RJ GI Bleed

download RJ GI Bleed

of 47

  • date post

    14-Apr-2018
  • Category

    Documents

  • view

    218
  • download

    0

Embed Size (px)

Transcript of RJ GI Bleed

  • 7/30/2019 RJ GI Bleed

    1/47

    Acute Gastrointestinal

    Bleeding

    Rajeev Jain, M.D.

  • 7/30/2019 RJ GI Bleed

    2/47

    GI Bleeding

    Clinical Presentation

    Acute Upper GI Bleed Acute Lower GI Bleed

  • 7/30/2019 RJ GI Bleed

    3/47

    Case Presentation

    CC: Melena

    HPI: 54 yo man taking ibuprofen 200

    mg po tid for the past 2 wks b/o acuteLBP after lifting presents with 2 day h/omelena

    PMHx: neg All: NKDA SHx/FHx: neg Vitals: BP 105/75 P 90

    PE: normal

  • 7/30/2019 RJ GI Bleed

    4/47

    Clinical Presentation

    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

  • 7/30/2019 RJ GI Bleed

    5/47

    Patient Assessment

    Hemodynamic status

    Localization of bleeding source

    CBC, PT, and T & C Risk factors

    Prior h/o PUD or bleeding

    Cirrhosis Coagulopathy

    ASA or NSAIDs

  • 7/30/2019 RJ GI Bleed

    6/47

    Resuscitation

    2 large bore peripheral IVs

    Normal saline or LR

    Packed RBCs

    Correct coagulopathy

  • 7/30/2019 RJ GI Bleed

    7/47

    Location of Bleeding

    Upper

    Proximal to Ligament of Treitz

    Melena (100-200 cc of blood)Azotemia

    Nasogatric aspirate

    Lower Distal to Ligament of Treitz

    Hematochezia

  • 7/30/2019 RJ GI Bleed

    8/47

    Acute UGIB

    Demographics

    10,000 - 20,000 deaths annually

    Mortality stable at 10%

    80% self-limited

    Continued or recurrent bleeding -mortality 30-40%

  • 7/30/2019 RJ GI Bleed

    9/47

    Cause of bleeding

    Severity of initial bleed Age of the patient

    Comorbid conditions

    Onset of bleeding duringhospitalization

    Acute UGIB

    Prognostic Indicators

  • 7/30/2019 RJ GI Bleed

    10/47

    NASOGASTRICASPIRATE

    STOOLCOLOR

    MORTALITY RATE(%)

    Clear Red, brown, or black 10

    Coffee Grounds Brown or black 10

    Red 20

    Red Blood Black 10

    Brown 20

    Red 30

    Acute UGIB

    Prognostic Indicators

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

  • 7/30/2019 RJ GI Bleed

    11/47

    Acute UGIB

    Differential Diagnosis

  • 7/30/2019 RJ GI Bleed

    12/47

    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

  • 7/30/2019 RJ GI Bleed

    13/47

    DIAGNOSES % OF TOTAL

    Duodenal ulcer 24

    Gastric erosions 23

    Gastric ulcer 21

    Varices 10

    Mallory-Weiss tear 7

    Esophagitis 6

    Acute UGIB

    Final Diagnoses of the Cause in 2225 Patients

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

  • 7/30/2019 RJ GI Bleed

    14/47

    DIAGNOSES % OF TOTAL

    Peptic ulcer 55

    Varices 14

    Angioma 6

    Mallory-Weiss tear 5

    Erosions 4Tumor 4

    Acute UGIB

    Causes in CURE Hemostasis Studies (n=948)

    Savides et al. Endos copy 1996;28:244-8.

  • 7/30/2019 RJ GI Bleed

    15/47

    Acute UGIB

    CORI Database

    University, VA, & privatepractices

    20 months (12/99-7/01)

    7822 EGDs for UGIB

    Boo npon gmaneeS. et al. Gastrointest Endos c 2004;59:788-94.

  • 7/30/2019 RJ GI Bleed

    16/47

    Endoscopic Appearance

    of Ulcers

  • 7/30/2019 RJ GI Bleed

    17/47

    Prognostic Features at Endoscopy

    in Acute Ulcer Bleeding

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

  • 7/30/2019 RJ GI Bleed

    18/47

    Thermal

    Bipolar probe

    Monopolar probe Argon plasma

    coagulator

    Heater probe

    Mechanical Hemoclips

    Band ligation

    Injection

    Epinephrine

    Alcohol Ethanolamine

    Polidocal

    Endoscopic Therapy of PUD

  • 7/30/2019 RJ GI Bleed

    19/47

    Endoscopic Therapy of PUD

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

  • 7/30/2019 RJ GI Bleed

    20/47

    Adjuvant Medical Therapy

    of PUD Acid suppression (intragastric pH > 4)

    Histamine 2 Receptor Antagonists

    (H2RAs) Ranitidine (Zantac)

    Famotidine (Pepcid)

    Proton Pump Inhibitors (PPIs)

    Pantoprazole (Protonix) Lansoprazole (Prevacid)

    Esomeprazole (Nexium)

  • 7/30/2019 RJ GI Bleed

    21/47

    Bleeding PUD: IV H2RAs

    Meta-Analysis Duodenal ulcer: no

    benefit

    Gastric ulcer: mildbenefit Mortality

    ARR 3%; NNT 33

    Surgery ARR 7%; NNT 14

    Rebleeding ARR 7%; NNT 14

    Caveats Tolerance develops

    within 24 hrs

    More potent acidsuppressionavailable

    Levi ne JE et al. Alim ent Pharm acol Ther 2002;16:1137-42.

