EM/IM Conference July 21, 2010

1. EM/IM ConferenceJuly 21, 2010 Erin Nasrallah M.D. Walter Conwell M.D.

2. One day in the Mitchell…. Called to Dr. Cart: DCAM Lobby…. 71 y/o F with apparent pre-syncopal episode with prodrome of dizziness/light-headedness, abdominal pain PMhx: HTN, CHF (EF 48%), CAD s/p stenting, Diverticulosis, PUD PSHx: Polypectomy, TAH Meds: ASA, Plavix, Simvastatin, Pantoprazole Allergies: NKDA SocialHx: Unremarkable

3. Vitals: T: 36.9 P: 98 BP: 142/87 R:18 Sat: 100%RA • Physical Exam: • Gen: No acute distress, awake and alert • HEENT: Conjunctival palor • CV: Tachy, distal pulses intact, warm and perfused, brisk cap refill • Resp: CTA bilaterally • Abd: Soft, non-tender, non-distended • Ext: Scant pitting edema in LE bilaterally • DRE: Normal tone, gross blood, blood soaked pants and sitting in clots in the bed

4. Initial Thoughts?

5. What’s your Initial Differential? Upper: PUD Esophageal varices Erosive gastritis Mallory Weiss tear Angiodysplasia Malignancy Dieulafoy’s Lesion Lower Diverticulosis Hemorrhoids Colitis Malignancy Angiodysplasia Aortoenteric fistulas

6. Principles of Management • Resuscitation • Localization • Hemostasis 6

7. Key Points in Management of GI Bleeding- Resuscitation • ABCs • Intubation if airway compromised • ACCESS: 2L bore IVs (18 guage or larger); Cordis 7.5 French – need at least 2 16g to equal a cordis (8uLQ/πr4) • Arterial Line, Foley (UO) • Orthostatics • Transfusion: Can order Oneg if uncertain of blood type when need blood fast!!!!

8. Key Point: Massive Transfusion Protocols Described in trauma literature Pre-determined ratios of transfusion of blood products found to improve survival in military and civilian settings, decrease blood products used, and decreased length of stay RBC: FFP: Platelet: Cryoprecipitate, ideally should be 1:1:1:1 Platelets: 1 for plt <50 Fresh frozen plasma (12ml/kg)is administered if PT or PTT are running higher than 1.5 times control levels Cryoprecipitate (1-1.5 packs/10kg) is given for Fibrinogen levels < 0.8g/l Aggressive transfusion improves mortality

9. Key Points in Management of GI Bleeding- Initial Localization • NG Lavage: • Important for risk stratification (blood in NG aspirate predictor of adverse outcomes as well as predictor of high risk lesions). Doesn’t get past the pylorus so NPV of only 0.6; (OK in esophageal varices)

10. What Next? Labs/Studies: Type and screen PT/PTT/INR CBC BMP EKG Cardiac Panel Interventions: 2 large-bore IVs NS 500ml bolus NG lavage MICU, GI, Surgery Notified Clinical Course: Dizzy/light-headed Repeat BPs: 80s/60s Continued BRBPR, passage of clots

11. Risk Stratification and Triage • Where would the patient be best served? • What Variables do you consider when making this decision?

12. Key Point: Risk Stratification

13. Pre-endoscopy Rockall Score Rockall, TA Et al Gut 1996; 38:316-21.

14. Implications of initial score • Initial risk score (pre-endoscopy) • Score Mortality • 0 0.2% • 1 2.4% • 2 5.6% • 3 11.0% • 4 24.6% • 5 39.6% • 6 48.9% • 7 50.0% Rockall TA et al Gut 1996; 38: 316-21

15. Triage • BLEED Classification • High risk defined as any of the following: • Ongoing Bleeding • Low Systolic Blood pressure • Elevated PT • Erratic Mental Status • Ustable comorbid Disease • External Validation • The combination of red blood or unstable comorbidity had a sensitivity of 0.73, a specificity of 0.55, a positive predictive value of 0.24, and a negative predictive value of 0.91 for complications within 24 hours. Das, A Crit Care. 2008;12(3):154. Kollef, M Crit Care Med 1997; 25(7):1125-32

