From Mouth to Rectum and Everywhere in Between GI Bleeding: From Mouth to Rectum and Everywhere in Between

Outline Epidemiology and Risk Factors Signs and Symptoms Physical Exam Findings Etiologies Diagnosis Management Will focus mostly on inpatients

Key Point: Mortality LGIB < UGIB < Variceal bleeds Epidemiology Key Point: Mortality LGIB < UGIB < Variceal bleeds Upper GI bleeds (UGIB) 100,000 admissions/year to US hospitals 10% mortality Variceal bleeds 30% of identified varices will bleed in 1 year 33% mortality with each bleed Lower GI bleeds (LGIB) Less common than UGIB 3% mortality

Risk Factors Most Important Part of History! Key Point: Risk Factors Most Important Part of History! NSAID Use Cirrhosis Anticoagulation/Coagulopathy Age Risk factors for colon cancer Previous history of GI bleeding

Signs and Symptoms Lightheadedness/Syncope Diarrhea Anemia Hematemasis Upper GI Bleed Lower GI Bleed Lightheadedness/Syncope Diarrhea Anemia Hematemasis Melena Stigmata of cirrhosis Heartburn Lightheadedness/Syncope Diarrhea Anemia Hematochezia

Physical Exam Findings Vital signs (more later) Dry mucus membranes Stigmata of cirrhosis Fetid breath DRE – gotta do it Weak pulses Cool skin Encephalopathy

Common Etiologies PUD – 55 % Varices – 14 % AVMs – 6% Upper GI Bleed Lower GI Bleed PUD – 55 % Varices – 14 % AVMs – 6% Mallory Weiss Tears – 5% Tumors/Erosions – 4% Dieulafoy’s lesions – 1% Others 15% Diverticular disease – 30% Colitis – 18% Ischemic Inflammatory Infectious Neoplasms – 10% AVMs – 8% Hemorrhoids – 5% Others – 20% Khilani et all, Emerg Med 37(10):27-32, 2005

Diagnosis Upper or Lower? Still bleeding? What’s the etiology? History Digital Rectal Exam Hemoglobin Still bleeding? Consider NG Lavage What’s the etiology? Diagnostic Testing Freebees These can usually make the diagnosis

For more information, do a GI fellowship! Diagnostic Testing EGD – standard for UGIB Colonoscopy – standard for LGIB Push Enteroscopy – can image through SB Capsule Endoscopy – good yield - can’t intervene Sigmoidoscopy – rarely used Barium studies – good to look for lesions/mass Tagged red cell scans – poor yield For more information, do a GI fellowship!

Management – General Principles Risk stratify Assess blood loss Blatchenford score Rockall score (after EGD) IV access Volume replacement Acid suppression therapy Plan for diagnostic procedure Beyond the scope of this discussion!

Management: Assess Blood Loss Category % loss HR BP Pulse Pressure UOP Stage 1 <15 % < 100 Normal > 30 Stage 2 15-30% > 100 Decreased 20-30 Stage 3 30-40% > 120 5-15 Stage 4 > 40% > 140 Negligible From Advanced Trauma Life Support Guidelines HR not useful if patients are on AV node blockers Tachycardic means they have lost about 1 liter of blood! If they are hypotensive, you are in trouble! Key Points

Management: Access and Volume IV Access Two large bore peripheral IVs is best Volume replacement Normal saline Blood products Consider FFT/Cryo/FFP

MGMT: Acid Suppression Applies to UGIB from ulcers Key Point: PPIs can improve mortality Gralnek I.M et al. NEJM 2008

MGMT: Acid Suppression (con’t) Other questions: Continuous versus bolus? IV versus oral? Duration of treatment?

Management – Suspected Varices Initial stabilization Splanchnic Vasoconstricters: Octreotide/Vasopressin TIPS Minnesota tube/Blakemoore tube Antibiotic prophylaxis A whole other talk

Key Points GI bleeding is a common hospital diagnosis – Look for it Risk factors are the most important part of the history Vital signs can help risk stratify patients PPIs can reduce need for surgery, rebleeding, and death

Questions?