Dyph Gi Bleed

8/3/2019 Dyph Gi Bleed

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Gastrointestinal Bleeding

Janak N. Shah, MD

Assistant Clinical Professor of Medicine

University of California, San Francisco

Director of Endoscopy

San Francisco VA Hospital

October 2007


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GI Bleeding : Definitions

IDA : iron deficiency anemia

FOBT: fecal occult blood test

From Zuckerman, Lewis, et al. (AGA Clin Practice Committee). Gastroenterol 2000; 118: 201


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Acute GI Bleeding : epidemiology

UGI ~ 100 hospitalizations /

100,000 persons per year

M > F Increases with age

Rockall, BMJ 1995, 311: 222

Mortality 7-14%Rockall, BMJ 1995; 311: 222

Longstreth, AJG 1995; 90: 206

Yavorski, AJG 1995; 90: 568.

LGI ~ 21 hospitalizations /

100,000 persons per year

M > F Increases with age

Mortality 4%

Longstreth, AJG 1997; 92: 419


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Manifestations of Overt GI BleedingHemetemesis

Red blood or coffee-ground emesis

Melena

Black, tarry, foul-smelling Blood in GI tract > 14 hours

Hematochezia Bright red / maroon stool, bloody diarrhea, clots

Usually LGI source : UGI source in 10%


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How much blood does it take to

produce

Melena?

Hematochezia from UGI source?

FOBT + ?


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How much blood does it take toproduce

Melena? 50-100cc

Hematochezia from UGI source? 500-1000cc

FOBT + ?

From UGI source: 10-20 cc

From LGI source: 0.5 cc


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Acute UGI Bleeding : Etiology

What are common causes of UGIhemorrhage?


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Acute UGI Bleeding : Etiology

Etiology N = 4137

Peptic ulcer disease 1448 (35%)

Erosive mucosal disease 873 (21%)

Mallory-Weiss syndrome 214 (5%)

Varices 180 (4%)

Malignancy 155 (4%)

Other diagnoses 253 (6%)

No diagnosis made 1014 (25%)

Rockall, BMJ 1995, 311: 222


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Acute UGI Bleeding : Less Common Etiologies

Hemobilia

Hemosuccus pancreaticus

Aorto-enteric fistulas

GAVE (watermelonstomach)

AV malformation /

vascular ectasias

Dieulafoys lesion

Portal HTN gastropathy

Hereditary hemorrhagic

telangiectasia (Osler-

Weber-Rendu)


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Acute LGI Bleeding : Etiology

What are common causes of LGIhemorrhage?


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Acute LGI Bleeding : Etiology

From Elta, GIE 2004; 59: 402


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Case 1:

65-year old male presents to the ED with a 1-dayhistory of melena and coffee-ground emesis. Pt

reports feeling weak and light-headed. You are

called by the ED to evaluate this patient

What are important history, physical, and laboratory featuresto assess in this patient ?


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Overt GI Bleeding : Clinical Assessment

History and Physical

ASA / NSAIDs / anti-coags

Alcohol intake

Vitals/postural changes (vol

depletion of 15%)

Hx/ Signs of liver disease

Rectal exam- stool color N/G lavage (dx / pre-egd) : 16%

of UGI bleeds: negative N/G

Lab studies

CBC / coagulation studies

type and crossmatch

Liver tests

Chem 7

Clinical prognostic factors

Hemodynamic instability

on presentation Red blood emesis +

hematochezia

Failure of N/G clearing Advanced age (>60)

Medical co-morbidities

Laine and Peterson, Bleeding pepticulcer, NEJM 1995; 331: 717


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Case 1: Clinical assessment performed

History + NSAIDs QD x 1 month for back pain

EtOH: 1-2 glasses wine, 2-3 x week

Physical exam VS: supine 120/70, 105-sitting 105/65, 120

No PE signs of liver disease Abd: soft, NT, rectal- black, tarry stool

N/G lavage: large vol clots, does not clear

after 2L lavage

Labs CBC: wbc 9, hct 44, plts 180

Coags: nl

Liver tests: nl

What should be done now?

A) Emergent EGD in ERB) Admit to ward, EGD

tomorrow

C) Start PPI (IV), no needfor EGD

D) Fluid resuscitation,

admit to ICU, urgent

EGD after stabilization


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Case 1:

There is a shortage of ICU beds. The ED team asks

if a general ward admission would be appropriate.

They argue that the HCT is normal, and thus this

patient is not having substantial hemorrhage.

What is your response ?


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Hematocrit to Assess Blood Loss


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Issues to consider prior to EGD for

UGI bleeding Adequate hemodynamic resuscitation

Good IV access Hemoglobin >8 g/dl (higher with cardiopulmonary dz)

Carson, Lancet 1988; 1:727 , Carson, Lancet 1996; 348:1055

Need for intubation Consider intubation for persistent hemetemesis or

bloody N/G output

Conscious sedation vs. deep sedation (anesthesia)

Clotting parameters Platelets > 50,000

INR 1.5-2.5 Choudari, Gut 1994; 35: 464.


