GI BLEEDING

Brad Martin, MD c/o Jason De Roulet, MD

July 18, 2012

OBJECTIVES

Define some common terms associated with GI bleeds Review the ways patients commonly present with GI

bleeds Review how to assess patients presenting with GI

bleed Identify the most common causes of both upper and

lower GI bleeds Identify key information to have available when calling

a GI consult Review the medical and endoscopic treatments for

both upper and lower GI bleeds

DEFINITIONS

Acute GI bleed < 3 days duration hemodynamic instability requires blood transfusion

Overt vs. occult overt = visible blood (melena, bright red blood,

coffee grounds) occult = only detected by lab tests

DEFINITIONS

Upper vs. Lower GI bleed UGIB = proximal to ligament of Treitz LGIB = distal to ligament of Treitz

Ligament ofTreitz

GOALS OF CARE

Stabilize patient’s hemodynamics Assess patient, determine source of bleed Stop any active bleeding Treat underlying cause Prevent recurrence

PRESENTATION

“The patient has been vomiting blood”

Usually indicates upper GI source

Can include: bright red blood coffee ground emesis clots

PRESENTATION

“The patient has had bloody stools” need to determine stool characteristics,

especially color, consistency, and frequency melena = black, tarry stool (melena ≠ dark,

formed stool!) usually indicates upper GI bleed, although ~5% can be

from small bowel or proximal colon only need around 50cc of blood to get melena adjective is melenic, not melanotic

hematochezia = BRBPR or clots usually indicates lower GI bleed, although can be brisk

upper bleed brown stool, formed stool usually not aggressive

bleed

INITIAL ASSESSMENT

Is the patient hemodynamically stable? Replace intravascular volume History, physical exam Nasogastric intubation Lab evaluation Floor vs. ICU

INITIAL ASSESSMENT – STABLE?

Is the patient orthostatic? requires loss of 20% of blood volume “dizzy when I get up”

Is the patient in shock? requires loss of 40% of blood volume hypotensive, tachycardic, pallor

INITIAL ASSESSMENT – RESUSCITATION

Establish good access 2 large bore (ideally 18-gauge peripheral IVs) in MICU, may place triple-lumen or Cordis

Replace intravascular volume if hypotensive and/or orthostatic, give NS

boluses if anemic, give PRBCs may need FFP and/or platelets if massive GI

bleed

INITIAL ASSESSMENT – HISTORY

Age risk, mortality increase with age

Previous bleeding Comorbidities

CAD heart failure AAA repair liver disease

Previous endoscopies (look at reports!) Associated symptoms

pain retching anorexia, weight loss nausea/vomiting early satiety dysphagia epistaxis, hemoptysis

Medication history – NSAIDs, warfarin, ASA, Plavix

INITIAL ASSESSMENT – PHYSICAL

Vital signs: tachycardia? hypotension? hypoxia?

Gen: distress? alert + oriented? HEENT: pallor, blood in nares or mouth Abd: distension, tenderness

Rectal – visualize the stool! BRB, melena, maroon, brown, no stool in vault “The ER said it was heme positive”

INITIAL ASSESSMENT – NG TUBE

Nasogastric intubation, NG lavage confirm NGT is in stomach (KUB) inject 250cc NS, then draw 250cc back or place to wall

suction can be repeated for up to total of 2L stop when fluid is clear (or when reach 2L)

Contraindications facial trauma, nasal bone fracture known esophageal abnormalities (strictures,

diverticuli) ingestion of caustic substances, esophageal burns generally, esophageal varices are NOT a

contraindication to NG tube placement

INITIAL ASSESSMENT – NG TUBE

Interpretation of aspirate: bright red, clots = active UGIB coffee grounds = slow bleeding, may have

stopped, localizes to upper GI source clear = indeterminate (NOT a guarantee that the

bleeding has stopped) bilious = bleeding has stopped

INITIAL EVALUATION – LABS

CBC H+H, including BASELINE

how often to check? goal H+H? may take up to 72 hrs to equilibrate

Platelets goal platelet count?

