the slow bleeder - transfusion guidelines€¦ · inherent risk of bleeding: ... warfarin re af and...
TRANSCRIPT
![Page 1: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/1.jpg)
The Slow BleederMel Gunn
RVI
![Page 2: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/2.jpg)
Through the eyes of a Gastroenterologist
Evidence free zone
The team
At risk groups
What I do .....
Cases to highlight management diverse and needs to be tailored to the individual
![Page 3: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/3.jpg)
Team based management Interested GI physician
Interested Haematologist
Dedicated Radiologist
Rarely (hopefully!) interested GI surgeon
![Page 4: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/4.jpg)
Patients at risk Heterogeneous and challenging group of patients
Anti- coagulated: warfarin, anti-platlets, NOACs
Inherent risk of bleeding: Haemophilia/ VWD/ ITP/ HHT
Complex post surgical bleeds – surgical bed almost always the site –aberrant vessels secondary to localised venous/ arterial thrombosis, anastomotic ulcers
Cardiac patients: LVADs (a ‘new’ disease)
The world of significant co-morbidity and polypharmacy – always a challenge
![Page 5: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/5.jpg)
Who?? Not the chronically Iron deficient…
Transfusion dependent
Parenteral iron dependent
Visible evidence of GI blood loss - melaena
Recurrent significant severe anaemia
Hb less than 100
Raised urea
![Page 6: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/6.jpg)
What I do … Minimise risk of bleeding
And optimise
‘Break the bleeding cascade’
Look hard and look again !!
![Page 7: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/7.jpg)
Minimising risk and optimising Stop/ fine tune anti-coagulant
consider risk/ benefit re continuing versus discontinuing
consider lower target range for INR
NOACs – ensure appropriate dose, ensure no liver disease/ eGFR
Switch from warfarin to therapeutic tinzaparin
BD dosing tinzaparin if renal impairment and monitor Factor Xa
Monotherapy anti-platlets where possible
Optimise iron stores: Regular parenteral Iron and load iron stores
Target ferritin 200-300
Minimise blood transfusions
![Page 8: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/8.jpg)
Break the cascade Chronic bleeder - ?low grade DIC, micro-nutrient
deficiencies
Trial of tranexamic acid – parenteral/ oral
Vitamin K, pabrinex, parenteral Iron
Thalidomide
Start 100mg and titrate with tolerance
Bridge to optimising
Review 4 weeks ?dose reduce/ stop
![Page 9: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/9.jpg)
Investigations Endoscopy –evolving therapeutic field
OGD/ Colonoscopy
Balloon Enteroscopy – single/ double
Capsule Enteroscopy – diagnostic, define the site of bleeding
Radiology
CTA rarely helpful unless to define unusual vessel anatomy post surgical or varices
CT abdomen/ pelvis
![Page 10: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/10.jpg)
Pathology to consider Gastric antral venous ectasia – ‘GAVE’
missed if not thought about
often mis-diagnosed as ‘gastritis’
amenable to APC/RFA
Angiodysplasia
Dieulafoy’s – gastric/ small bowel
If anti-coagulated or inherent bleeding disorder it doesn’t take much to bleed!
![Page 11: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/11.jpg)
The LVAD patient Left Ventricular assist device
Initially intended as a bridge to transplant
Now so successful cohort of patients too well for transplant and have LVAD long term
Concern re VAD thrombus so
Warfarin INR 3-4
Clopidogrel
Asprin
![Page 12: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/12.jpg)
And they wonder why they bleed???
