Upper GI Bleed: Clinical Case Presentation Lisa Philipose 4 / 25/ 06

History CC: 79 y.o. white male presents via EMS to the Bayview E.D. with two days of loose black tarry stools. HPI: On the morning PTA, patient felt weak and light-headed, so wife called EMS. VS in the field were: HR:136; BP: 82/48; RR:18; O2sat: 98% on RA; D-stick: cc bolus was administered by EMS and BP increased to 107/61 and HR decreased to 96.

History ROS: Pt denies N/V/D/C, and denies chest/abdominal/ back/flank/rectal pain. PMH: HTN, DM, no h/o bleeding d/o; no h/o GI disorders –Last colonoscopy 3 yrs ago reported normal per patient. PSH: None Meds: Lisinopril, Metformin, Glucophage, HCTZ, ASA All: NKDA SH: No h/o tobacco/alcohol/illicits

Physical Vital Signs: T: 98.8 HR: 104 RR: 18 BP: 127/89 O 2 Sat: 98%, RA Gen: Pale, smiling, NAD HEENT: Moist mucus membranes Lungs: CTAB CV: RRR, no M/R/G Abdomen: Nontender, nondistended, +BS Rectal: Grossly heme positive with black tarry foul smelling stool, one small external hemorrhoid-not ruptured, inflamed, or bleeding Extremities: No swelling/tenderness, 2+DP pulses Neuro: Alert and oriented, nonfocal

E.D. course Two large bore IVs in place- 1L NS bolus followed by NS infusion Patient placed on O2 and cardiac monitor. EKG: Normal sinus rhythm Hemocue: 8.9 g/dl Labs sent: CBC (hgb=9.4), CMP, T&S, coags, cardiac enzymes CXR: normal. No free air under diaphragm Rectal exam grossly positive NG lavage: 300 cc clear output  NG d/c Protonix 40mg IV

E.D. course Orthostatics: Lying(77, 132/77) Sitting (73,120/70) Standing (95,114/62) + pt reports lightheadedness Repeat CBC (hgb=8.4) and CE 1 unit PRBCs given VS stable; Pt admitted for observation and inpatient endoscopy GI team aware

Laboratory Data WBC: 9310 w/ nl diff Hgb:9.4  8.4 Hct: 26.5  24 Platelets:226 Coags: normal Blood Type: A+ CE X 2: negative UA: normal Na: 135 K: 4.5 Cl: 103 CO2: 22 BUN: 77 Cr: 1.6 Glucose: 120 Extended panel: normal

Differential Diagnosis Upper GI bleed Lower GI bleed –Slow bleed from right colon –Bleeding from small bowel Other causes of black stools: –Iron pills –Licorice –Bismuth (Pepto-Bismol) –Blueberries Melena

Upper GI Bleed Location: Proximal to ligament of Treitz Incidence: 100 per 100,000 population Symptoms: -Melena (70-80%): (>60 ml blood in gut for 8 hrs) -Hematemesis (45-50%) -Presyncope (40%) -Hematochezia (15-20%) -Syncope (15%) *80% bleeds stop spontaneously UGI bleed has 10% mortality

Etiologies of UGI Peptic ulcer disease (risk factors: HP, NSAIDs, stress, gastric acid) Esophageal varices Mallory Weiss-tears Esophagitis Gastric/esophageal tumor Gastritis Aortoenteric fistula Lymphoma Vascular lesions: Dieulafoy, angiodysplasia Coagulopathy Anticoagulant use

1.Assess hemodynamic stability (Shock?) - ABC’s 2. Clinical assessment/ Resuscitation (Transfuse?) - 1st use crystalloid, use pRBCs if >2-3L crystalloids needed or signs of ischemia on EKG -O2 -CXR, EKG - Foley, labs - Place NGT: confirm UGI source, assess rapidity of bleeding/ need for endoscopy -involve consultants early if needed -acid suppression therapy (PPI decreases risk of acute rebleed) 3. Risk stratify (Endoscopy? Inpatient or outpatient?) 4. Diagnose Approach to UGI Bleed in ED