16. Vitals and Labs at MICU Eval 4:30am • Denies any sob, no cp, airway clear. denies any pain. However patient has ongoing BRBPR. • Total Infused: • 6 units PRBC, • 2 units FFP, • 5 liters NS 0.9 • BP 164/88 | Pulse 88 | Temp 36.1 °C (97 °F)| Resp 20| SpO2 91% • CBC: WBC13.5, Hgb11.5, HCT 33.9, Plat 82 • Hgb Trend 10.7>13.2>11.0>11.5 • BMP: Na 143,K 3.6,Cl 117, HCO3 17,BUN 30, Cr. 1.3, Glu 128 • ABG: 7.32/35/43/81.1% 16

17. Next Steps in Management- Localization • What is the most likely source of bleed? • What historical factors can help you to localize? 17

18. Most Common Sources of LGIB 18 Zuccaro, G Amer J Gastro 1998; 93: 1202

19. What diagnostic procedures would you pursue?

20. Initial Localization Zuccaro, G Amer J Gastro 1998; 93: 1202

21. NG Lavage negative for blood or bile • EGD on 07/09/2010 at 5:10 am- Normal esophagus. Two gastric polyps. Normal duodenum. • Colonoscopy on 07/09/2010 at 8:45am- LGIB likely secondary right-sided diverticular disease given blood observed throughout the colon.Diverticulosis in entire colon. No active bleeding from one diverticulum. Normal terminal ileum with no blood washing down. The entire colonicmucosa was not visualized due to blood clots. 21

22. Next Steps • How would you proceed? 22

23. 23

24. Tagged Scan Vs. Angiography? • RBC scan requires 0.1-0.5 ml/min bleeding • TRBC is more sensitive but less specific than angiography • TRBC scan is most often used as a screening test before angiography. Given that a negative TRBC scan will likely yield a negative angiogram. Mesenteric angiography, requires 1-1.5 ml/min bleeding 100% specificity, sensitivity ranges 30-47% Potential for Therapeutic intervention. Fioritio, J Am J Gastroenterol 1989 84(8):878-81 Dusold R; Am J Gastroenterol 1994;89(3):345-8 24

25. Nuclear medicine tagged red blood cell scan on 07/09/2010 at 12:30pm- Positive GI bleeding from ascending colon/hepatic flexure. • IR Mesenteric Angiogram and embolization on 07/09/2010 at 3:30pm-Positive GI bleed off of terminal third branches of vasa recta from right colic artery. Extravasation was successfully treated with coils with no significant bleeding on followup angiogram. Of note multiple feeders in the area where not accesible. 25

26. Pts hemoglobin stabilized post procedure • She was transferred to general medical service on July 10, 2010, for further management. 26

27. She subsequently had several episodes of maroon stools with slow decrease in HgB from 10 to 8.5. 27

28. Next Steps 28

29. Watchful Waiting • 76% of diverticular bleeds stop spontaneously. • Nearly all patients requiring < 4units /24hrs spontaneously stop. • Patients who required >4 units/24hrs had a 60% chance of going to Surgery. McGuire,H Ann Surg 1994;20:653-6 29

30. When to Consult Surgery • Surgery usually is employed for hemorrhage in two settings: massive (exanguinating) or recurrent bleeding. • It is required in 15% to 25% of patients who have diverticular bleeding and is recommended for patients with a high transfusion requirement (generally more than four units within a 24-hour period or greater than 10 units total) • Recurrent bleeding from diverticula occurs in 20% to 40% of patients and generally is considered an indication for surgery • Important to localize before surgery, operative mortality is 10% even with accurate localization and up to 57% with blind subtotal colectomy. Setya, V Ann Surg 1992; 58: 295-9 30

31. Surgery was re-consulted as she was not a candidate for IR embolization or endoscopic management at this point. 31

32. Pts. Hgb bumped appropriately to subsequent transfusions and remained stable at approx 10. • Her aspirin was restarted on July 14,2010, prior to her discharge. Plavix was discontinued as per her cardiologist. 32

33. Take Home PointsPrinciples of Managment • Resuscitation • Adequate Access • Massive Transfusion Protocol • Appropriate Triage • Localization • History • NG Lavage • Endoscopy • Tagged RBC Scan and Angiography • Hemostasis • Correct Coagulapathy • Nexium and Octreotide for Upper or Variceal Bleeds • Embolization • Surgical Intervention