Need Ix to exclude pathology but
Majority normal
Change to tinzaparin – bd with factor Xa monitoring
Stop aspirin
Group of patients who have low grade gut ischaemia, venous congestion, liver congestion – minimal lesion to bleed
![Page 13: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/13.jpg)
Case 1 EM
92 year old
Colostomy re diverticular disease
AF on warfarin
2013: Melaena –normal OGD. CTA showed right colonic extravasation – normal colonoscopy
2015 – recurrent melaena. Warfarin stopped – lacunar infarct. Warfarin re-started
2016 – further bleed. Repeat OGD/Colon normal
![Page 14: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/14.jpg)
Case 1 2017
Further melaena Hb 80, normal urea, INR 1.8– transfusion dependent despite stopping warfarin
Concern from patient re risk of CVA
Repeat OGD normal
Repeat colon
![Page 15: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/15.jpg)
Colonoscopy
![Page 16: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/16.jpg)
Oozing post flush
![Page 17: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/17.jpg)
Post treatment
![Page 18: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/18.jpg)
Post treatment
![Page 19: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/19.jpg)
Reviewed 3 months Well
No further bleeding on warfarin
Discharged
![Page 20: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/20.jpg)
Case 2 DA, 49 year old lady
PMHx – ovarian teratoma 10 years ago – surgery only
Carlisle – 2014 ‘dark stool’
Hb 80s, increased urea
Normal OGD, Colonoscopy
Referred for capsule
Possibility of prominent veins ?varices in small bowel
CTA recommended locally
![Page 21: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/21.jpg)
Lost to Carlisle Represents with further melaena
Admitted to Carlisle - normal OGD
On going bleeding – non compromising
Transfer to RVI
Capsule repeated as in-patient
Bleeding settled
Capsule findings ;
![Page 22: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/22.jpg)
![Page 23: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/23.jpg)
![Page 24: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/24.jpg)
![Page 25: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/25.jpg)
![Page 26: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/26.jpg)
![Page 27: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/27.jpg)
To date Confirmed multiple level varices
Normal LFTs, liver screen
Abnormal fibro-scan ?for liver biopsy
Further low grade oozing – requiring regular Iron infusions
Options ?? SBE/DBE with glue if significant bleed
??relevance of teratoma
![Page 28: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/28.jpg)
Case 3 DC 60 year old male
Transfusion dependent anaemia many years but increase last 6 months
Normal OGD/ Colonoscopy
Episode of possible melaena – admitted local hospital
Repeat OGD – normal
CT scan normal
Meckles scan – no Meckles but bleeding point in small bowel
Referred to Newcastle for capsule
![Page 29: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/29.jpg)
Case 3 Telephone assessed
Capsule performed
![Page 30: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/30.jpg)
![Page 31: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/31.jpg)
![Page 32: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/32.jpg)
Proceeded to DBE
![Page 33: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/33.jpg)
![Page 34: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/34.jpg)
Ongoing bleeding Further DBE – couple of non specific lesions treated
History re visited – no visible bleeding despite needing transfusions 3 times per week
Atypical
Haemolysis screen negative
Blood film – suspicion of MDS!
![Page 35: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/35.jpg)
Case 4 83 year old lady
Warfarin re AF and CVA – Rehab in Walkergate
Melaena – transferred RVI. INR 3.5
Normal OGD, warfarin stopped
Continued to bleed – repeat OGD normal
Capsule – refused then agreed. Poor views and in complete – didn’t enter the colon in the test time. Some altered blood in stomach
![Page 36: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/36.jpg)
Continued Trial of tranexamic acid – stopped bleeding for 72 hours
Re bled – 2 units per week
Patient depressed and not agreeable to interventions
Thalidomide started 100mg
Persuaded for further OGD with placement of capsule
![Page 37: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/37.jpg)
Capsule – blood in D3 ?transported with capsule
placement
![Page 38: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/38.jpg)
Re –look OGD
![Page 39: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/39.jpg)
Post flushing
![Page 40: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/40.jpg)
APC
![Page 41: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/41.jpg)
Reviewed 3 months Well
Thalidomide reduced and discontinued
No CVA so far!
![Page 42: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/42.jpg)
Summary Complex heterogeneous group
Simplify bleeding risk wherever possible
If complex surgery almost always bleeding from the surgical bed
Patients subject to multiple and duplication of invasive and un pleasant investigations therefore consider early referral to an interested team
Give the patient re-assurance that slow bleed therefore have time to access hospital – give them open access, oral tranexamic acid and give them confidence in you that this is a manageable situation!
![Page 43: The Slow Bleeder - Transfusion Guidelines€¦ · Inherent risk of bleeding: ... Warfarin re AF and CVA –Rehab in Walkergate Melaena –transferred RVI. INR 3.5 Normal OGD, warfarin](https://reader033.vdocuments.us/reader033/viewer/2022060805/608a041e593c734d1e6b4180/html5/thumbnails/43.jpg)
Questions?
Thank you!