1. Brad Martin, MD c/o Jason De Roulet, MD July 18, 2012
GI BLEEDING
Brad Martin, MD c/o Jason De Roulet, MD
July 18, 2012

2. OBJECTIVES Define some common terms associated with GI bleeds
Review the ways patients commonly present with GI bleeds
Review how to assess patients presenting with GI bleed
Identify the most common causes of both upper and lower GI bleeds
Identify key information to have available when calling a GI consult
Review the medical and endoscopic treatments for both upper and lower GI bleeds

3. DEFINITIONS Acute GI bleed Overt vs. occult < 3 days duration
hemodynamic instability
requires blood transfusion
Overt vs. occult
overt = visible blood (melena, bright red blood, coffee grounds)
occult = only detected by lab tests

4. DEFINITIONS Upper vs. Lower GI bleed
UGIB = proximal to ligament of Treitz
LGIB = distal to ligament of Treitz
Ligament of
Treitz

5. GOALS OF CARE Stabilize patient’s hemodynamics
Assess patient, determine source of bleed
Stop any active bleeding
Treat underlying cause
Prevent recurrence

6. PRESENTATION “The patient has been vomiting blood”
Usually indicates upper GI source
Can include:
bright red blood
coffee ground emesis
clots

7. PRESENTATION “The patient has had bloody stools”
need to determine stool characteristics, especially color, consistency, and frequency
melena = black, tarry stool (melena ≠ dark, formed stool!)
usually indicates upper GI bleed, although ~5% can be from small bowel or proximal colon
only need around 50cc of blood to get melena
adjective is melenic, not melanotic
hematochezia = BRBPR or clots
usually indicates lower GI bleed, although can be brisk upper bleed
brown stool, formed stool usually not aggressive bleed

9. INITIAL ASSESSMENT Is the patient hemodynamically stable?
Replace intravascular volume
History, physical exam
Nasogastric intubation
Lab evaluation
Floor vs. ICU

10. INITIAL ASSESSMENT – STABLE?
Is the patient orthostatic?
requires loss of 20% of blood volume
“dizzy when I get up”
Is the patient in shock?
requires loss of 40% of blood volume
hypotensive, tachycardic, pallor

11. INITIAL ASSESSMENT – RESUSCITATION
Establish good access
2 large bore (ideally 18-gauge peripheral IVs)
in MICU, may place triple-lumen or Cordis
Replace intravascular volume
if hypotensive and/or orthostatic, give NS boluses
if anemic, give PRBCs
may need FFP and/or platelets if massive GI bleed

12. INITIAL ASSESSMENT – HISTORY
Age
risk, mortality increase with age
Previous bleeding
Comorbidities
CAD
heart failure
AAA repair
liver disease
Previous endoscopies (look at reports!)
Associated symptoms
pain
retching
anorexia, weight loss
nausea/vomiting
early satiety
dysphagia
epistaxis, hemoptysis
Medication history – NSAIDs, warfarin, ASA, Plavix

13. INITIAL ASSESSMENT – PHYSICAL
Vital signs: tachycardia? hypotension? hypoxia?
Gen: distress? alert + oriented?
HEENT: pallor, blood in nares or mouth
Abd: distension, tenderness
Rectal – visualize the stool!
BRB, melena, maroon, brown, no stool in vault
“The ER said it was heme positive”

14. INITIAL ASSESSMENT – NG TUBE
Nasogastric intubation, NG lavage
confirm NGT is in stomach (KUB)
inject 250cc NS, then draw 250cc back or place to wall suction
can be repeated for up to total of 2L
stop when fluid is clear (or when reach 2L)
Contraindications
facial trauma, nasal bone fracture
known esophageal abnormalities (strictures, diverticuli)
ingestion of caustic substances, esophageal burns
generally, esophageal varices are NOT a contraindication to NG tube placement

15. INITIAL ASSESSMENT – NG TUBE
Interpretation of aspirate:
bright red, clots = active UGIB
coffee grounds = slow bleeding, may have stopped, localizes to upper GI source
clear = indeterminate (NOT a guarantee that the bleeding has stopped)
bilious = bleeding has stopped

16. INITIAL EVALUATION – LABS
CBC
H+H, including BASELINE
how often to check?
goal H+H?
may take up to 72 hrs to equilibrate
Platelets
goal platelet count?
Renal function panel
BUN/Cr ratio
see increased BUN in UGIB due to absorbed blood proteins
ratio usually > 20:1
Coags
goal INR < 1.5
reverse with FFP, vitamin K unless contraindicated
LFTs
Iron studies

