RJ GI Bleed

7/30/2019 RJ GI Bleed

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Acute Gastrointestinal

Bleeding

Rajeev Jain, M.D.


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GI Bleeding

Clinical Presentation

Acute Upper GI Bleed Acute Lower GI Bleed


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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


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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


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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


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Resuscitation

2 large bore peripheral IVs

Normal saline or LR

Packed RBCs

Correct coagulopathy


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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


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Acute UGIB

Demographics

10,000 - 20,000 deaths annually

Mortality stable at 10%

80% self-limited

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 duringhospitalization

Acute UGIB

Prognostic Indicators


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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.


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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



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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.


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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.


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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.


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Endoscopic Appearance

of Ulcers


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Prognostic Features at Endoscopy

in Acute Ulcer Bleeding

Lain e 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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Endoscopic Therapy of PUD

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


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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)


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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.


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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


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Adjuvant Medical

Therapy of PUD

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


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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.


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Mallory-Weiss Tear


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Esophageal Varices


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Variceal Band Ligation


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Variceal Band Ligation


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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


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TIPS

IVC

Portal Vein

Splenic Vein

Coronary Vein


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Aortoduodenal Fistula

Aorta

Duodenum

Graft

Fistula


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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%


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Acute UGIB

Surgery

Recurrent bleeding despite

endoscopic therapy

> 6-8 units pRBCs


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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


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Acute LGIB



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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



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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.


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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 severebleeding (>4 hrsafter hospitalization)

1st 73 pts: nocolonoscopic tx

Last 48 pts eligiblefor colonoscopic tx

Colonoscopy w/in 6-12 hrs


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Urgent Colonoscopy for the Diagnosis and

Treatment of Severe Diverticular

Hemorrhage

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


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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 %

Etiology Incomplete obliteration of

the vitelline duct.

Pathology 50% ileal, 50% gastric,

pancreatic, colonic mucosa

Complications Painless bleeding (children, currant jelly)

Intussusception

Acute LGIB

Meckels Diverticulum


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StudyYield

%Comments

Colonoscopy 69-80 Therapeutic

Arteriography 40-781 ml/min,

risks

Tagged RBC Scan 20-72 Localization

Acute LGIB

Evaluation

Zuccaro. ASGE Clinic al Upd ate. 1999.


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Resuscitation

UGI source

Most bleeding ceases Colonscopy - early

No role for barium studies

5% Mortality

Acute LGIB

Key Points

RJ GI Bleed

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