Approach to Upper GI Bleeding Julia Lee, PGY-2 March 2016 UCI Internal Medicine Residency

Learning Objectives Review the major causes of upper GI bleeding Learn how to triage patients with upper GI bleeding to ICU vs floors Understand acute management of upper GI bleeding

Esophagogastric varices Major Causes Cause Prevalence Peptic ulcer 33.9% Esophagogastric varices 32.8% Erosive esophagitis 8.1% Mallory-Weiss tear 6.4% Erosion 5.1% Tumor Esophageal ulcer 2.1% Portal gastropathy 1.0% Dieulafoy lesion 0.9% Cameron lesion 0.7% Other 2.7% When initially evaluating patients with upper GIB, think about the major causes -Note that the majority of causes are 2/2 PUD and esophagogastric varices -When asking about NSAID/aspiring or anticoagulant use, try to quantify amount, frequency, duration, last use Image: clipartpanda.com Data: MKSAP 17

Characteristics of Bleeding Hematemesis – coffee ground vs bright red blood Bright red blood: moderate to severe bleeding Coffee-ground emesis: slower bleed Melena – dark, tarry, pungent Usually due to an upper GI bleed Can also be from the small intestine or proximal colon if it’s a slow bleed Hematochezia – bright red blood Usually lower GI bleed Can be seen with massive/brisk upper GI bleeding Characteristics of Bleeding Hematemesis – suggests bleeding proximal to the ligament of Treitz. Bright red blood suggests moderate to severe bleeding that may be ongoing Coffee-ground emesis suggests slower bleed Melena Dark, tarry, pungent Usually due to an upper GI bleed, but can also be from the small intestine or proximal colon if it’s a slow bleed Stool can turn black with only 50-100cc of upper GIB Note: iron and bismuth  melanotic stool Hematochezia Usually bright red blood Most often with lower GI bleed, but can be seen with massive/brisk upper GI bleeding Note: Beets  red stool Image: surgsoc.ucc.ie

Examination Vitals Abdominal examination Rectal examination Signs of hemodynamic instability Abdominal examination Stigmata of liver disease Signs of perforation Rectal examination NG lavage (not required for upper GIB), but can help differentiate between upper and lower GIB -Resting tachycardia usually means mild to mod hypovolemia, while orthostatic hypotension is ~15% blood volume loss, and supine hypotension can mean ~40% blood volume loss Significant abdominal tenderness or rebound – think perforation!!! Rectal exam can provide a clue to the location of the bleeding, but it is not very reliable Assess for any masses or hemorrhoids Skin exam looking for evidence of liver disease, such as jaundice, telangiectasias, asterixis, caput, etc. NG lavage if unsure if bleed is upper or lower GI Note: Guaiac positive stool -Occult blood in stool -Does not provide information on location -Indicates low volume, slow bleed

Labs CBC, coags LFTs, albumin BUN/Cr >30 Note: Guaiac testing does not provide information in location

Emergent Management Monitor hemodynamic stability Triage – ICU vs Wards Hemodynamic instability or active bleeding -> ICU Immediate GI consult Two large bore IV lines (16 gauge or larger) Bolus infusions of isotonic crystalloid Transfusion STAT Type and Cross pRBCs – Hgb <7, hemodynamic instability FFP, platelets – coagulopathy, plt <50 or plt dysfunction Trend H/H q6 hours NPO What do you do now that you’ve established an upper GI bleed? -First step is always ABCs!!! -Two large bore IVs can actually infuse more fluid faster than a central line -Adequate resuscitation is essential prior to endoscopy or other intervention -You will typically transfuse for a Hgb <7, active bleeding or hemodynamic instability. Consider transfusion of Hgb <10 with active cardiac ischemia -Trend H/H: you can trend more or less frequently based on clinical judgment -NPO for scoping/procedures; keep NPO until GI clears Image: photosearch.com

Triage Rockall Score (most commonly used) to help triage <60 60-79 >80 Shock None Pulse >100 SBP <100 Major Comorbidity Cardiac Failure, Ischemic Heart Disease, similar major morbidity Renal failure, liver failure, metastatic cancer Evidence of bleeding Blood, adherent clot, spurting vessel Diagnosis Mallory-Weiss tear, but no major lesions and no stigmata of recent bleed Other nonmalignant gastrointestinal diagnoses Upper gastrointestinal tract malignancy Various tools exist to help assess GI bleeding, such as: -Rockall Score -Identifies patients at risk of adverse outcomes/mortality following acute UPPER GIB -Blatchford Clinical Prediction Score -For low-risk patients with specifically UPPER GIB and possible outpatient management -JAMA published article in 2012 concluding that Blachford score is efficient in identifying low risk patients who do not require emergent intervention -Srygley F, Gerardo CJ, Tran T, Fisher DA. Does This Patient Have a Severe Upper Gastrointestinal Bleed?. JAMA.2012;307(10):1072-1079. -BLEED Criteria -Applied at initial emergency department evaluation and before admission -Predicts hospital outcomes for patients with acute UPPER OR LOWER GI bleeding (not just upper GIB) Score < 3 carries good prognosis Score >8 carries high risk of mortality

