Gastrointestinal Bleeding

Why is GI bleeding important? Mortality rates from upper GI

bleeding vary from 3.5% to 7% in the U.S.

Mortality rates for lower GI bleeding is reported at 3.6%

If new GI bleed in hospital, mortality can be 25%

Billions of dollars spent for >300,000 hospitalizations per year

Why is GI bleeding important Complications

Integrilin Heparin, etc.

Iatrogenic causes NSAIDS Aspirin Coumadin

Approach to GI Bleeding Identify the Clinical Setting

ER vs. Ward vs. MICU vs. CCU vs. Clinic Clinical presentation – i.e.

history/assessment Resuscitation Labs Localize Bleed Definitive therapy

Resuscitation Key component to GI Bleed Identify stumbling blocks

Pt with sign comorb. – CHF, valvular hrt dz, etc.

Review setting where res. should occur Access

Should be automatic – 2 large bore IVs

Resuscitation cont. Mention on size:

Poiseuille’s law Triple Lumen: two

18 g, one 16 g with length 20 cm

Central line: 8F with 10 cm length

Short and wide will get the job done

Resuscitation cont. Fluid of choice

Isotonic fluid – Normal Saline or Ringer’s are both good choices

Patients with active bleeding and a coagulopathy (INR>1.5) or thrombocytopenia (<50,000) should be transfused with FFP and platelets, respectively

Resuscitation cont. Frequent vitals checks and gauging

initial status Orthostatics, pulse, hypoxia, symptoms

(agitation, lightheadedness, etc.) Vitals:

Normal BP: minor blood loss <10% of volume + orthostatics: mod blood loss 10-20% of vol. Resting hypotension: SEVERE BLOOD LOSS

>20-25%

HPI Goal is to help identify likely

source and potential etiologies Also to identify those patients

most at risk – i.e. who will crump on the way to the unit

Focus on the details – how much, how long, pain, meds, etc.

HPI – cont. Upper GI bleed commonly presents with

hematemesis (vomiting blood or coffee-ground material) or melena (black, sticky maladorous stool) 5x more likely to be an upper source Defined as bleeding occurring proximal to

the ligament of trietz Melena: at least 50 cc of blood loss –

typically upper source, but cecal bleeds can be melanic

If pt is vomiting BRB – GET NERVOUS!!!

HPI – cont. Bleeding from a lower GI source refers

to blood loss originating from a sight distal to the ligament of Treitz.

Lower GI bleeding typically presents with hematochezia (passage of maroon or bright red blood from the rectum)

Up to 11% of patients with hematochezia may have an upper source

Patient’s historyImportant historical features include:1. Age: elderly are more likely to bleed

from diverticula, ischemic colitis, malignancy and younger patients are more likely bleeding from PUD, esophagitis, varices

2. Prior bleeding3. Known GI disease: diverticulosis, IBD,

PUD, portal hypertension4. Previous surgery

Patient’s history cont.

5.Medications: coumadin, heparin, NSAIDs, aspirin

6.Abdominal pain: PUD, mesenteric ischemia

7.Change in bowel habits, weight loss, anorexia

8.Other comorbid conditions: CKD, coagulation d/o

9.Previous retching: Mallory-Weiss

Lab’s and Rad’s CBC – may be normal LFTs, coags – screening tool and

identifying synthetic dysfunction Chemistry or P2 – watch BUN – will

tend to trend up if upper CXR / AAS – specific clinical

presentations – looking for catastrophe – free air – mediastinum or abdomen

Bedside Studies“Never trust anyone’s lavage” – Todd Sheer

NG Lavage – were the money is made (90% sensitive for UGI) Blood (18% mortality) – GET

NERVOUS Coffee grounds (10% mortality) –

likely not actively bleeding Clear (6% mortality) – could have bled

and stopped Bilious – rules out upper bleed

Bedside Studies cont. Proctoscope

Typically performed by general surgery and for hematochezia

Looking for obvious ulcerations, fissures, etc. - limited exam as only 10-20 cm observed and messy!

Diagnostic Studies and Therapeutics EGD Colonoscopy Tagged RBC scan Angiography Surgery

Further Evaluation and Therapy

EGD: Can be performed at the bedside Has high diagnostic accuracy, is

therapeutic and associated with low morbidity

Should be performed early in the course

Patient must be hemodynamically stable

Further Evaluation and Therapy

Colonoscopy: Advantages include precise

localization of bleeding and potential therapeutic intervention.

