rebecca burton-macleod feb 15th, 2007 emerg med resident rounds
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Overview Anatomy Upper GI bleeds Lower GI bleedsTRANSCRIPT
GI BleedsRebecca Burton-MacLeodFeb 15th, 2007Emerg Med Resident Rounds
Overview Anatomy Upper GI bleeds Lower GI bleeds
Anatomy UGI vs. LGI defined by Ligament of
Treitz…located in 4th section of duodenum
UGI vs. LGI ? Melena and hematemesis means
UGI bleed, right? Hematochezia—10-15% of pts will be
UGI presentation
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
75%80%
Ddx in adults No identifiable source found for GIB
in 10% of patients
Elderly and LGIB Tips from EMR… Don’t rely on the color of stool to determine the bleeding site.
Colors change as transit times vary and blood products break down.• All that bleeds bright red is not a hemorrhoid. Unless it’s bleeding before your eyes, look for another diagnosis.• Elderly patients may not manifest orthostatic changes from blood loss as readily as their younger counterparts. • The initial hemoglobin may not be a reliable indicator of the volume of blood lost, as the volume may be contracted. • Look for other systemic causes if your investigation of the abdominal structures turns up negative and the patient still has abnormal vitals, especially if the rectal bleeding has ceased.• Order typed blood products.• Peritoneal signs may take up to 20 hours to manifest.• Perform a digital exam and anoscopy on a patient with anorectal bleeding.
Case 78M presents with hematemesis and
hematochezia x 2hrs. States he has had increasing episodes over last 30min. Feeling presyncopal.
PMHx: HTN, CAD, AAA repair 3mos ago O/e: HR 110, BP 100/70; pale, clammy Any thoughts?
Ddx in peds
UGI: Esophagitis Gastritis Ulcer Varices Mallory-Weiss tear
LGI: Anal fissure Infectious colitis IBD Polyps Intussusception
Case 47M brought in with hematemesis…
EMS reports just vomited 1-2L of BRB. He reports this is his third episode in last 1hr
Feeling weak, pale. Says he thinks he’s going to vomit again…
HR 132, BP 86/62 Plan?
Case cont’d Monitors, supplemental O2 2 x 18G IVs CBC, INR/PTT, T+S 2L bolus IV N/S with monitoring
vitals Consider PRBC if ongoing vomiting,
vitals fail to improve Consult GI ASAP
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 Don’t forget the DRE…and good ol’ FOB
testing!
Case 56F who presents c/o abdo pain and “black
stool”. Epigastric pain x1day. No emesis. 1x episode of black stool this a.m. No previous hx
PMHx: HTN Meds: HCTZ, pepto-bismol (used last nite for
epigastric pain) O/E: HR 82, BP 140/80. exam unremarkable
except black stool on DRE (FOB negative) Any thoughts?
Ddx bleeding
Melena: Requires >150ml
blood digested over prolonged period (~8h)
Pepto-bismol Iron Blueberries
Hematochezia: Only 5ml of blood
required to turn “toilet water bright red”
Beets
FOB testing False positives:
Red fruits/meats Methylene blue Chlorophyll Iodide Cupric sulfate Bromide
False negatives: Rare! Bile Ingestion of Mg-
containing antacids Ascorbic acid
HOB testing What about pt with “coffee ground
emesis” appearing vomitus…any role for HOB testing?
Case 2day-old post SVD, no
complications. Discharged home earlier today. At home, had a bloody BM (parents bring the diaper just to show you!)
Pt exams well. Normal vitals. Any investigations?
GIB investigations CBC, INR/PTT, T+S
Remember, Hct lags behind clinical picture, and is affected by hemodilution
Consider lytes, BUN, Cr EKG Upright CXR if suspect perf
Case 78M presents to ED with hx of melena
x3days…wife convinced him to come get it checked. Slightly dizzy.
PMHx: Afib, diverticulosis Meds: metoprolol, warfarin O/e: HR 72 BP 118/69, obvious melena
stool on DRE. Exam otherwise unremarkable.
Thoughts ? Investigations ?
