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Basics of GI Bleeding. Ron Thomas, MD Fellow Division of Gastroenterology and Hepatology. Early July on ART 6W…. Overnight admit 69 yo male with recent melena and Hgb to 5 g/dl Prior perforated gastric ulcer with Graham patch Recent hemicolectomy for colonic signet ring adenoCA
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Basics of GI Bleeding Ron Thomas, MD Fellow Division of Gastroenterology and Hepatology
Early July on ART 6W… • Overnight admit • 69 yo male with recent melena and Hgb to 5 g/dl • Prior perforated gastric ulcer with Graham patch • Recent hemicolectomy for colonic signet ring adenoCA • EGD two days prior with large nonbleeding ulcer extending from lesser curvature to incisura • Was in rehab for a few hours before hematemesis
During Rounds • “This patient was admitted for hematemesis” • [Pause, quick glance at patient in room] • “And he’s having active hematemesis now!!”
What do you do now? • Assess hemodynamics • Ensure large bore IV access • Consider PPI infusion • Could we be dealing with varices? • Key labs: CBC, INR, BUN • Think about NG lavage • Don’t think about Fecal Occult
Definitions • Inpatient • Overt • Outpatient • Occult • Obscure • UGIB • LGIB
Magnitude • Acute UGIB estimated to be 400,000 U.S. hospital admissions per year1 • 80-90% of UGIB is nonvariceal2 • Peptic ulcer bleeding • Affects patients > 60 years old3 • 5-10% mortality 2,4 • $2B in U.S. health care spending per year5 1Lewis JD et al. Am J Gastroenterol 2002; 97. 2Barkun A et al. Am J Gastroenterol 2004;99. 3Ohmann C et al. Scand J Gastroenterol 2005; 40. 4Lim CH et al. Endoscopy 2006;38. 5Viviane A et al. Value Health2008;11.
Initial Steps • Estimate hemodynamics • Volume resuscitate • Rectal exam • Identify high risk patients • Early endoscopy is key • Within 24 hours • High risk window 72 hours from presentation
Initial Steps • Understand anti-coagulation history • Assess level of care and airway • Make a differential diagnosis • Find old endoscopy reports
Melena Courtesy of Joseph Thomas, MD
Hematochezia Courtesy of Joseph Thomas, MD
Maroon Stools Courtesy of Joseph Thomas, MD
UGIB: Brief DDx • Peptic ulcer disease • H. pylori • NSAIDs • Malignancy • Mallory-Weiss tear • Erosive esophagitis • Erosive gastritis • Esophageal ulcers
UGIB: Brief DDx • Vascular malformations • Angiodysplasia in CRI • Dieulafoy’s lesion (submucosal arteriole) • GAVE • PHG • Miscellaneous • AE fistula • Pancreatic pseudoaneurysm • Hemobilia
Varices • Some adjustments to protocol • Octreotide drip • Decrease splanchnic blood flow • Reduce portal pressure • Antibiotics • Lower transfusion requirement • Correcting coagulopathy if appropriate • Intubate
LGIB: Brief DDx • Diverticulosis • Angiodysplasia • Neoplastic disease • Colitis • Ischemia, infection, XRT, IBD • Internal hemorrhoids • Solitary rectal ulcer • UGIB
Risk Stratification • Important way to predict who might do poorly • Rockall Score • Age • Shock (HR, BP) • Coexisting illness • Add endoscopic component • Diagnosis • High risk stigmata
Endoscopic Stigmata of Bleeding Peptic Ulcer, Classified as High Risk or Low Risk. Gralnek IM et al. N Engl J Med 2008;359:928-937. Gralnek IM et al. NEJM 2008; 359.
Basic Endoscopic Therapy • Injection AND • Thermal (e.g. heater probe, APC) OR • Mechanical (e.g. clip) • Thermal or mechanical alone • For varices, • Band ligation
Why PPI’s? • Goal of PPI therapy is to raise the gastric PH • High dose PPI infusion decreases basal and stimulated acid secretion by parietal cells • Cochrane meta-analysis that included 6 RCT from 1992-2007 found that IV PPI prior to endoscopy did NOT experience any statistically significant differences in outcomes of mortality, rebleeding, or progression to surgery. • However, analysis did show that PPI therapy resulted in significantly reduced rates of high risk stigmata identified on endoscopy and need for endoscopic therapy. Courtesy of Joseph Thomas, MD
Post-Endoscopy • High risk lesions • PPI infusion for 72 hours after endoscopic hemostasis • Technically • Can advance diet to clears after 6 hours (if hemodynamic instability) • Can go to oral PPI after infusion complete • Discuss with GI consultant • No role for repeat endoscopy in 24 hours; relook if rebleed
Post-Endoscopy • Varices • Octreotide infusion for up to 5 days in conjunction with band ligation1 • Result of meta-analysis • 5 day period highest for re-bleed • Antibiotics for 1 week • For non-variceal bleeding • H pylori testing (preferably from mucosal biopsy) 1Banales R et al. Hepatology2002; 305.
What if Endoscopy Fails? • IR • Tagged RBC scan • Bleeding > 0.1 ml/min • Angiography • Need localization • Renal contrast load • Bleeding 0.5-1.5 ml/min (CT angiography) • Can be therapeutic • Embolization
What if Endoscopy Fails? • Surgery • Uncontrolled bleeding • Recurrent diverticular bleeding • Get on board early
Summary While “all bleeding eventually stops…” • Assess • Resuscitate • Risk-stratify • Form a differential diagnosis • Be particularly vigilant in the first 24 hours