  • 7/30/2019 RJ GI Bleed

    22/47

    472 patients required no

    endoscopic treatment

    27 patients not included:

    comorbid or no consent

    120 patients received IV

    omeprazole 80 mg bolus

    then 8 mg/hr for 72 hours120 patients received placebo

    267 received endoscopic treatment

    739 patients admitted with GI bleeding

    Lau et al. New Eng J Med 2000;343:310-316.

    Adjuvant Medical Therapy of

    PUD

    Adj t M di l

  • 7/30/2019 RJ GI Bleed

    23/47

    Adjuvant Medical

    Therapy of PUD

    Lau et al. New Eng J Med 2000;343:310-316.

  • 7/30/2019 RJ GI Bleed

    24/47

    Bleeding PUD: PO/IV PPIs

    Meta-Analysis Reduction in:

    Rebleeding NNT* 4-17

    Surgery NNT* 6-25 No change in mortality

    PPIs add to endoscopic

    therapy but do notsupplant endoscopictherapy

    * Estimates from pooled ORsLeon tiadis , GI et al. BMJ 2005;330:568-75.

  • 7/30/2019 RJ GI Bleed

    25/47

    Mallory-Weiss Tear

  • 7/30/2019 RJ GI Bleed

    26/47

    Esophageal Varices

  • 7/30/2019 RJ GI Bleed

    27/47

    Variceal Band Ligation

  • 7/30/2019 RJ GI Bleed

    28/47

    Variceal Band Ligation

  • 7/30/2019 RJ GI Bleed

    29/47

    Vasopressin/Glypressin

    Nonselective vasoconstrictor

    50% efficacy in controlling bleeding

    25% vasospastic side effects

    Octreotide

    Cyclic octapeptide analog ofsomatostatin

    Longer acting than somatostatin

    Equivalent to sclerotherapy and

    improves endoscopic results

    MEDICAL THERAPY

    Acute Variceal Bleeding

  • 7/30/2019 RJ GI Bleed

    30/47

    TIPS

    IVC

    Portal Vein

    Splenic Vein

    Coronary Vein

  • 7/30/2019 RJ GI Bleed

    31/47

    Aortoduodenal Fistula

    Aorta

    Duodenum

    Graft

    Fistula

  • 7/30/2019 RJ GI Bleed

    32/47

    Acute Bleeding

    Changes Before and After 2 Liter Bleed

    0

    1

    2

    3

    4

    5

    6

    Before During 24-72 Hrs

    VOLUME(L)

    Plasma RBC

    27%45%45%

  • 7/30/2019 RJ GI Bleed

    33/47

    Acute UGIB

    Surgery

    Recurrent bleeding despite

    endoscopic therapy

    > 6-8 units pRBCs

  • 7/30/2019 RJ GI Bleed

    34/47

    Case Presentation

    CC: Hematochezia

    HPI: 74 yo woman presents with 6 hour

    history of painless maroon blood per rectum PMHx: CAD, Chol, AFib, CABG, L-CEA

    Meds: ASA, coumadin, digoxin, lovastatin

    Vitals: BP 105/75 P 90 PE: irreg rhythm, maroon blood on DRE

  • 7/30/2019 RJ GI Bleed

    35/47

    Acute LGIB

    Differential Diagnosis

  • 7/30/2019 RJ GI Bleed

    36/47

    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

  • 7/30/2019 RJ GI Bleed

    37/47

    DIAGNOSES % OF TOTAL

    Diverticulosis 40

    Vascular anomalies 30Colitis 21

    Neoplasia 14

    Anorectal 10Upper GI sites 10

    Acute LGIB

    Diagnoses in pts with hemodynamic compromise.

    Zuccaro. ASGE Clin ical Upd ate. 1999.

  • 7/30/2019 RJ GI Bleed

    38/47

    Diverticulosis

  • 7/30/2019 RJ GI Bleed

    39/47

    Diverticular Bleeding

  • 7/30/2019 RJ GI Bleed

    40/47

    Urgent Colonoscopy for the Diagnosis

    and Treatment of Severe Diverticular

    Hemorrhage

    121 pts with severebleeding (>4 hrsafter hospitalization)

    1st 73 pts: nocolonoscopic tx

    Last 48 pts eligiblefor colonoscopic tx

    Colonoscopy w/in 6-12 hrs

  • 7/30/2019 RJ GI Bleed

    41/47

    Urgent Colonoscopy for the Diagnosis and

    Treatment of Severe Diverticular

    Hemorrhage

    Jens en DM, et al. New Eng J Med 2000:342:78-82.

  • 7/30/2019 RJ GI Bleed

    42/47

    Hemorrhoids

  • 7/30/2019 RJ GI Bleed

    43/47

    Bleeding AVM

  • 7/30/2019 RJ GI Bleed

    44/47

    Radiation Proctitis

  • 7/30/2019 RJ GI Bleed

    45/47

    Inc