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GI Bleeds

GI Bleeds. Rebecca Burton-MacLeod Feb 15 th , 2007 Emerg Med Resident Rounds . Overview . Anatomy Upper GI bleeds Lower GI bleeds. Anatomy . UGI vs. LGI defined by Ligament of Treitz…located in 4 th section of duodenum. UGI vs. LGI ? . Melena and hematemesis means UGI bleed, right?

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GI Bleeds

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  1. GI Bleeds Rebecca Burton-MacLeod Feb 15th, 2007 Emerg Med Resident Rounds

  2. Overview • Anatomy • Upper GI bleeds • Lower GI bleeds

  3. Anatomy • UGI vs. LGI defined by Ligament of Treitz…located in 4th section of duodenum

  4. UGI vs. LGI ? • Melena and hematemesis means UGI bleed, right? • Hematochezia—10-15% of pts will be UGI presentation

  5. UGI: PUD Gastric erosions Varices Mallory-Weiss tear Esophagitis Duodenitis LGI: UGI bleed Diverticulosis Angiodysplasia Ca/polyps Rectal disease (hemorrhoids, fistulas, fissures) IBD Infectious Ddx in adults 75% 80%

  6. Ddx in adults • No identifiable source found for GIB in 10% of patients

  7. Elderly and LGIB • Tips from EMR… • Don’t rely on the color of stool to determine the bleeding site. Colors change as transit times vary and blood products break down.• All that bleeds bright red is not a hemorrhoid. Unless it’s bleeding before your eyes, look for another diagnosis.• Elderly patients may not manifest orthostatic changes from blood loss as readily as their younger counterparts. • The initial hemoglobin may not be a reliable indicator of the volume of blood lost, as the volume may be contracted. • Look for other systemic causes if your investigation of the abdominal structures turns up negative and the patient still has abnormal vitals, especially if the rectal bleeding has ceased.• Order typed blood products.• Peritoneal signs may take up to 20 hours to manifest.• Perform a digital exam and anoscopy on a patient with anorectal bleeding.

  8. Case • 78M presents with hematemesis and hematochezia x 2hrs. States he has had increasing episodes over last 30min. Feeling presyncopal. • PMHx: HTN, CAD, AAA repair 3mos ago • O/e: HR 110, BP 100/70; pale, clammy • Any thoughts?

  9. UGI: Esophagitis Gastritis Ulcer Varices Mallory-Weiss tear LGI: Anal fissure Infectious colitis IBD Polyps Intussusception Ddx in peds

  10. Case • 47M brought in with hematemesis…EMS reports just vomited 1-2L of BRB. He reports this is his third episode in last 1hr • Feeling weak, pale. Says he thinks he’s going to vomit again… • HR 132, BP 86/62 • Plan?

  11. Case cont’d • Monitors, supplemental O2 • 2 x 18G IVs • CBC, INR/PTT, T+S • 2L bolus IV N/S with monitoring vitals • Consider PRBC if ongoing vomiting, vitals fail to improve • Consult GI ASAP

  12. Diagnosis • History: • Hematemesis, melena, hematochezia • Duration/amount of bleeding, previous episodes, recent meds/Etoh/surgeries • s/s of blood loss • Physical: • Vitals—sustained tachycardia is most sensitive • Don’t forget the DRE…and good ol’ FOB testing!

  13. Case • 56F who presents c/o abdo pain and “black stool”. Epigastric pain x1day. No emesis. 1x episode of black stool this a.m. No previous hx • PMHx: HTN • Meds: HCTZ, pepto-bismol (used last nite for epigastric pain) • O/E: HR 82, BP 140/80. exam unremarkable except black stool on DRE (FOB negative) • Any thoughts?

  14. Melena: Requires >150ml blood digested over prolonged period (~8h) Pepto-bismol Iron Blueberries Hematochezia: Only 5ml of blood required to turn “toilet water bright red” Beets Ddx bleeding

  15. False positives: Red fruits/meats Methylene blue Chlorophyll Iodide Cupric sulfate Bromide False negatives: Rare! Bile Ingestion of Mg-containing antacids Ascorbic acid FOB testing

  16. HOB testing • What about pt with “coffee ground emesis” appearing vomitus…any role for HOB testing?

  17. Case • 2day-old post SVD, no complications. Discharged home earlier today. At home, had a bloody BM (parents bring the diaper just to show you!) • Pt exams well. Normal vitals. • Any investigations?