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Case 1: Upper Endoscopy Performed

Visible vessel in duodenal bulbar ulcer (3cm). Active bleeding

started during EGD prior to endoscopic therapy.


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Endoscopic Prognostic Factors in

Ulcer Hemorrhage

What are the endoscopic factors associatedwith a worse prognosis (rebleeding, death)

in this patient?


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Endoscopic Prognostic Factors

What are the endoscopic factors associatedwith a worse prognosis (rebleeding, death)

in this patient?

Actively bleeding ulcerLaine, NEJM 1995; 331: 717.

Large ulcer size (>1cm)

24% vs 12% rebleed, 13% vs 1.6% mortalityBranicki, World J Surg 1990; 14: 262.


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Prevalence and Outcome of Bleeding Ulcer by

Endoscopic Appearance

From Laine, NEJM 1995; 331: 717.


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Endoscopic Stigmata in PUD

Flat spot Clot

Clean base


Visible vessel Active bleeding


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Endoscopic Treatments for PUD with High-risk

Stigmata (active bleeding / visible vessels)

Epinephrine injection (1:10000)

Contact thermocoagulation(BPEC, heater probes)

Non-contact thermal (laser,

APC)

Endoclips

Sclerosant injection

(polidocanol, absolute alcohol)

Fibrin glue, thrombin injection Saline injection (tamponade)

Combo tx superior to mono tx (epi alone) for high risk lesions

10% vs 18% rebleeding (Meta-analysis) Calvet, Gastroenterol 2004; 126: 441.


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Endoscopic Techniques : Coaptive Thermocoagulation

Large caliber probe (10F)

Firm tamponade

Bipolar (multipolar electrocautery) : 15-25 Watt setting

Heater probe : 30 joule setting

hemostasis: > 90% Complications: induce bleeding 0.3%; perforation 0.5%



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Endoscopic Techniques : Endoclips

hemostasis: > 90%

From Raju, GIE 2004; 59: 267.


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Case 1 : Endoscopic Therapy

successful hemostasis with contact thermocoagulation and hemoclips


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Case 1: Post-treatment recommendations:

Endoscopic treatment is successful in achieving

hemostasis. The ICU nurse manager asks you

Can the patient be transferred to the medical ward?

Should any other medications be started?


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Algorithm for the Management of

Bleeding Ulcers

ICU for 1 day;

Ward for 2 days

Endoscopic Therapy

Active Bleeding

or

Visible Vessel

Ward for 3 days

No Endoscopic Therapy

Clot or

Flat Spot

Discharge within 1 day

No Endoscopic Therapy

Clean Base

ULCER

Adapted from Laine, NEJM 1995; 331: 717.


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PPI for Bleeding Ulcers

Low intragastric pH (


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Case 1: continued

The patient is hemodynamically stable over the next

22 hours. Just prior to transfer to the medical

floor, the patient develops hemetemesis, withhypotension and tachycardia.

What is the recommended management :

A) Repeat endoscopyB) Endoscopic therapy has failed call IR for angio

C) Continue PPI (IV), no need for EGD

D) Endoscopic therapy has failed call surgery


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Recurrent Bleeding after Endoscopic Therapy

~ 20% rebleed after endoscopic txLower with PPI therapy Lau, NEJM 2000; 343: 310

Permanent hemostasis with repeat endo tx in 50%

of re-bleeders

~ 10% with high-risk stigmata require surgery

Laine, NEJM 1994; 331: 717


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Non-endoscopic Therapy for Bleeding Ulcers

Surgery:

Endoscopic failures

Angiographic treatment:

Intra-arterial vasopressin : 50% success

Embolization: 75% success, but rebleed in 50%;complications- ischemia, perforation

High surgical risk, endoscopic failure

Laine, NEJM 1994; 331: 717

C 2


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Case 2:

A 45 old female with known cirrhosis secondary to alcoholabuse presents with a 2-day history of melena.

PE:

vitals: 85/65, 115vitals: 85/65, 115 AbdAbd: soft,: soft, nontendernontender,, splenomegalysplenomegalyRectal: black, tarry stool

N/G lavage: 200cc maroon blood / clots, clear after 1L lavage

Labs: hct 27, plts 130, INR 1.7

She is presumptively dxd in the ED with acute varicealhemorrhage, and is awaiting a bed in the ICU. Blood, Plts,

FFP transfusions have been started.

The ED resident pages the on-call medical intern and asks,

Should any medications be started while awaiting endoscopy?


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Case 2 : Endoscopy performed

Active variceal bleeding

noted

What types ofendoscopic treatments

are available ?


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Endoscopic techniques for variceal hemorrhage

Band ligation vs sclerotherapy

Similar / better initial hemostasis

> 90%

Decreased complications

Esophageal strictures / ulcers

infectionsLo, Hepatol 1997; 25:1101

Laine, Ann Int Med 1993; 119:1

Stiegmann, NEJM 1992; 326: 1527

Decreased mortality ?19% vs. 35% Lo, Hepatol 1997; 25:1101

28% vs. 45% Stiegmann, NEJM 1992;326:1527From Rockey, NEJM 2001; 345:669


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Endoscopic Variceal Band Ligation

From Helmy, APT 2001; 15: 575


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Case 2 : Endoscopic therapy performed

Deployment of bands was suboptimal due to

ongoing hemorrhage and difficult

visualization, and was unsuccessful.

