Gi bleeding Angel Qin, MD PGY 3
Objectives • Define GI bleed • Common presentations • Initial assessment • Common causes of UGIB and LGIB • Different diagnostic tests and therapeutic options • Updates in GI bleeding • Practical tidbits along the way
Definitions • AcuteGI bleed • < 3 days duration • Hemodynamic instability • Requires blood transfusion • Overtvsoccult • Overt: visible blood (melena, hematochezia, bright red blood per rectum, coffee ground emesis) • Occult: detected only on lab tests (ie stool cards)
UGIB: proximal to the ligament of Treitz LGIB: distal to the ligament of Treitz Ligament of Treitz
Common presentations… • “I am vomiting blood” • “When I wipe, there is blood on the toilet paper” • “My stools have changed color” • New finding of anemia on routine labwork
Initial assessment • Is 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? • Appearance • In distress? • Pale? • Actively bleeding in front of you? • Vital signs • Tachycardic? • Hypotensive? • Hypoxic?
ABCs • Airway • 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 • IVF • 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… • Has this ever happened before? • Medical 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… • VITAL 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 • Labs (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 • Consider 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 • Gastric and/or duodenal ulcers • Esophageal varices w/wo portal gastropathy • Esophagitis • Erosive gastritis/duodenitis • More 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 • IV 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 • 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 • 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. • 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 • PUD • 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
Rockall Risk Scoring System for Assessment After an Episode of Acute Upper Gastrointestinal Bleeding
Common causes of LGIB • Diverticulosis • Ischemia • Anorectal disease (hemorrhoids, fissures, ulcers) • Neoplasm (benign and malignant) • Inflammatory bowel disease • More rare causes • Angiodysplasia • Radiation colitis • Colitis NOS
Therapy for LGIB • No medical therapies • Bleeding 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 • Rarely an emergent procedure • Standard 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 GoLytelyproceed 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 • Check 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!
