostic Indicators

Tedesco et al. ASGE Bleeding Survey. Gastro Endo. 1981.

Acute UGIBDifferential Diagnosis

• Peptic ulcer disease– Gastric ulcer– Duodenal ulcer

• Mallory-Weiss tear• Portal hypertension

– Esophagogastric varices

– Gastropathy

• Esophagitis

• Dieulafoy’s lesion• Vascular anomalies• Hemobilia• Hemorrhagic

gastropathy• Aortoenteric fistula• Neoplasms

– Gastric cancer– Kaposi’s sarcoma

Acute UGIBDifferential Diagnosis

DIAGNOSES % OF TOTAL

Duodenal ulcer 24Gastric erosions 23Gastric ulcer 21Varices 10Mallory-Weiss tear 7Esophagitis 6

Acute UGIBFinal Diagnoses of the Cause in 2225 Patients

Tedesco et al. ASGE Bleeding Survey. Gastro Endo. 1981.

DIAGNOSES % OF TOTAL

Peptic ulcer 55 Varices 14 Angioma 6 Mallory-Weiss tear 5 Erosions 4 Tumor 4

Acute UGIBCauses in CURE Hemostasis Studies (n=948)

Savides et al. Endoscopy 1996;28:244-8.

Acute UGIB

CORI Database

University, VA, & privatepractices

20 months (12/99-7/01)

7822 EGDs for UGIB

BoonpongmaneeS. et al. Gastrointest Endosc 2004;59:788-94.

Endoscopic Appearanceof Ulcers

Prognostic Features at Endoscopy in Acute Ulcer Bleeding

Laine and Peterson New Eng J Med 1994;331:717-27.

• Thermal– Bipolar probe– Monopolar probe– Argon plasma

coagulator– Heater probe

• Mechanical– Hemoclips– Band ligation

• Injection– Epinephrine– Alcohol– Ethanolamine– Polidocal

Endoscopic Therapy of PUD

Endoscopic Therapy of PUD

Laine and Peterson New Eng J Med 1994;331:717-27.

Adjuvant Medical Therapy of PUD

• Acid suppression (intragastric pH > 4)– Histamine 2 Receptor Antagonists (H2RAs)

• Ranitidine (Zantac)• Famotidine (Pepcid)

– Proton Pump Inhibitors (PPIs)• Pantoprazole (Protonix)• Lansoprazole (Prevacid)• Esomeprazole (Nexium)

Bleeding PUD: IV H2RAsMeta-Analysis

• Duodenal ulcer: no benefit

• Gastric ulcer: mild benefit– Mortality

• ARR 3%; NNT 33

– Surgery• ARR 7%; NNT 14

– Rebleeding• ARR 7%; NNT 14

• Caveats– Tolerance develops

within 24 hrs– More potent acid

suppression available

Levine JE et al. Aliment Pharmacol Ther 2002;16:1137-42.

472 patients required no endoscopic treatment

27 patients not included: comorbid or no consent

120 patients received IV omeprazole 80 mg bolusthen 8 mg/hr for 72 hours

120 patients received placebo

267 received endoscopic treatment

739 patients admitted with GI bleeding

Lau et al. New Eng J Med 2000;343:310-316.

Adjuvant Medical Therapy of PUD

Adjuvant Medical Therapy of PUD

Lau et al. New Eng J Med 2000;343:310-316.

Bleeding PUD: PO/IV PPIsMeta-Analysis

• Reduction in:– RebleedingNNT* 4-17– Surgery NNT* 6-25

• No change in mortality• PPIs add to endoscopic

therapy but do not supplant endoscopic therapy

* Estimates from pooled ORsLeontiadis, GI et al. BMJ 2005;330:568-75.

Mallory-Weiss Tear

Esophageal Varices

Variceal Band Ligation

Variceal Band Ligation

• Vasopressin/Glypressin• Nonselective vasoconstrictor• 50% efficacy in controlling bleeding• 25% vasospastic side effects

• Octreotide• Cyclic octapeptide analog of

somatostatin• Longer acting than somatostatin• Equivalent to sclerotherapy and

improves endoscopic results

MEDICAL THERAPYAcute Variceal Bleeding

TIPS

IVC

Portal Vein

Splenic Vein

Coronary Vein

Aortoduodenal Fistula

Aorta

Duodenum

Graft

Fistula

Acute BleedingChanges Before and After 2 Liter Bleed

0

1

2

3

4

5

6

Before During 24-72 Hrs

VO

LU

ME

( L

)

Plasma RBC

27%45%45%

Acute UGIB Surgery

• Recurrent bleeding despite endoscopic therapy

• > 6-8 units pRBCs

Case Presentation

• CC: Hematochezia• HPI: 74 yo woman presents with 6 hour

history of painless maroon blood per rectum • PMHx: CAD, Chol, AFib, CABG, L-CEA• Meds: ASA, coumadin, digoxin, lovastatin• Vitals: BP 105/75 P 90• PE: irreg rhythm, maroon blood on DRE

Acute LGIBDifferential Diagnosis

• Diverticulosis• Colitis

– IBD (UC>>CD)– Ischemia– Infection

• Vascular anomalies• Neoplasia• Anorectal

– Hemorrhoids– Fissure

• Dieulafoy’s lesion• Varices

– Small bowel– Rectal

• Aortoenteric fistula• Kaposi’s sarcoma

• UPPER GI BLEED

Acute LGIBDifferential Diagnosis

DIAGNOSES % OF TOTAL

Diverticulosis 40Vascular anomalies 30Colitis 21Neoplasia 14Anorectal 10Upper GI sites 10

Acute LGIBDiagnoses in pts with hemodynamic compromise.

Zuccaro. ASGE Clinical Update. 1999.

Diverticulosis

Diverticular Bleeding

Urgent Colonoscopy for the Diagnosis and Treatment of Severe Diverticular

Hemorrhage

• 121 pts with severe bleeding (>4 hrs after hospitalization)

• 1st 73 pts: no colonoscopic tx

• Last 48 pts eligible for colonoscopic tx

• Colonoscopy w/in 6-12 hrs

Urgent Colonoscopy for the Diagnosis and Treatment of Severe Diverticular

Hemorrhage

Jensen DM, et al. New Eng J Med 2000:342:78-82.

Hemorrhoids

Bleeding AVM

Radiation Proctitis

• Incidence 0.3 - 3.0 %• Etiology Incomplete obliteration of

the vitelline duct.• Pathology50% ileal, 50% gastric,

pancreatic, colonic mucosa• Complications

– Painless bleeding (children, currant jelly)– Intussusception

Acute LGIBMeckel’s Diverticulum

Study Yield

% Comments

Colonoscopy 69-80 Therapeutic

Arteriography 40-78 1 ml/min,

risks

Tagged RBC Scan 20-72 Localization

Acute LGIBEvaluation

Zuccaro. ASGE Clinical Update. 1999.

• Resuscitation• UGI source• Most bleeding ceases• Colonscopy - early• No role for barium studies• 5% Mortality

Acute LGIBKey Points