Gastroenterology and Hepatology - GI Bleed

8/22/2019 Gastroenterology and Hepatology - GI Bleed

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Acute GI Bleed:

The GI ApproachRami El Abiad, MDAssistant Professor

Gastroenterology and HepatologyUniversity of Iowa Hospitals and Clinics


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GI Bleeding: Definition

GI bleed = intra-luminal blood loss within theGI tract

Overt = clinically evident

Occult = No visible blood; +ve FOBT/IDA

Obscure = GIB that persists or recurs w/o an

obvious etiology after endoscopic and radiologicevaluation- can be Overt or Occult


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GI Bleeding: Definition

Acute vs. Chronic (intermittent)

Massive GI bleed = hemodynamic instability

(shock, orthostatic hypotension, >6% in Hct,> 2u pRBC transfusion)

or

active bleeding (manifested by hematemesis,BRB per NG, or hematochezia)


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Upper GI Bleed

Proximal to the ligament of Trietz (DJ-J)

Hematemesis (coffee-ground or bloodyvomitus) and/or melena

Hematochezia from UGIB suggests massivebleeding (hemodynamic instability)

Variceal vs. non-variceal**Hemoptysis (coughing blood), swallowed blood

(upper airways)**


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Lower GI Bleed

Distal to the ligament of Treitz (? Middle GIB)

Hematochezia (maroon colored stools, brightred blood -or fresh clots- per rectum)

10-15% of patients presenting withhematochezia have an UGI source

In general, the closer (or faster) the bleeding siteis to the anus, the brighter red the blood will be


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Case

A 54 y.o. presents with several episodes ofmelena over the past 3 d. BP at presentation=95/60 with HR=110. What is the most

important next step in managing this patient?a) NG intubation and lavage

b) IV PPI and octreotide

c) IV access, fluids and blood producttransfusion

d) IV erythromycin followed by EGD


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Case

A 54 y.o. presents with several episodes ofmelena over the past 3 d. BP at presentation=95/60 with HR=110. What is the most

important next step in managing this patient?a) NG intubation and lavage

b) IV PPI and octreotide

c) IV access, fluids and blood producttransfusion

d) IV erythromycin followed by EGD


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GIB: Management

The basic principles of resuscitation

and management of acute GI bleeding

are the same regardless of the origin ofbleeding


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At presentation:

Assess/establishABCs:

-Airway/Breathing: O2 supplementation, ETintubation (airway protection for AMS/massiveUGIB)


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At presentation:

- Circulation: IV access with 2 large bore needles (18gauge)/central line -obtain labs- , volume replacement

with IVF,transfusion of blood products (pRBC/platelets),hold/reverse anticoagulation (vitamin K/FFP) andanti-platelet therapy (ASA, NSAIDs, Clopidogrel)

Plan to correct for goal of: Hct 20-30%,INR50k/l

DO NOT OVER-RESUSCITATE


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At presentation:

Risk stratification/Assess hemodynamic status(r/o shock/hypotension; check for orthostaticchanges, volume status, urine output)

Decision for ICU admission (hemodynamicinstability/ massive bleeding)


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Focused History

- age (>60 yrs)

- onset of bleeding

- prior h/o bleeding

- co-morbid conditions(CAD, CHF, CRF, cirrhosis,malignancy)

- prior abdominal surgeries(AAA/graft)

- h/o polyps/Cancer

- recent intervention (e.g.colonoscopy)/surgery

- associated symptoms (pain)

- anti-platelet/anticoagulation use

- medications (Antibiotics,SSRI)/herbals (devils claw,

ginkgo, garlic, echinacea)

- ETOH or illicit drug abuse

Try to Establish a Differential Diagnosis


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At presentation:

Physical Exam: mental status (intoxication,encephalopathy), stigmata of liver disease(jaundice, ascites,), (?)NG placement/lavage

ANDDREMelena =

Sticky,

Smelly

and Tarry

Black


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At presentation:

Neither a clear NG aspirate nor the presence ofbile w/o blood rules out an UGIB

No role for occult-blood testing (includingGastroccult)


