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Gastrointestinal Bleeding Rajeev Jain, M.D.

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GI Bleeding Background Acute Upper GI Bleed Acute Lower GI Bleed

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Clinical Presentation Definitions Hematemesis: bloody vomitus (bright red or coffee-grounds) Melena: black, tarry, foul-smelling stool Hematochezia: bright red or maroon blood per rectum Occult: positive guaiac test Symptoms of anemia: angina, dyspnea, or lightheadedness

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Clinical Presentation Reflection of bleeding: Site Etiology Rate

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Initial Patient Assessment Hemodynamic Status

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Resuscitation 2 large bore peripheral IVs Colloid (normal saline or lactated Ringers) Transfuse packed RBCs In elderly, goal Hct 30% In young, goal Hct 20-25% In cirrhotics, goal Hct 25-28% Correct coagulopathy Reassess hemodynamics

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History Prior history of bleeding Previous gastrointestinal illnesses Previous surgery Other medical conditions (ie, cirrhosis) Medications Aspirin, NSAIDs, & anti-platelet agents Anticoagulants ? SSRIs Abdominal pain, weight loss

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Physical Exam & Labs Focused but thorough Look for markers of liver disease Laboratory studies CBC INR Electrolytes Type and crossmatch RBCs

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Acute Bleeding Changes Before and After 2 Liter Bleed 27% 45%

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Location of Bleeding Upper Proximal to Ligament of Treitz Melena (100-200 cc of blood) Azotemia Nasogastric aspirate Lower Distal to Ligament of Treitz Hematochezia

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Acute UGIB Demographics Annual incidence of hospitalization: 100/100,000 persons 80% self-limited Mortality stable at 10% Continued or recurrent bleeding - mortality 30-40%

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Cause of bleeding Severity of initial bleed Age of the patient Comorbid conditions Onset of bleeding during hospitalization Acute UGIB Prognostic Indicators

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Tedesco et al. ASGE Bleeding Survey. Gastro Endo. 1981.

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Acute UGIB Differential Diagnosis

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Peptic ulcer disease Gastric ulcer Duodenal ulcer Mallory-Weiss tear Portal hypertension Esophagogastric varices Gastropathy Esophagitis Dieulafoys lesion Vascular anomalies Hemobilia Hemorrhagic gastropathy Aortoenteric fistula Neoplasms Gastric cancer Kaposis sarcoma Acute UGIB Differential Diagnosis

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Acute UGIB Final Diagnoses of the Cause in 2225 Patients Tedesco et al. ASGE Bleeding Survey. Gastro Endo. 1981.

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Acute UGIB Causes in CURE Hemostasis Studies (n=948) Savides et al. Endoscopy 1996;28:244-8.

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Acute UGIB CORI Database: 7822 EGDs b/n 1999-2001 Boonpongmanee S. et al. Gastrointest Endosc 2004;59:788-94.

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Peptic Ulcers Stigmata of Recent Hemorrhage (SRH)

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Acute Peptic Ulcer Bleeding Prognosis by SRH Laine and Peterson. New Eng J Med 1994;331:717-27.

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Thermal Bipolar probe Monopolar probe Argon plasma coagulator Heater probe Mechanical Hemoclips Band ligation Injection Epinephrine Alcohol Ethanolamine Polidocal Endoscopic Therapy of PUD

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Laine and Peterson New Eng J Med 1994;331:717-27.

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Peptic Ulcer Bleeding Adjuvant Medical Therapy Erythromycin 250 mg IV 30 minutes before endoscopy decreases blood in stomach Proton pump inhibitor therapy 80 mg IV bolus followed by 8 mg/hr continuous infusion for 72 hrs Reduced risk: Rebleeding (NNT 12) Surgery (NNT 20) Leontiadis, G. et al. BMJ 2005;330:568

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Mallory-Weiss Tear

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Esophageal Varices

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Variceal Band Ligation

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Octreotide Cyclic octapeptide analog of somatostatin Longer acting than somatostatin Equivalent to sclerotherapy and improves endoscopic results MEDICAL THERAPY Acute Variceal Bleeding

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Transjugular Intrahepatic Portosystemic Shunt (TIPS) IVC Portal Vein Splenic Vein Coronary Vein

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Aortoduodenal Fistula Aorta Duodenum Graft Fistula

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Acute UGIB Surgery Recurrent bleeding despite endoscopic therapy > 6-8 units pRBCs

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Acute LGIB Differential Diagnosis

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Diverticulosis Colitis IBD (UC>>CD) Ischemia Infection Vascular anomalies Neoplasia Anorectal Hemorrhoids Fissure Dieulafoys lesion Varices Small bowel Rectal Aortoenteric fistula Kaposis sarcoma UPPER GI BLEED Acute LGIB Differential Diagnosis

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Acute LGIB Diagnoses in pts with hemodynamic compromise. Zuccaro. ASGE Clinical Update. 1999.

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Etiology of Acute LGIB Strate LL. Gastroenterol Clin North Am. 2005 Dec;34(4):643-64.

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Outcomes of Acute LGIB Strate LL. Gastroenterol Clin North Am. 2005 Dec;34(4):643-64.

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Diverticulosis

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Diverticular Bleeding

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Urgent Colonoscopy for the Diagnosis and Treatment of Severe Diverticular Hemorrhage 121 pts with severe bleeding (>4 hrs after hospitalization) 1 st 73 pts: no colonoscopic tx Last 48 pts eligible for colonoscopic tx Colonoscopy w/in 6- 12 hrs

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Urgent Colonoscopy for the Diagnosis and Treatment of Severe Diverticular Hemorrhage Jensen DM, et al. New Eng J Med 2000:342:78-82.

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Ischemic Colitis Most common form of intestinal ischemia Transient and reversible Abdominal pain Watershed areas Splenic flexure Rectosigmoid junction

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Hemorrhoids

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Bleeding AVM

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Radiation Proctitis

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Incidence 0.3 - 3.0 % EtiologyIncomplete obliteration of the vitelline duct. Pathology50% ileal, 50% gastric, pancreatic, colonic mucosa Complications Painless bleeding (children, currant jelly) Intussusception Acute LGIB Meckels Diverticulum

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Acute LGIB Evaluation Zuccaro. ASGE Clinical Update. 1999.

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Annual incidence of hospitalization: 20-30/100,000 persons Resuscitation Exclude an UGI source Most bleeding ceases Colonoscopy No role for barium studies Acute LGIB Key Points