  18. GIB investigations • CBC, INR/PTT, T+S • Remember, Hct lags behind clinical picture, and is affected by hemodilution • Consider lytes, BUN, Cr • EKG • Upright CXR if suspect perf

  19. Case • 78M presents to ED with hx of melena x3days…wife convinced him to come get it checked. Slightly dizzy. • PMHx: Afib, diverticulosis • Meds: metoprolol, warfarin • O/e: HR 72 BP 118/69, obvious melena stool on DRE. Exam otherwise unremarkable. • Thoughts ? • Investigations ?

  20. Case cont’d • Blwk: • Hgb 117, Plt 450 • INR >9 • Reverse INR? • Vit K? • FFP?

  21. Role of CT ? • Not indicated in UGIB cases • Sensitivity for identifying mesenteric ischemia is 64-82% • Identification of other colonic pathology is 75% sensitive • specificity 96% • NPV 96%

  22. Case • 58M with hx of CAD. Presents with 2x episodes of melena yest and 1x episode hematemesis after breakfast this a.m. C/o epigastric pain which radiates into his chest, SOB, dizziness. No previous episodes • O/E: HR 92 BP 120/80 • You order CBC, INR/PTT, T+S, EKG

  23. EKG

  24. Case cont’d • His labs are still pending • What do you want to do? • One of your colleagues walks by and eyeballs the EKG and says “wow, that patient needs ASA, b-blocker, heparin, cardiology consult STAT”…what do you think?

  25. UGIB and NG tubes • Any role for NG tube insertion? • May aid in ruling out LGIB in pt with hematochezia • Otherwise, 10% of established UGIB will have negative NGT aspirates…so NOT useful! • Lots of false negatives (ex: bleeding in duodenum or bleeding already stopped) • Bottomline…not very useful…

  26. UGIB management • GI—endoscopy • Gen Surg—operative • Intervent Radiol—angio Melena, Cuba

  27. UGIB and endoscopy • Most accurate diagnostic tool • Identifies source in 78-95% of pts, when performed within 12-24hrs post-UGIB • Allows for risk stratification (rebleeding and mortality) as well as treatment (banding or sclerosing of varices)

  28. When to scope ? • Most authors suggest within 12-24hrs • Lin et al (1996): • Large RCT (n=124pts) showed that endoscopy within 12h is safe and effective • Leads to dec transfusion requirements • Dec length of hospital stay • Dec costs

  29. UGIB and angiography • Detects location of UGIB in 2/3 of pts • Usually performed during active bleeding • Unstable vitals • Ongoing transfusion requirements

  30. UGIB and surgery • Mortality for pts undergoing surgery for UGIB is 23% • Hemodynamically unstable pts, not responsive to medical/transfusion mgmt, endoscopy unavailable • Consider if >5U PRBC given over first 6h or when 2U PRBC required q4h after replacing initial losses—and still unstable!

  31. UGIB medications • PPI—pantoloc • Bolus 80mg then run @ 8mg/h x 72hrs • Role in pts with PUD as cause • Is an adjunct, not therapy for UGIB…still need endoscopy • Somatostatin analogues—octreotide • Bolus 40ug then continuous infusion • Role in esophageal varices • Peptide analogue which causes splanchnic vasoconstriction by direct effect on vascular smooth muscle

  32. Pantoloc ?

  33. Octreotide ? • Multicenter RCT of octreotide vs. injection sclerotherapy for acute variceal hemorrhage • N=150 • No significant differences in control of bleeding, re-bleeding, and mortality • Octreotide felt to be as effective as injection sclerotherapy Jenkins SA, et al. A multicentre randomised trial comparing octreotide and injection sclerotherapy in the mgmt and outcome of acute variceal hemorrhage. GUT. 1997.

