Upper GI BleedLeigh Vaughan, MD

April 30, 2013Division of Hospital Medicine

General Internal Medicine and Geriatrics, MUSC

Identify common causes for acute gastrointestinal bleeding in the hospitalized patient

Describe clinical presentation and appropriate evaluation of patients with an acute upper GI bleed

Outline appropriate resuscitative measures for the patient with consideration given to co-morbid illnesses

Delineate high risk patients who may need more aggressive intervention or level of care

Objectives

The history and physical are essential to identifying the cause of an acute GI bleed

Physical exam and laboratory data can assess the severity of illness and the likelihood of clinical decompensation

Initial and rapid stabilization with IV fluids and blood products followed by intensive monitoring are the mainstays of resuscitation efforts

Key Messages

‣ Peptic ulcer disease ‣ Gastritis‣ Esophagogastric varices‣ Arteriovenous malformation ‣ Tumor‣ Mallory-Weiss (esophageal) tears

Causes Upper GI Bleed

History Physical examination Laboratory tests Assess the severity of the bleed Identify potential sources of the bleed

Initial evaluation

HPI◦ Inquire about hematemesis ◦ Coffee ground emesis suggests limited bleed ◦ BRBPR suggests faster bleed◦ Melena- tarry black stools*◦ Clots in stool less likely upper GI bleed

PMHx◦ Prior GI bleed- 60 % patients with a history of prior GI bleed,

rebleed from same cause◦ H. pylori status◦ Relevant comorbidities

Prior surgeries that may have affected anatomy Social history

◦ Prior smoking◦ Alcohol use

History – Pertinent points

Family history◦ Coagulopathy◦ Congenital disorders with AV malformation

Medications◦ ASA, NSAID◦ Pill esophagitis- bisphosphonates, doxycycline,

KCl, quinidine, iron◦ Anticoagulants◦ Bismuth, iron- darken stool

History -continued

Assessing clinical stability◦ Resting tachycardia suggests mild to moderate volume

loss◦ Orthostatic hypotension suggests blood volume loss of

at least 15%◦ Supine hypotension indicates blood volume loss of at

least 40%◦ Involuntary guarding consider perforation

Stigmata of liver disease Skin manifestations of systemic disorders (such

as petechiae or telangiectasia) that may predispose to gastrointestinal bleeding

Rectal exam

Physical Exam – Pertinent findings

RUQ pain, epigastric discomfortPUD Dysphagia, odynophagia, GERD

esophageal ulcer Retching, cough that precedes emesis

Mallory Weiss tear Weight loss, early satiety, cachexia

cancer

Finding that may correlate with etiology

Nasogastric lavage- not uniformly recommended◦ Assess ongoing bleeding◦ Confirm upper GI bleed as source◦ Identify those who might benefit from an early endoscopy

Type and cross CBC, serum chemistries, liver tests, and coagulation

studies◦ Elevated BUN: linear correlation with likelihood of source of

bleed being upper GI◦ Other labs depending on clinical scenario (LFT, alb)

Serial EKG’s and cardiac enzymes Once stable, all patients should undergo H. Pylori

testing

Workup & laboratory,

Initial Hgb in acute bleed- likely reflects baseline (no time to drop)

Check Hgb q 2-8 depending on clinical scenario

Over resuscitation can falsely dilute Hgb Normocytic anemia most expected type in

acute GI bleed; microcytic anemia suggests chronic bleed

Interpretation of data

Multiple validated models -Blatchford and Rockall Many include endoscopic data (which not available at

presentation) Poor prognostic indicators: age, shock, comorbidities, Hgb,

need for blood, sepsis, BUN, Cr., AST, high APACHE score AIM 65 - each risk factor gets a point, endpoints

mortality & hospital stay◦ Album <3.0, INR >1.5, altered mental status, SBP <

90mmHg, age > 65◦ Zero risk factors conveys 0.3% chance of death during

hospitalization. 5 risk factors 31.8 % chance of death during hospitalization

Saltzman JR, Tabak YP,. Gastrointest Endosc. 2011;74(6):1215.

