1. Ashley Trotter PGY-3

3.  Understand the Definitions Involved in GI Bleeds  First Signs of a Bleed  Introduce the Type of GI Bleeds  Be Able to Recognize Key Signs of Significant GI Bleeds  How to Approach the Bleeding Patient  Additional Information on Variceal Bleeds Specifically

4.  Hematochezia- Bright red rectal bleeding, often L colon or distal  Hematemesis- Vomiting red blood, often stomach or proximal (not digested)  Coffee Grounds- Vomiting partially digested blood  Melena- Dark, tarry stools, digested blood. Requires about 16 hrs of bacterial breakdown, so can be upper or as distal as the right colon with slow motility.

5.  Upper GI bleeds account for >300,000 hospitalizations per year  80% stop spontaneously  Re-bleeding increases mortality 10-fold  Overall mortality is 14%, in US hospital 2-3%  Anticoagulation and antiplatelets or coagulopathies clearly increase risks  FYI: You do not die from bleeding, you die form the resulting organ failures

6.  Is there obvious blood from the mouth or bottom?  Is the stool tarry, block, and very sticky?  Is the patient having loose stools?  It YES, then:  If from the mouth, check for epistaxis, and think about lung source as well  If from the bottom, consider a rectal to check for gross blood, and to check for hemorrhoids or lesions that may be bleeding.  Often it is very obvious though!

7.  Upper versus Lower  Upper is by definition BEFORE the Ligament of Treitz  Lower are more distal, typically colon, rectum or anus

8.  More Likely UPPER  Hematemesis  Coffee Grounds  Melena (though can still be below the Ligament of Treitz)  *Bright red blood per rectum (BRBPR) with instability may be brisk upper bleed  More Likely LOWER  Hematochezia  Tenesmus  BRBPR with stable vitals

9.  Epigastric pain- Think about ulcers (stress, H Pylori, other)  Do they have cirrhosis?(cirrhotics get varices)  Hx of a lot of vomiting? (bulimics, viral illnesses, ingestion of toxins- frequent vomiting can get Mallory Weis Tears  NSAID use? (webs/ulcers can bleed)  IBD history? (tenesmus with bloody diarrhea in flares)  Bad vascular dx w/wo abdominal pain? (ischemia)  Food exposures/travel (think bacterial infection, often with pain, fevers, cramping)  On anticoagulation?  Ask about: Quality, Quantity, Time frame, Color, sxs of instability (dizzy, SOB, racing heart, syncope)

10.  Remember. Blood is a cathartic. Constipated patients are not usually having severe GI bleeds, with exceptions (obstructions)  Do not rely on FOBT alone! Trauma from the exam, recent meals (red meat) can lead to positive result even if not truly bleeding!  Some medications can make a stool look black without bleeding: iron, bismuth, licorice, charcoal  The labs do not equilibrate right away, may take 12-24 hrs to really be accurate. Check frequently! BID for minor bleeding, q4-6hr for severe bleeds.

11.  There are many sources for GI bleed, and many can be upper or lower. Approach by WHERE you think the lesion is:  UPPER  Variceal –a sign of advanced liver disease  Non Variceal-COMMON CAUSES  #1 Peptic Ulcer Disease (50% cases)  Mallory Weis Tears  Dielafoy Lesions  Angodysplasias/AVMs/telangectasias  Portal HTN  LESS COMMON: GERD, stress ulcers, foreign bodies, drug erosions, aortoenteric fistulas, radiation, hemobilia, tumors, Zollinger-Ellison  We see a lot of NSAID induced bleeding here!

12.  LOWER  #1 Diverticulosis  AVMs/Angiodysplasia/telangectasias  Ischemia  Hemorrhoids  Post Polypectomy  Inflammatory (IBD)  LESS COMMON: Infectious, trauma, fistulas

13.  UPPER GI BLEED  Initial assessment  Initial resuscitation (concomitant)  Determine if seems like HIGH or LOW risk (amount of bleeding, past bleeds, comorbid conditions, age, vital signs)  If high risk, ICU, if low risk FLOOR ok  Urgent vs elective scope by severity  Did the bleed stop? If no, may need repeat endoscopy, angiography, or surgery  ACUTE LOWER GI BLEED  Initial assessment/resuscitation  Is there a possible upper source? (vital instability, melena)  If yes, upper endoscopy first  If NO or NEGATIVE  Colonoscopy  Did the bleed stop? If no, consider further assessment (Capsule, Angiography, Surgery)

14.  PPIs (IV): These are the only proven medication to increase the stomach pH to >6.0, preventing fibrinolysis of clots (PUD management!)  Current protocol is bolus PPI then 8units/hr x 72 hrs  Some data supports BID IV push as non-inferior (we only use this currently in cases where other medications are needed constantly through the IV)  Octreotide: Primarily for variceal bleeds, consider in non-variceal bleeds resistant to therapy  ABX (ceftriaxone 1 g/day for 7 days): For variceal bleeds, which are high risk for infection

