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GI Bleeds: The Basics

GI Bleeds: The Basics. EM Rounds 2009. Anatomy. UGI vs. LGI defined by Ligament of Treitz…located in 4 th section of duodenum. Epidemiology . UGIB more common in men LGIB more common in women. Ddx in adults. UGI: PUD Gastric erosions Varices Mallory-Weiss tear Esophagitis

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GI Bleeds: The Basics

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  1. GI Bleeds: The Basics • EM Rounds 2009

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

  3. Epidemiology • UGIB more common in men • LGIB more common in women

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

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

  6. 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 • FOB?........

  7. Resuscitation • Two large bore IV’s....foot IV’s don’t count! • Oxygen • 2 liters crystalloid if hypotensive

  8. Ddx bleeding • Melena: • Requires >150ml blood digested over prolonged period (~8h) • Pepto-bismol (will not test FOB positive) • Iron • Blueberries • Hematochezia: • Only 5ml of blood required to turn “toilet water bright red” • Beets

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

  10. GIB investigations • CBC, INR/PTT, T+S, LFT’s • Remember, Hct lags behind clinical picture, and is affected by hemodilution • Consider lytes, BUN, Cr • EKG • Upright CXR if suspect perf

  11. UGIB management • GI—endoscopy • Gen Surg—operative (hemodynamically unstable patients unresponsive to conventional treatments) • or some suggest if > 5U blood in 1st 4 - 6 hrs... • Intervent Radiol—angio

  12. 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)

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

  14. 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 50ug then continuous infusion of 25 - 50ug/hr • Role in esophageal varices • Peptide analogue which causes splanchnic vasoconstriction by direct effect on vascular smooth muscle

  15. 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

  16. 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…

  17. SB tubes… • 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

  18. SB tube

  19. 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

  20. 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

  21. Disposition • Very low risk (can be d/c’d home) • Low risk • Moderate risk • High risk

  22. Very low risk • 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…

  23. Persistent moderate/severe tachycardia Mild ongoing tachycardia for 1 hr 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 No moderate-risk or high-risk clinical features No transfusion requirement Transfusions required ≤4 U Transfusion required >4 U No active 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 high-risk clinical features Stable major comorbid diseases Initial ED stratification

  24. Close monitoring ≥72-hr hospitalization Endoscopy Low Risk Moderate Risk High Risk Close monitoring for 24 hr; 48–72 hr hospitalization Close monitoring for 24 hr; 48–72 hr hospitalization High risk Clinical Risk Stratification Low risk hospitalization Close monitoring for 24 hr[‡]; ≥48-hr Close monitoring for 24 hr; ≥48-hr hospitalization 24-hr inpatient stay (floor)[†] 24-hr patient stay[†] Immediate discharge[*] Moderate risk 24–48 hr inpatient stay (floor)[†] Final Stratification for Pt’s with UGIB after endoscope combined with initial ED stratification

  25. So what does this mean at FMC for UGIB pts… • 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

  26. 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

  27. Airway in GI Bleeds • Low threshold for capturing airway • Have suction (or two) ready • Extra hands • Follow the bubbles • Airway Rescue devices ready

  28. Pearls • Elderly patients or those with underlying CAD can present with ischemic chest pain secondary to blood loss from GI bleed. • Don’t forget NSAID or EtOH hx • Correct coags ASAP • BUN is often elevated in UGI bleeds secondary to absorption of blood from GI tract and hypovolemia causing prerenal azotemia (BUN:CR ratio > 20)

  29. Pearls • AAA repair and GI bleed need to r/o aorto-enteric fistula • Fever and GI bleed consider aorto-esophageal fistula • Resuscitate, resusciate, resuscitate

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