Angel Qin, MDPGY 3

GI BLEEDING

Objectives•D

efine GI bleed •C

ommon presentations•I

nitial assessment•C

ommon causes of UGIB and LGIB•D

ifferent diagnostic tests and therapeutic options•U

pdates in GI bleeding•P

ractical tidbits along the way

Definitions•A

cute 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)

Ligament of Treitz

UGIB: proximal to the ligament of Treitz

LGIB: distal to the ligament of Treitz

Common presentations…•“

I am vomiting blood”•“

When I wipe, there is blood on the toilet paper”•“

My stools have changed color”•N

ew finding of anemia on routine labwork

Initial assessment•I

s 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?•A

ppearance• In distress?• Pale?• Actively bleeding in front of you?

•Vital signs• Tachycardic?• Hypotensive?• Hypoxic?

ABCs•A

irway• 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•I

VF• 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…•H

as this ever happened before?•M

edical 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…•V

ITAL 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•L

abs (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•C

onsider 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•G

astric and/or duodenal ulcers•E

sophageal varices w/wo portal gastropathy•E

sophagitis•E

rosive gastritis/duodenitis•M

ore rare causes:• Mallory-Weiss syndrome• Angiodysplasia• Mass lesions (polyps/malignancy)• Dieulafoy’s lesions

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): 468-76

Medical therapy for UGIB•I

V 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•P

UD• 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

VARIABLE*

SCORE

0 1 2 3

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 gastrointestinal tract

—

Stigmata of recent hemorrhage

None or dark spot only

— Blood in upper gastrointestinal tract, adherent clot, visible or spurting vessel

—

RISK OF REBLEEDING AND MORTALITY BASED ON ROCKALL RISK SCORE

RISK

SCORE

0 1 2 3 4 5 6 7 ≥ 8

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

Rockall Risk Scoring System for Assessment After an Episode of Acute Upper Gastrointestinal Bleeding

Common causes of LGIB•D

iverticulosis •I

schemia •A

norectal disease (hemorrhoids, fissures, ulcers)•N

eoplasm (benign and malignant)•I

nflammatory bowel disease•M

ore rare causes• Angiodysplasia• Radiation colitis• Colitis NOS

Therapy for LGIB•N

o medical therapies•B

leeding 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•R

arely an emergent procedure•S

tandard 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•C

heck 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 NEJM1, 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!