17. THE STOOL GUAIAC
Stool guaiac is a great tool for colon cancer screening
It is NOT a test for acute GI bleed
Causes of false-positives include:
Trauma
Extraintestinal blood loss
epistaxis
hemoptysis
Medications
ASA, NSAIDs (gastric irritation)
Exogenous peroxidase activity
red meat consumption
fruits (grapefruit, cantaloupe, figs)
uncooked vegetables (broccoli, cauliflower, radish, cucumber, carrot)

18. INITIAL EVALUATION - TRIAGE
What necessitates a MICU admission?
Hemodynamic instability despite adequate volume resuscitation
NG lavage does not clear with 2L
History of cirrhosis, concern for variceal bleed
Continued bleeding
Be concerned when:
Age > 60
Multiple comorbidities
Coagulopathy (i.e. Plavix, warfarin, cirrhosis)
Known portal hypertension
Hematemesis is bright red blood
History of AAA repair in the past

20. DETERMINING THE SOURCE
History is crucial
NSAIDs, postprandial epigastric pain (ulcer?)
hypotension preceding BRBPR (mesenteric ischemia?)
retching or recurrent vomiting (Mallory-Weiss?)
history of cirrhosis (variceal bleed?)
Stool exam
NG lavage
11% of patients initially suspected of LGIB actually have UGIB

21. UPPER GI BLEED
(Other includes Dieulafoy’s lesion, GAVE, foreign body, etc.)

22. LOWER GI BLEED Differential diagnosis: Diverticulosis (up to 42%)
Ischemia (up to 18%)
Hemorrhoids, fissures (up to 16%)
UGI or small bowel bleed (up to 13%)
Neoplasia (up to 11%)
Other (IBD, infectious colitis, post-polypectomy)
Unknown cause in up to 23% of cases

23. CALLING A GI CONSULT Presentation
PMHx, especially if h/o liver disease
NG lavage results
RECTAL EXAM!!-Stool characteristics
Vital signs, hemodynamics, orthostatics
Labs
Previous endoscopy reports
Have a differential

25. MEDICAL THERAPY FOR UGIB
PUD:
PPI bolus of 80mg, then drip at 8mg/hr
has been shown to accelerate resolution of bleeding and decrease need for therapy during EGD
Varices
Octreotide mcg bolus, then 50mcg/hr drip
If pt has ascites, will need antibiotics for 7 days for SBP prophylaxis
norfloxacin 400mg BID
Bactrim DS BID

26. ENDOSCOPIC THERAPY FOR UGIB
PUD
epinephrine injection
bipolar cautery
hemoclip
Varices
endoscopic band ligation
>90% success
30% rebleeding rate
TIPS for hemorrhage refractory to banding
also used for gastric varices

27. UGIB ADMISSION NPO after midnight
Call GI fellow first thing the next morning (8am)
If patient cannot consent, make sure medical decision maker is identified and have phone numbers available

28. TREATMENT OF LGIB No medical treatments
Diverticular bleeds stop on their own 75% of the time
Bleeds due to angiodysplasia stop spontaneously around 85% of the time
If pt continues to bleed
CT angiography to localize bleed
can often be accompanied by embolization to stop the bleeding
requires > 0.5cc per minute of blood loss
Tagged RBC scan
can detect bleeding at > 0.1cc per minute
unreliable localization, high false positive rate

29. TREATMENT OF LGIB Usually no need for emergent colonoscopy
If stable but continued bleeding can do “rapid purge” (GoLYTELY 4L given quickly) and colonoscopy can be done in 6-12 hours
Colonoscopy reveals cause in > 70% of cases
Tools used include
epinephrine injection
cautery
hemoclip
surgery

30. LGIB ADMISSION (ON THE FLOOR)
Clear liquid diet the day prior to endoscopy
1 gallon GoLYTELY started the afternoon/evening before procedure
Goal is for stool to be CLEAR

31. SUMMARY A detailed history is crucial in diagnosing GIB
It is also very important to characterize the emesis and/or stool to aid in diagnosis
Stool guaiac testing is not indicated in acute GIB
Most important step is assessing hemodynamic (in)stability and resuscitating with NS and/or blood if needed
In most cases, the patient will need endoscopy, but you can help to improve outcomes with specific medical treatments

32. Enjoy your time in Cleveland!
Thank you!
Enjoy your time in Cleveland!