Risk Assessment: Clinical Lancet 2000 Triage for Outpatient management: Pts with low risk of requiring intervention such as endoscopic therapy or transfusion Factors: -BUN* 13(men), >12 (women) -SBP>110 HR<100

Risk Assessment: Clinical Triage for Inpatient management: -unknown/suspected variceal bleed -hemodynamic instability -ongoing symptoms of bleeding/ recurrent bleeding -comorbidity req. hospitalization (angina) -mental impairment or noncompliance -coagulopathy -anemia requiring transfusion

Role of Endoscopy Urgent endoscopy generally performed for: -unstable patients, continued bleeding -diagnostic and therapeutic Elective Endoscopy -for stable admitted patients Endoscopic Prognostic Factors (NEJM 1994) FindingIncidence(%)Re-bleed (%) 1.Active bleeding Visible vessel Adherent clot Dark spots Clean-based

*Risk of re-bleeding is difficult to assess clinically Is endoscopic triage a solution? -Perform urgent endoscopy on all patients with acute UGI bleed before admission/triage? better health outcomes? More cost effective? -identify high-risk patients early even if clinically silent -discharge low risk patients Non-variceal UGIB:The Controversy of Endoscopic Triage in the ED…

*Prospective RCT Endoscopy within 2 days of admission (control group) Median LOS: 2 days Median cost: $3,662 Early endoscopy in ED *46%(26/56) with low risk lesions d/c’d from ED per GI recs without adverse outcome *8 pts upgraded (ward  IMC  ICU) based on unexpected high risk endoscopic lesions Median LOS: 1 days Median cost: $2,068 Assess clinical outcomes and costs prospectively for next 30 days 110 patients :upper GI bleed (nonvariceal) and stable VS randomized

The other side… -Randomized multicenter trial of nonvariceal UGI bleed (2004) -no difference in LOS or clinical outcomes -difference in study: 40% were recommended for d/c based on endoscopy findings, however only 9% patients actually d/c’d from ED (vs 46% in Lee study) -mimics clinical practice…attending physician admitted patients based on own clinical judgment despite low risk endoscopic results.

Conclusion.. Endoscopic triage is effective in avoiding hospitalization and reducing costs of low- risk patients However, if findings of endoscopy do not affect clinical practice by nonendoscopists (ED docs), endoscopic triage is not an effective tool

Back to our patient…. Post-ED Course: Patient admitted on a Friday  had another episode of melena over the weekend  Slight drops in hct, managed with fluids  EGD on Tuesday showed: 1) antral erosions 2) healing Mallory Weiss ulcer Pt d/c’d with following recs per GI: -check HP Ab and tx with triple tx if + -continue PPI -outpatient colonoscopy

Summary Assess hemodynamic stability Resuscitate History/physical: risk factors? Re-assess need for resuscitation often NG lavage Endoscopy? All bleeding stops…eventually

References Bjorkman DJ. Endoscopic triage for nonvariceal upper gastrointestinal bleeding: the optimal approach in 2001? ASGE wesbite, Bjorkman DJ et al., Urgent vs elective endoscopy for acute nonvariceal upper GI bleeding: an effectiveness study. Gastrointest endosc 2004; 60: Blatchford O et al., A risk score to predict need for treatment for upper- gastrointestinal hemorrhage. Lancet 2000; 356: Eisen GM et al., Guidelines: An annotated algorithmic approach to gastrointestinal bleeding. Gastro Endo 2001; 53:853. Jutabha R, Jensen D. Approach to the Adult patient with upper gastro- intestinal bleeding In: UpToDate, Wellesley, MA, Laine L, Peterson WL. Bleeding peptic ulcer. NEJM 1994; 331: Lee JG, et al., Endoscopy-based traige significantly reduces hospitalization rates and costs of upper GI bleeding: a randomized controlled trial. Gastrointest Endosc 1999;50: Peter DJ and Daughtery JM, Evaluation of the patient with gastrointestinal bleeding: An evidence-based approach. Emerg Med Clin NA 17:239, 1999.