Sclerotherapy was also attempted, butfailed.

What other treatment options are available ?


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Balloon Tamponade

Minnesota Tube High rates of initial bleed

control (>70%)Fort, Hepatol 1990; 11:678

Paquet, Hepatol 1985; 5:580

High rebleed rates (40%)Paquet, Hepatol 1985; 5:580

Complications:

esophageal perforation

< 8%Chojkier, Dig Dis Sci 1980; 25:267

TIPS f A t R f t


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TIPS for Acute Refractory

Variceal Hemorrhage

~ 10% fail endo tx

Rockey, NEJM 2001; 345:669

TIPS effective > 95%Sanyal, Gastroenterol 1996; 111:138

Boyer, Gastroenterol 2003; 124:1700

Rebleed 18%

Mortality (in acute

setting) 38%From Boyer, Gastroenterol 2003; 124:1700


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TIPS Complications

From Boyer, Gastroenterol 2003; 124:1700


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TIPS vs Endoscopic Therapy

From Boyer, Gastroenterol 2003; 124:1700


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Surgical Shunts for Variceal Hemorrhage

for variceal bleeding unresponsive to

endo/pharmacologic tx; and TIPS unavailable

High rates of bleeding control

High 30-day mortality rates (~ 80%)Jalan, AJG 1995; 90: 1932

Case 3:


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Case 3:

A 75-year old male with hx of HTN and osteoarthritis presents with 1-dayhistory of hematochezia (large volume, maroon color). Denies nausea,

vomiting, or abdominal pain.

PMH: otherwise unremarkable meds: ACE inhib, NSAIDs

PE: Patient is comfortable, no acute distress

vitals- 130/90, 95 supine : 110/85, 98 sitting

abd- soft, nontender rectal- maroon stool, clotsN/G lavage- bilious aspirate

labs- plts 190, INR 1.1, init hct 32, 4hr f/u hct 30

IVF fluids were started and the patient is placed in a monitored bed.

The ED resident calls the on-call medical team.

What are the possible management options ?


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LGI Bleeding : Diagnostic / Tx Options

Bleeding scan- nuclear scintigraphy

Urgent colonoscopy

IR-angiogram

Surgery


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Nuclear Scintigraphy Bleeding rate: 0.2-0.5 cc/min

Positive yield in acute LGIB: 40%

Accurate positive yield: 48%

Contradictory bleeding site: 10%

Increased yield with increased transfusion requirement

Olds, J Clin Gastroenterol 2005; 39.


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LGI Bleeding : Urgent Colonoscopy

12-48 hrs of admission

Dx made in 74-90%

Oral purge technique

Polyethylene glycol

1 L every 30-45 min (consider N/G)

Median 5.5 L , 3-4 hrs

Elta, GIE 2004; 59: 402

l f d


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Case 3: urgent colonoscopy performed

What is the diagnosis ? Can this patient be endoscopically treated ?


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Diverticular Hemorrhage : Endoscopic Treatment


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Diverticular Hemorrhage : Endoscopic Treatment

From Elta, GIE 2004; 59: 402

UCSF experience 2003-2004: 11 with active or visible vessel treated with clips +/- epi

100% initial hemostasis

18% rebleed during mean 13.5 month follow-up

Management of Massive LGI Bleeding


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Management of Massive LGI Bleeding

Angiography / IR

+/- nuclear bleeding scan for localization

Requires 0.5-1.0 cc/min bleeding rate

Techniques: intra-arterial vasopressin (>90% success, 50% rebleed)

Selective embolization (>90% success, 76% ITT basis)

Complications: ischemia 7%, rebleed 20%, surgery 20%Gordon, Am J Surg 1997; 174.

Surgery

Hemicolectomy with accurate localization (endo / IR) Subtotal colectomy

Consider for large transfusion requirements: > 6U/24hrs


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From GIE 2001; 53:859


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Endoscopic Bleeding Lesions


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Endoscopic retroflexed view, GE junction

Diagnosis ?


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Mallory-Weiss tear treated with endoclip


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Endoscopic view, fundus of stomach

Diagnosis ?


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Dieulafoys lesion treated with contact

thermocoagulation and endoclip


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Endoscopic view, distal esophagus

Diagnosis ?


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Mallory-Weiss tear closed with endoclip


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Endoscopic image through a side-viewing scope,

2nd portion of duodenum

Diagnosis?


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Endoscopic view, distal esophagus

Diagnosis ?


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Esophageal ulcer with actively bleeding visible vessel

treated with epinephrine injection and endoclip

Varices with stigmata of bleeding:


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Varices with stigmata of bleeding:


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Dyph Gi Bleed

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