Early colonoscopy has been associated with reduced length of hospital stay

Further Evaluation and Therapy

Radionuclide Imaging with TRBC scan: Noninvasive modality Detects bleeding that is occurring at a

rate of 0.1 to 0.5 ml/m. Accuracy rates range from 24 to 91% Clinical utility of this test is for

screening before arteriography

Further Evaluation and TherapyAngiography Requires active blood loss of 1 to 1.5 ml/m 100% specific but sensitivity varies from

30-47% If an active lesion is found, intraarterial

vasopressin can be infused causing vasoconstriction and cessation of bleeding

Complications such as intrarterial thrombosis, embolization and renal failure occur in 11% of patients

Further Evaluation and Therapy

Surgery: General indications for surgery are:

Transfusion requirements that exceed 4-6 units over 24 hours or 10 units overall

More than two to three recurrent bleeding episodes from the same source

Upper GI Bleed

Final Diagnosis of the Cause of UGIB in 2225 Patients (Silverstein, et al, Gastrointest Endo)

1. Gastric/Duodenal Ulcer 45%2. Gastric Erosions 23%3. Varices 10%4. Mallory-Weiss Tear 7%5. Esophagitis 6%6. Neoplasm 3%7. Other 6%

PUD Dr. Robin Warren and Professor

Barry Marshall – fought the battle to prove h. pylori was associated with PUD

Marshall swallowed a culture or h. pylori

Koch would be proud:

PUD cont. Other risk factors: NSAIDS and stress Initial approach: high dose PPI

Capozza: “High dose PPI is as good as endoscopy initially in stopping the bleed”

IV pantoprazole: 80 mg bolus then 8 mg/hr drip

Definitive therapy: endoscopy with injection versus thermal coagulation

Later that night…. Re-bleeding:

Active arterial bleeding 90%

Non-Bleeding visible vessel 50%

Adherent clot 25-30% Oozing without visible

vessel 10-20% Flat Spot 7-10% Clean ulcer base 3-5%

Mallory-Weiss Tear A mucosal tear at

the gastroesophageal junction

Bleeding ceases spontaneously in almost all instances

Consider PPI for 1-2 weeks to promote healing

Mallory-Weiss

Esophageal Varices Variceal hemorrhage requires an ICU

admission Consider endotracheal intubation in

patients who are thought to be actively bleeding for airway protection

Start Octreotide infusion immediately (50 to 100 mcg bolus followed by infusion at 25-50 mcg/hour)

Endoscopy with variceal ligation or banding is the therapy of choice

Esophageal VaricesTIPS (transjugular intrahepatic

portosystemic shunt) A radiologic procedure where a

metal stent is placed between the hepatic veins and portal vein

Indication for TIPS: intractable bleeding unresponsive to variceal ligation or sclerotherapy

Uncommon Causes of Upper GI bleed Gastric antral vascular ectasia Portal hypertensive gastropathy Hemobilia Hemosuccus pancreaticus Aortoenteric Fistulas Upper GI tumors Dieulafoy’s lesion Cameron lesions

Final Diagnosis in Major Lower GI Bleeding

Diverticulosis 43%Angiodysplasia 20%Undetermined 12%Neoplasia 9%Colitis 9%Other 7%

Management of Lower GI Bleed

Acute Hematochezia

Eval and Res.

NGT aspiration

Bile and NO BLOOD

All other

EGD UGI source

Treat as appropriate

negativecolonoscopy

Source identified Negative Exam Not possible due to severity of bleeding

Treat as appropriateHas hematochezia ceased?

no

YES

Small bowel studies

Arteriography versus nuc med scan

Surgical consultation

Diverticular Bleeding Occurs in only 3% of patients with

diverticulosis 75% of diverticula occur in the left side of

the colon Source of diverticular bleed is right sided

50-90% of the time Acute, painless hematochezia Self-limited 70-80% of the time Colonoscopy is diagnostic and

therapeutic

Angiodysplasia Dilated, tortuous submucosal vessels May be the most frequent cause of

acute lower GI bleed in patients over 65

Painless hematochezia Self limited Colonoscopy is diagnostic and

therapeutic

Ischemic Colitis Common entity in the elderly Usually caused by low flow states and

small vessel disease rather than large vessel occlusion

Most commonly occurs at splenic flexure, descending or sigmoid colon

Typically presents with mild, crampy abdominal pain localized to LLQ

May see “thumb printing” on plain films Most cases resolve with supportive care

References Shields, W. “GI Bleed (what I learned from

Patrick)” July, 2003. Uptodate, of course Zuccaro, G. Management of the Adult Patient

with Acute Lower Gastrointestinal Bleeding. Am J Gastro 1998;93:1202-08.

Barkun, A. et al. Consensus Recommendations for Managing Patients with Nonvariceal Upper Gastrointestinal Bleeding. Ann Internal Med. 2003;139:843-857.