15. Dailymail.uk

16.  Unstable or patients at risk for acute decompensation need emergent treatment and management to stabilize  *Orthostatic hypotension is equivalent to >15% blood volume loss*  Tachycardia is often the first sign of hemodynamic instability/large volume blood loss

17.  Class I hemorrhage means up to 15% of blood volume lost  HR 30ml/hr, may be anxious  Usually treated with IVF  Usually does not require transfusion in the otherwise healthy patient  Class II hemorrhage means from 15% to 30% blood volume lost  HR 100-120, may still have normal BP but starts to lower, inc RR, may be anxious  May require transfusion at some point, but can usually be stabilized with IVF  Class III hemorrhage means from 30% to 40% blood volume loss  HR 120 to 140, BP decreased, RR 30 to 40, UOP usually 5 to 15 mL/hr, or less, may be confused  Almost all of these patients will have tachycardia and tachypnea  Most of these patients need blood  Class IV hemorrhage means blood loss of greater than 40%  HR >140, BP decreased, RR greater than 35, urine output is negligible or NONE, mental status is confused and/or lethargic  These patients are in immediate danger of death Advanced Trauma Life Support Student Course Manual,9th ed, 2013, American College of Surgeons, pp. 68-70.

18.  Ask yourself:  Can they protect their airway? (persistent hematemesis, mental status issues = elective intubation)  Do they have at least 2 large bore (18 gauge or larger) IVs?  Are they anticoagulated?  INR should be corrected to <2.5 with FFP or Vit K  Plts should be corrected when able to >50,000  HOLD NSAIDS and anticoagulation when possible  Do they need blood now?  Treat hgb <7, or approaching this and still bleeding plus symptomatic  Some conditions may require higher goals (CAD)  Do not be OVERLY aggressive, this may worsen some conditions (varices)  Do they need pressure support?  Crystaloids (LR/NS by pressure bag)  Put their legs up  DO THEY NEED THE ICU NOW?  WHILE THINKING THESE THNGS: Have someone call GI!  NGs are usually not done now, as they have been found to not change outcomes

20. DO NOT PANIC!!!

22.  GET TO THE UNIT, do not take no for an answer…GI/Senior/Chief Can Help!  We have a massive transfusion protocol, the MICU nurses can help and so can the blood bank!  We always have uncrossed blood at the Blood Bank window! (2 nd floor, Lerner Tower, next to the SICU)  CALL GI, plus the things in the prior emergent bleed slide  This is most often seen here for traumas (not us) or variceal bleeds, which will be discussed next

23.  A sign of advanced liver disease  Larger varices bleed more!  They have high infection rates  Can be esophageal OR gastric  Tips  Do not over resuscitate. The varices are pressure driven, and increased intravascular pressure may increase the bleeding.  They require endoscopic therapy (banding, ligation), and not just once!  Continued bleeding is bad…mortality approaches 80%

24.  Medications:  IV PPI-80 IV 1x then 8mg/hr x72 hr after bleed stops  Octreotide- 50 ug IV x1 then 50ug/h  Ceftriaxone 1G/day x 7 days  Call GI right away  As with other upper bleeds, protect the airway if needed  If these continue to bleed and EGD is not plausible/possible due to extent of bleed, you may get to see…

26.  If you have been unfortunate enough that your patient needed (but fortunate enough that they survived) a Blakemore, you will need to get the patient an EMERGENT TIPS. This is done by IR. Usually someone from GI is calling them while the Blakemore is being prepared.

27. You can do it! Remember:  High or low risk?  Stable or not stable?  Upper or lower?  Keep pressure up, check counts, keep blood >7  Floor or ICU?  PPI, Octreotide, and Ceftriaxone are the only meds you need!***  Call GI for help! See its that easy!

28.  Definitions Involved in GI Bleeds  Hematochezia, hematemesis, melena  First Signs of a Bleed  History and exam are key  Types of GI Bleeds  Upper and Lower Sources  Frequent sources are PUD, Diverticulosis, AVMs  Be Able to Recognize Key Signs of Significant GI Bleeds  Tachycardia comes first  Orthostasis shows >15% blood loss in general  How to Approach the Bleeding Patient  Floor or ICU? Minor or severe bleed? Medication choices. Call GI for endoscopy.  Additional information on variceal bleeds specifically  Medications, emergent procedures

29.  Current Diagnosis and Treatment: Gastroenterology, Hepeatology, and Endoscopy. 3 rd Edition. Lange 2016.  Advanced Trauma Life Support Student Course Manual,9th ed, 2013, American College of Surgeons, pp. 68-70.