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At presentation:

We bleed whole blood

Presenting H/H may significantlyunderestimate the amount of blood lost during

an acute bleed serial H/H (72H to stabilize)


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At presentation:

Labs: CBC, E2 (BUN), LFT (bilirubin,albumin, INR) TXM, ? H. pylori, cardiacenzymes

Other studies: CT (AoE-F), CXR, AXR, EKG*Avoid barium studies*


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Post Stabilization: Medications

- PPIs (IV): reduce signs of bleeding and needfor endoscopic therapy, pH>6 stabilizes clot; [NEJM2007;356:1631]

-PPI offers no additional benefit to octreotide inmanagement of acute variceal bleed [Pharmacotherapy 2009;29(3):248]

-No role for H2 blockers


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Post Stabilization: Medications

- Somatostatin/Octreotide (splanchnicvasoconstriction) for variceal bleed

No adjunct benefit for octreotide in non-variceal

GIB [J Clin Gastroenterol. 2004;38(3):243]

- Prokinetics: IV Erythromycin can improvevisibility, EGD time, and need for 2nd look

EGD[GIE 2002; 56:174]

- Antibiotics (3rd G cephalosporin): for cirrhotics(with ascites) presenting with GIB


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Post Stabilization:

Urgent Endoscopy (within 24H, sooner if inICU/ continued bleed despite resuscitation/cirrhosis)- 95% diagnostic rate- localization,

therapeutic intervention, risk stratification(?recurrence)

Risks: aspiration, adverse reaction to conscious

sedation, perforation, and bleeding


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Post Stabilization:

Re-evaluation and triage (repeat endoscopy- notroutinely recommended-, nuclear scan[>0.1/min]/angiography [>0.5cc/min], balloon

tamponade, TIPS, surgery consult)


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Post Stabilization:

Long-term plan (address underlying cause(s)/abnormalities- NSAIDs, eradicate H.pylori-prevent further bleeding, repeat endoscopy-

variceal obliteration- subspecialty f/u)


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Case

The previous patient endorses history of ETOHabuse. She is conversant. The abdomen isprotuberant. Adequate resuscitation was started

in ICU. EGD was performed.


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Case

Which of the following is NOT part of the earlymanagement:

a) Perform endoscopic band ligation

b) Start IV octreotide

c) Start prophylactic antibiotics

d) Start beta-blockerse) Transfuse to keep Hb>8


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Case

Which of the following is NOT part of the earlymanagement:

a) Perform endoscopic band ligation

b) Start IV octreotide

c) Start prophylactic antibiotics

d) Start beta-blockerse) Transfuse to keep Hb>8


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Etiology of UGIB

Esophagitis (peptic,infectious, pill-induced)

Ulcerative/Erosive (PUD-54%, ZE, drug/NSAID, H.

pylori, infectious, stress-induced)

Portal hypertension(varices-13%, PHG)

Vascular Malformations(Dieulafoys, GAVE, HHT,BRBNS, idiopathicAVM-9%, radiation-induced)

Truama/Post-op (MW-T,FB, AoE-fistula, post-polypectomy)

Tumors (benign/malignant)

Other (Hemobilia,hemosuccus pancreaticus,Cameron)


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Etiology of LGIB

Diverticulosis-30%

Hemorrhoids-14%

Ischemic colitis-12%

AVM Anal fissures

Polyps/neoplasms

IBD (UC, CD)

Infectious colitis

Radiation-induced colitis

Meckel diverticulum

Intussusception

Aorto-enteric fistula

Rectal ulcers

NSAID-enteropathy


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Conclusion

GI bleeding is common and can result in highmorbidity/mortality and health cost

Clinical findings (H&P) can narrow the

differential diagnosisThe basic principles of resuscitation and

management of acute GI bleeding are the same

regardless of the origin of bleedingThe choice of diagnostics/intervention is guided

by endoscopic findings


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Thank You!

Gastroenterology and Hepatology - GI Bleed

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