Acute Gastrointestinal Bleeding Naveed Ahmad M.D November 2012

QUESTION 1 Endotracheal intubation for airway protection in the management of acute Upper GI bleeding should be considered: A. in all cirrhotic patients B. in all patients with UGI bleeding C. in patients with altered mental status and ongoing hematemesis D. in patients with stable COPD E. in all patients unless it delays urgent endoscopy

QUESTION 2 A 73 year old man presents with several episodes of hematemesis. Examination shows signs of orthostatic hypotension and melena. What is the first priority in caring for this patient? A. Nasogastric tube placement and gastric lavage. B. Resuscitation with adequate IV access and appropriate fluid and blood product infusion. C. Intravenous infusion of H2-receptor antagonists to stop the bleeding. D. Urgent upper endoscopy. E. Urgent surgical consultation.

QUESTION 3. A 58 year old female patient presents to the ED with a 24-hour history of several bloody bowel movements. She denies any abdominal pain but complains of light headedness. She is found to be hypotensive with systolic blood pressure of 90mmHg supine. Hb 7gm/dl. Resuscitative measures are instituted. What is the most appropriate next step? A. Nasogastric tube placement B. Flexible sigmoidoscopy C. Colonoscopic examination D. Tagged RBC scan E. Angiography

Intraluminal blood loss anywhere from oropharynx to anus Upper : above ligament of Treitz Lower Below the ligament of Treitz

Incidence Annual rate of hospitalization for any type of GIB in US 350/100,000 Annually, approximately 100,000 patients are admitted to US hospitals UGIB 50%, Lower GIB 40%, 10% obscure bleeding. Mortality rates from UGIB are 6-10% overall The incidence of UGIB is 2-fold greater in males than in females, in all age groups; however, the death rate is similar in both sexes

Signs Hematemesis : blood in vomitus (UGIB) Hematochezia : bloody stools (LGIB or rapid UGIB) Melena : Black Tarry stools from digested blood (Usually UGIB but can be anywhere including right colon)

Etiologies (UGIB) Source Prevalence (%) Duodenal Ulcer 24.3 Gastric Erosions 23.4 Gastric Ulcer 21.3 Esophagogastric Varices 10.3 Mallory-Weiss tear 7.2 Esophagitis 6.3 Erosive Duodenitis 5.8

Etiologies (UGIB) Oropharyngeal bleeding and epistaxis Immunocompetent host : GERD/Barrett’s/XRT Immunocompromised host : CMV,HSV, Candida

Vascular Malformations (5%) Dieulafoy’s Lesion (superficial ectatic artery in cardia -> sudden massive UGIB) AVMs (isolated or with Osler-Weber-Rendu syndrome) Aorto-enteric fistula (AAA or aortic graft erodes into 3rd portion of duodenum;presents with herald bleed) Vasculitis Neoplastic disease (esophageal or gastric)

Etiologies (LGIB) Source Prevalence (%) Diverticulosis 17 – 44 Colonic Angiodysplasia 2 – 30 Ischemic Colitis 9 – 21 Malignancy 4 – 14 Hemorrhoids/Anorectal 4 – 11 Postpolypectomy 6 Unknown 8 - 12

Clinical Manifestations UGIB>LGIB: Nausea, vomiting, hematemesis, coffee ground emesis, epigastric pain, vasovagal reaction, syncope, melena LGIB>UGIB: Diarrhea, tenesmus,BRBPR or maroon stools

Work Up History : Acute or chronic GIB, number of episodes, most recent episode, hematemesis, vomiting prior to hematemesis, melena, hematochezia, abdominal pain, use of NSAIDs, anti coagulants, alcohol abuse, cirrhosis, prior GI or aortic surgery

Physical Exam Tachycardia at 10% volume loss Orthostatic hypotension at 20% loss Shock at 30% volume loss Pallor, talengectesia (ETOH,cirrhosis, OWR Synd) Chronic liver disease: jaundice,spider angiomata, gynecomastia, testicular atrophy, palmer erythema, caput medusae Localized abdominal tenderness or peritoneal signs, masses, signs of prior surgery Rectal Exam: appearance of stools, hemorrhoids, anal fissure