Medications PPI Avoid NSAIDs, ASA, anticoagulants, antiplatelets Protonix 80mg IV bolus, then 8mg/hr infusion Studies have shown that intermittent PPI boluses are noninferior to bolus followed by infusion Avoid NSAIDs, ASA, anticoagulants, antiplatelets Acid suppression H2 blockers have not been shown to reduce re-bleeding in PUD. Always use PPIs. Studies have shown that intermittent bolus PPI is noninferior to the traditional bolus followed by infusion. Sachar H, Vaidya K, Laine L. Intermittent vs Continuous Proton Pump Inhibitor Therapy for High-Risk Bleeding Ulcers: A Systematic Review and Meta-analysis. JAMA Intern Med.2014;174(11):1755-1762. doi:10.1001/jamainternmed.2014.4056. http://archinte.jamanetwork.com/article.aspx?articleid=1901116 Protonix and Esomeprazole are the only two IV formulations available in US Somatostatin Analogues Decrease portal venous inflow, portal pressures, azygos flow, and intravariceal pressures decrease  (splanchnic circulation) Antibiotics: Bacterial infections are present in up to 20% of patients with cirrhosis who are hospitalized with gastrointestinal bleeding; up to an additional 50% develop an infection while hospitalized Reduces variceal rebleeding, infection and mortality in patients with cirrhosis +/- ascites Most common regimen is Ceftriaxone Can also use Ciprofloxacin, but there is a high rate of FQ resistance

Suspected variceal bleeding/cirrhosis Somatostatin analogues Octreotide 50mcg IV bolus, then 50mcg/hr infusion Antibiotics Most common regimen is Ceftriaxone (1 g/day) x5-7 days Can switch to Norfloxacin PO upon discharge

Assessment & Resuscitation (vitals, exam, labs, stabilization, IV fluids, transfusion) Triage Hemodynamically unstable? Active bleeding? Floors ICU Medications Protonix If variceal bleeding/cirrhosis: Octreotide Antibiotics GI Consult NPO No Yes

Clinical Scenario 67 yo M with medical history significant for HTN and osteoarthritis who presents to the ED with 3 episodes of coffee–ground emesis today. Denies previous episodes of hematemesis. No history of liver disease or coagulopathy. Denies any abdominal pain, melena, hematochezia, lightheadedness or dizziness. Surgeries: None Social: Occasionally uses EtOH on weekends. No other tobacco or illicit drug use. Medications: HCTZ, Lisinopril, and Ibuprofen PRN for joint pain Allergies: None

Physical exam Vital Signs on arrival: General: AAOx3, conversant T 98.9, HR 102, BP 108/72 (lying), 106/68 (standing) , Pox 99% on RA General: AAOx3, conversant HEENT: NC/AT, no scleral icterus, conjunctiva pink. CV: Tachycardic, no m/r/g Lungs: CTAB Abdomen: soft, non-tender, non-distended, no HSM Rectal: dark brown stool present, +guaiac

Labs WBC 7.8, Hgb 9.8, Plt 245 PT 12, INR 1.0, AST 20, ALT 17, ALP 50, Albumin 3.7, TP 7, Bili 0.6 BUN 28, Cr 1.4 -What stands out about these labs? Hgb low at 9.8 Coags are WNL Liver panel WNL BUN and Cr are elevated Image: alibaba.com

Clinical Scenario What is the likely etiology of the bleeding? Where should the patient be triaged? What is the appropriate acute management? What is the likely etiology of the bleeding? Suspect peptic ulcer disease or gastritis due to NSAID Where should the patient be triaged? Medicine Wards: no signs of active bleeding, tachycardia improved with IVFs, no orthostasis What is the appropriate acute management? Airway stabilization, cardiac monitoring Two 16 gauge IVs, immediately given 1L NS bolus and tachycardia improved Type and cross sent Protonix 80mg IV x 1, then continuous infusion of 8mg/hr GI consult called Image: http://vecto.rs/design/vector-of-a-bored-cartoon-patient-iv-fluid-bag-while-resting-in-a-hospital-bed-line-drawing-by-ron-leishman-732

Take-Home Points Obtain a good history Triage to ICU vs Wards Contact GI immediately Exam and diagnostic data Emergent management ABCs, two large bore peripheral IVs, fluid resuscitation, possible transfusion PPI If you suspect variceal bleed/cirrhosis, add somatostatin analogue and empiric antibiotics

References Saltzman J, Feldman M. (2015, November 12) Approach to acute upper gastrointestinal bleeding in adults. Retrieved from www.uptodate.com. Srygley F, Gerardo CJ, Tran T, Fisher DA. Does This Patient Have a Severe Upper Gastrointestinal Bleed?. JAMA.2012;307(10):1072-1079. Sachar H, Vaidya K, Laine L. Intermittent vs Continuous Proton Pump Inhibitor Therapy for High-Risk Bleeding Ulcers: A Systematic Review and Meta-analysis. JAMA Intern Med.2014;174(11):1755-1762. Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med.2013;368(1):11-21. MKSAP 17