  34. Vasopressin ? • Has been used in pts with esophageal variceal hemorrhages • No effect on overall mortality • High rate of complications (9% major, 3% fatal) • Only role would be in exsanguinating pt, with endoscopy or other measures unavailable

  35. Sengstaken-Blakemore tubes • Useful if esophageal variceal bleeding source • Linton tube if gastric varices • High risk of complications (14% major, 3% fatal) • One of those last-ditch efforts! • Insertion techniques…

  36. Equipment: Sterile Sengstaken-Blakemore tube Pair of scissors 50ml syringe 2 x rubber tipped artery forceps Water soluble lubricant 3 metres of white linen tape Pressure gauge Weight for traction Pulley PPE Precautions: Balloon pressure should always be <45mmHg Pt should be intubated prior to procedure Keep scissors near bed at all times (to cut tube prn if migrates and causes resp distress) Check tube placement by: Aspirate and check pH Inject air and auscultate over stomach XR SB tubes…

  37. Insertion… • Any takers ?

  38. SB tube

  39. Sengstaken vs. Linton tubes ? • RCT of SB vs. LN tubes in pts with known esophageal/gastric varices • N=79 • Primary hemostasis in 86% of pts • If esophageal varices as cause, SB more effective at permanent hemostasis (52 vs. 30%) • If gastric varices as cause, LN tube much more effective (50 vs. 0%) Teres J et al. Esophageal tamponade for bleeding varices. Controlled trial between the Sengstaken-Blakemore tube and the Linton-Nachlas tube. Gastro 1978.

  40. LGIB and scopes • Must r/o UGIB source first usually • If mild LGIB with no evidence of hemorrhoids, then anoscopy / proctosigmoidoscopy recommended • Absence of blood above rectum indicates rectal source; however, blood above rectum does not r/o rectal source

  41. LGIB and angiography • Does not usually diagnose cause of bleeding, but identifies source in 40% of pts • Arterial embolization may be useful if ongoing bleeding

  42. Disposition • Very-low risk • Low risk • Medium risk • High risk

  43. D/c home if: • No comorbid disease • Normal vitals • Normal or trace FOB positive • +/- neg gastric aspirate • Normal (or near) Hgb/Hct • Good social situation • F/u within 24hrs • Understanding as to when to return…

  44. Low Risk Moderate Risk High Risk Age <60 Age >60 Initial SBP ≥100 mm Hg Initial SBP <100 mm Hg Persistent SBP <100 mm Hg Normal vitals for 1 hr Mild ongoing tachycardia for 1 hr Persistent moderate/severe tachycardia No transfusion requirement Transfusions required ≤4 U Transfusion required >4 U No active major comorbid diseases Stable major comorbid diseases Unstable major comorbid diseases No liver disease Mild liver disease—PT normal or near-normal Decompensated liver disease—i.e., coagulopathy, ascites, encephalopathy No moderate-risk or high-risk clinical features No high-risk clinical features Initial ED stratification

  45. Clinical Risk Stratification Endoscopy Low Risk Moderate Risk High Risk Low risk hospitalization Immediate discharge[*] 24-hr inpatient stay (floor)[†] Close monitoring for 24 hr[‡]; ≥48-hr Moderate risk 24-hr patient stay[†] 24–48 hr inpatient stay (floor)[†] Close monitoring for 24 hr; ≥48-hr hospitalization High risk Close monitoring for 24 hr; 48–72 hr hospitalization Close monitoring for 24 hr; 48–72 hr hospitalization Close monitoring ≥72-hr hospitalization Stratification with initial and endoscopy findings

  46. Low-risk pts: Hold o/n in ED until scoped Consider admission to Hospitalist until scoped (depending on GI suggestions) Med risk pts: Admit to Hospitalist/Medicine until scoped Scope immediately High risk pts: Scope immediately Admit to Medicine/ICU So what does this mean at FMC for UGIB pts…

  47. Disposition LGIB pts • If not clearly due to hemorrhoids, fissures, proctitis then should admit • Low risk: admit to Hospitalist with scoping • Med/High risk: admit to Medicine/ICU with scoping +/- angio

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