Lab Studies Hct: maybe normal before equiliberation which may take 24 hours, decreased 2-3%-> loss of 500cc blood. Platelet count, PT,PTT BUN/Cr (ratio>36 in UGIB due to GI resorption of blood and prerenal azotemia) LFTs

NG tube: Useful for localization (presence of non-boody bile in lavage excludes active bleeding proximal to ligament of Treitz), can also clear GI contents prior to EGD and detect continued bleeding

Glasgow-Blatchford Score scores of 6 or more were associated with a greater than 50% risk of needing an intervention

Rockall Score A score less than 3 carries good prognosis but total score more than 8 carries high risk of mortality

Diagnostic Studies UGIB  EGD (potentially therapeutic) LGIB  (r/o UGIB) Stable. Spontaneously stops- colonoscopy diagnostic in 70% cases also potentially therapeutic Stable, ongoing bleeding- colonoscopy or Bleeding scan (Tc tagged RBC/albumin) detects rates >0.1 ml/min, localization difficult Unstable, arteriography bleeding rates >0.5ml/min, potentially therapeutic Ex Lap

RBC scan

Angiogram

Treatment IV access with 2 large bore (18 gauge or larger) IV lines Vol resuscitiation (saline, Ringer’s) Transfusion therapy Correct Coagulopathies NG/Prokinetics Airway management Consult GI and Surgery service as needed

Peptic Ulcer Disease Pharmacologic therapy High Dose PPI therapy (Pantoprazole 80 mg IV bolus followed by 8gm/hr infusion) Endoscopic therapy (Injection, Thermal, Laser) Arteriography with embolization Surgery if endoscopic and pharmacologic therapy fails

Varices Pharmacologic Non Pharmacologic Octreotide 50 microgram IVB  50microgram/hr infusion (84% success; Lancet 1993) Non Selective Beta Blocker therapy (once stable) Non Pharmacologic EVL has replaced sclerotherapy (>90% success) Balloon Temponade (Sengstaken-Blakemore) TIPS if Endoscopy fails

Esophagitis/Gastritis Mallory-Weiss Tear Usually stops spontaneously, endoscopic therapy if active Esophagitis/Gastritis PPI, H2- Antagonists

Diverticular Disease Usually stops spontaneoulsy Endoscopic therapy Arterial vasopressin or embolization Surgery

Angiodysplasia Endoscopic therapy Arterial vasopressin Surgery Hormonal therapy

Risks of Rebleeding without Endoscopic Intervention

Summary Acute GI bleeding remains a important cause for morbidity, hospital admissions and mortality Early and prompt resuscitation is the key to management Diagnostic and therapeutic modalities are ever improving

Thank you

QUESTION 1 Endotracheal intubation for airway protection in the management of acute Upper GI bleeding should be considered: A. in all cirrhotic patients B. in all patients with UGI bleeding C. in patients with altered mental status and ongoing hematemesis D. in patients with stable COPD E. in all patients unless it delays urgent endoscopy

QUESTION 2 A 73 year old man presents with several episodes of hematemesis. Examination shows signs of orthostatic hypotension and melena. What is the first priority in caring for this patient? A. Nasogastric tube placement and gastric lavage. B. Resuscitation with adequate IV access and appropriate fluid and blood product infusion. C. Intravenous infusion of H2-receptor antagonists to stop the bleeding. D. Urgent upper endoscopy. E. Urgent surgical consultation.

QUESTION 3. A fifty-eight year old female patient presents to the emergency department with a 24-hour history of several bloody bowel movements. She denies any abdominal pain but complains of light headedness. She is found to be hypotensive with systolic blood pressure of 90mmHg supine. Hb 7gm/dl. Resuscitative measures are instituted. What is the most appropriate next step? A. Nasogastric tube placement B. Flexible sigmoidoscopy C. Colonoscopic examination D. Tagged RBC scan E. Angiography