Renal function panel BUN/Cr ratio

see increased BUN in UGIB due to absorbed blood proteins ratio usually > 20:1

Coags goal INR < 1.5 reverse with FFP, vitamin K unless contraindicated

LFTs Iron studies

THE STOOL GUAIAC

Stool guaiac is a great tool for colon cancer screening

It is NOT a test for acute GI bleed Causes of false-positives include:

Trauma Extraintestinal blood loss

epistaxis hemoptysis

Medications ASA, NSAIDs (gastric irritation)

Exogenous peroxidase activity red meat consumption fruits (grapefruit, cantaloupe, figs) uncooked vegetables (broccoli, cauliflower, radish,

cucumber, carrot)

INITIAL EVALUATION - TRIAGE

What necessitates a MICU admission? Hemodynamic instability despite adequate volume

resuscitation NG lavage does not clear with 2L History of cirrhosis, concern for variceal bleed Continued bleeding

Be concerned when: Age > 60 Multiple comorbidities Coagulopathy (i.e. Plavix, warfarin, cirrhosis) Known portal hypertension Hematemesis is bright red blood History of AAA repair in the past

DETERMINING THE SOURCE

History is crucial NSAIDs, postprandial epigastric pain (ulcer?) hypotension preceding BRBPR (mesenteric

ischemia?) retching or recurrent vomiting (Mallory-Weiss?) history of cirrhosis (variceal bleed?)

Stool exam NG lavage 11% of patients initially suspected of LGIB

actually have UGIB

UPPER GI BLEED

(Other includes Dieulafoy’s lesion, GAVE, foreign body, etc.)

LOWER GI BLEED

Differential diagnosis: Diverticulosis (up to 42%) Ischemia (up to 18%) Hemorrhoids, fissures (up to 16%) UGI or small bowel bleed (up to 13%) Neoplasia (up to 11%) Other (IBD, infectious colitis, post-polypectomy) Unknown cause in up to 23% of cases

CALLING A GI CONSULT

Presentation PMHx, especially if h/o liver disease NG lavage results RECTAL EXAM!!-Stool characteristics Vital signs, hemodynamics, orthostatics Labs Previous endoscopy reports Have a differential

MEDICAL THERAPY FOR UGIB

PUD: PPI bolus of 80mg, then drip at 8mg/hr

has been shown to accelerate resolution of bleeding and decrease need for therapy during EGD

Varices Octreotide 50-100mcg bolus, then 50mcg/hr drip If pt has ascites, will need antibiotics for 7 days

for SBP prophylaxis norfloxacin 400mg BID Bactrim DS BID

ENDOSCOPIC THERAPY FOR UGIB

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

UGIB ADMISSION

NPO after midnight Call GI fellow first thing the next morning

(8am) If patient cannot consent, make sure medical

decision maker is identified and have phone numbers available

TREATMENT OF LGIB

No medical treatments Diverticular bleeds stop on their own 75% of the

time Bleeds due to angiodysplasia stop spontaneously

around 85% of the time

If pt continues to bleed CT angiography to localize bleed

can often be accompanied by embolization to stop the bleeding

requires > 0.5cc per minute of blood loss Tagged RBC scan

can detect bleeding at > 0.1cc per minute unreliable localization, high false positive rate

TREATMENT OF LGIB

Usually no need for emergent colonoscopy If stable but continued bleeding can do “rapid

purge” (GoLYTELY 4L given quickly) and colonoscopy can be done in 6-12 hours

Colonoscopy reveals cause in > 70% of cases Tools used include

epinephrine injection cautery hemoclip surgery

LGIB ADMISSION (ON THE FLOOR)

Clear liquid diet the day prior to endoscopy 1 gallon GoLYTELY started the

afternoon/evening before procedure Goal is for stool to be CLEAR

SUMMARY

A detailed history is crucial in diagnosing GIB It is also very important to characterize the

emesis and/or stool to aid in diagnosis Stool guaiac testing is not indicated in acute

GIB Most important step is assessing

hemodynamic (in)stability and resuscitating with NS and/or blood if needed

In most cases, the patient will need endoscopy, but you can help to improve outcomes with specific medical treatments

Thank you!Enjoy your time in Cleveland!