Case cont’d Blwk:
Hgb 117, Plt 450 INR >9
Reverse INR? Vit K? FFP?
Role of CT ? Not indicated in UGIB cases Sensitivity for identifying
mesenteric ischemia is 64-82% Identification of other colonic
pathology is 75% sensitive specificity 96% NPV 96%
Case 58M with hx of CAD. Presents with
2x episodes of melena yest and 1x episode hematemesis after breakfast this a.m. C/o epigastric pain which radiates into his chest, SOB, dizziness. No previous episodes
O/E: HR 92 BP 120/80 You order CBC, INR/PTT, T+S, EKG
EKG
Case cont’d His labs are still pending What do you want to do? One of your colleagues walks by and
eyeballs the EKG and says “wow, that patient needs ASA, b-blocker, heparin, cardiology consult STAT”…what do you think?
UGIB and NG tubes Any role for NG tube insertion?
May aid in ruling out LGIB in pt with hematochezia
Otherwise, 10% of established UGIB will have negative NGT aspirates…so NOT useful!
Lots of false negatives (ex: bleeding in duodenum or bleeding already stopped)
Bottomline…not very useful…
UGIB management GI—endoscopy Gen Surg—operative Intervent Radiol—angio
Melena, Cuba
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)
When to scope ? Most authors suggest within 12-24hrs Lin et al (1996): Large RCT (n=124pts) showed that
endoscopy within 12h is safe and effective Leads to dec transfusion requirements Dec length of hospital stay Dec costs
UGIB and angiography Detects location of UGIB in 2/3 of pts Usually performed during active
bleeding Unstable vitals Ongoing transfusion requirements
UGIB and surgery Mortality for pts undergoing surgery for
UGIB is 23% Hemodynamically unstable pts, not
responsive to medical/transfusion mgmt, endoscopy unavailable
Consider if >5U PRBC given over first 6h or when 2U PRBC required q4h after replacing initial losses—and still unstable!
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 40ug then continuous infusion Role in esophageal varices Peptide analogue which causes splanchnic
vasoconstriction by direct effect on vascular smooth muscle
Pantoloc ?
Octreotide ? Multicenter RCT of octreotide vs. injection
sclerotherapy for acute variceal hemorrhage
N=150 No significant differences in control of
bleeding, re-bleeding, and mortality Octreotide felt to be as effective as
injection sclerotherapy Jenkins SA, et al. A multicentre randomised trial comparing octreotide and
injection sclerotherapy in the mgmt and outcome of acute variceal hemorrhage. GUT. 1997.
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
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…
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
Insertion… Any takers ?
SB tube
Sengstaken vs. Linton tubes ? RCT of SB vs. LN tubes in pts with known
esophageal/gastric varices N=79 Primary hemostasis in 86% of pts If esophageal varices as cause, SB more
effective at permanent hemostasis (52 vs. 30%)
If gastric varices as cause, LN tube much more effective (50 vs. 0%)
Teres J et al. Esophageal tamponade for bleeding varices. Controlled trial between the Sengstaken-Blakemore tube and the Linton-Nachlas tube. Gastro 1978.
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
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
Disposition Very-low risk Low risk Medium risk High risk
D/c home if: 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…
Initial ED stratification 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 Mild ongoing tachycardia for 1 hr
Persistent moderate/severe tachycardia
No transfusion requirement Transfusions required ≤4 U Transfusion required >4 U
No active major comorbid diseases
Stable 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 moderate-risk or high-risk clinical features
No high-risk clinical features
Stratification with initial and endoscopy findings
Clinical Risk Stratification
Endoscopy Low Risk Moderate Risk High Risk
Low risk hospitalization
Immediate discharge[*] 24-hr inpatient stay (floor)[†] Close monitoring for 24 hr[‡]; ≥48-hr
Moderate risk 24-hr patient stay[†]
24–48 hr inpatient stay (floor)[†]
Close monitoring for 24 hr; ≥48-hr hospitalization
High risk Close monitoring for 24 hr; 48–72 hr hospitalization
Close monitoring for 24 hr; 48–72 hr hospitalization
Close monitoring ≥72-hr hospitalization
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
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