Risk stratification tools

 All patients with hemodynamic instability (shock, orthostatic hypotension)

All patients with active bleeding (hematemesis, BRB per nasogastric tube, or hematochezia)

Resuscitation and close observation◦ Monitoring blood pressure, pulse oximetry, urine

output◦ Electrocardiogram monitoring

Who needs ICU? & Why?

• Fluid resuscitation with 2 large bore IVs• Bolus (not only hourly drip) of isotonic crystalloid• Consideration for invasive hemodynamic monitoring• Packed RBCs – revised transfusion criteria:

◦ Hemodynamic instability, despite fluid resuscitation◦ Hgb < 8 high risk patient, intolerant to anemia

(CAD, Pulmonary HTN, Pulmonary disease)◦ Hgb < 7 in low risk patient◦ Overall data supportive of restrictive transfusion if

early endoscopy available◦ Every 4 u PRBC’s necessitates unit of FFP

Management – volume resuscitation

Barkun AN, Bardou M, Kuipers EJ, et al., Ann Intern Med. 2010; 152(2):101Carson JL, et al., Ann Intern Med 2012;157:49-58

NPO O2 supplement Correction of coagulopathy

◦ INR > 1.5 FFP (not vit K acutely)◦ Platelets < 50,000 transfusion◦ Recent use of ASA/ antiplatelet agent- indication for platelet

transfusion in massive bleed 2/2 induced platelet dysfunction

Empiric IV PPI (Omeprazole IV 80 bolus, plus hourly infusion)- until etiology established

Provide appropriate nutritional support Assess aspiration risk, need for intubation Early GI/ IR/ surgery involvement

Management

Beware of over zealous fluid resuscitation in CHF, renal disease

Avoid over transfusion in variceal bleed- do not exceed Hgb >10g/dL

Esophageal varices, cirrhosis◦ IV somatostatin bolus, followed by hourly infusion◦ Broad spectrum antibiotics* - 20% patients have

concurrent infection, 50% develop infection during hospital course

Confounding variables

Do NOT delay endoscopy-moderately anticoagulated (INRs of 1.3 -2.7) success rates are comparable to those not anticoagulated ◦ INR > 3.0 urgent reversal prior to endoscopy◦ Attempt to lower below 2.5 -3.0 when possible

No reversal agent for direct thrombin inhibitors or Factor Xa inhibitors

Anticoagulation & active bleed

Endoscopy- #1 tool, used early (24 hr)◦ Can locate bleed◦ Can achieve hemostasis◦ Can prevent rebleed◦ Requires hemodynamic stability◦ Patients likely get erythromycin (as prokinetic)

prior to procedure in severe bleed Tagged red cell Angiography NO GI barium- contraindicated

Invasive tests, studies

Reliable patient with good follow-upFavorable factors

Few comorbiditiesNegative NG aspirateHemodynamic stablilityNormal labs (Hgb, BUN, Cr.)Likely source of bleed identified (from endoscopy

or other modality)Absence of factors associated with rebleed

(variceal bleeding, active bleeding, bleeding from a Dieulafoy's lesion, or ulcer bleeding with high-risk stigmata)

Who can be discharged quickly & safely?

All decisions predicated on favorable risk benefit analysis

Resumption of warfarin after bleed◦ Many risk stratification tools (HAS-BLED, ATRIA)◦ If risk/benefit ratio favors resuming, wait 4 days after bleed

‣ Patients who require NSAIDS - PPI with a cyclooxygenase-2 inhibitor can reduce, not prevent, rebleed

‣ Discharge in cardiac patients requiring ASA- ASA +PPI may be resumed in 7 days

‣ Most patients should receive a single Rx for daily dosing of PPI; duration should be determined by cause of bleed

Discharge medications

Barkun AN, Bardou M, Kuipers EJ. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010;152(2):101.

The role of endoscopy in the management of acute non-variceal upper GI bleeding. Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy. Gastrointest Endosc. 2012;75(6):1132.

Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012 Mar;107(3):345-60; quiz 361. Epub 2012 Feb 07.

Carson JL, Grossman BJ, Kleinman S, et al. Red blood cell transfusion: a clinical practice guideline from the AABB. Ann Intern Med 2012;157:49-58

References