1. Gastrointestinal Bleeding

2. Why is GI bleeding important? Mortality rates from upper GI bleeding vary from 3.5% to 7% in the U.S. Mortality rates for lower GI bleeding is reported at 3.6% If new GI bleed in hospital, mortality can be 25% Billions of dollars spent for >300,000 hospitalizations per year

3. Why is GI bleeding important Complications Integrilin Heparin, etc. Iatrogenic causes NSAIDS Aspirin Coumadin

4. Approach to GI Bleeding Identify the Clinical Setting ER vs. Ward vs. MICU vs. CCU vs. Clinic Clinical presentation – i.e. history/assessment Resuscitation Labs Localize Bleed Definitive therapy

5. Resuscitation Key component to GI Bleed Identify stumbling blocks Pt with sign comorb. – CHF, valvular hrt dz, etc. Review setting where res. should occur Access Should be automatic – 2 large bore IVs

6. Resuscitation cont. Mention on size: Poiseuille’s law Triple Lumen: two 18 g, one 16 g with length 20 cm Central line: 8F with 10 cm length Short and wide will get the job done

7. Resuscitation cont. Fluid of choice Isotonic fluid – Normal Saline or Ringer’s are both good choices Patients with active bleeding and a coagulopathy (INR>1.5) or thrombocytopenia (<50,000) should be transfused with FFP and platelets, respectively

8. Resuscitation cont. Frequent vitals checks and gauging initial status Orthostatics, pulse, hypoxia, symptoms (agitation, lightheadedness, etc.) Vitals: Normal BP: minor blood loss <10% of volume + orthostatics: mod blood loss 10-20% of vol. Resting hypotension: SEVERE BLOOD LOSS >20-25%

9. HPI Goal is to help identify likely source and potential etiologies Also to identify those patients most at risk – i.e. who will crump on the way to the unit Focus on the details – how much, how long, pain, meds, etc.

11. HPI – cont. Upper GI bleed commonly presents with hematemesis (vomiting blood or coffee-ground material) or melena (black, sticky maladorous stool) 5x more likely to be an upper source Defined as bleeding occurring proximal to the ligament of trietz Melena: at least 50 cc of blood loss – typically upper source, but cecal bleeds can be melanic If pt is vomiting BRB – GET NERVOUS!!!

12. HPI – cont. Bleeding from a lower GI source refers to blood loss originating from a sight distal to the ligament of Treitz. Lower GI bleeding typically presents with hematochezia (passage of maroon or bright red blood from the rectum) Up to 11% of patients with hematochezia may have an upper source

13. Patient’s history Important historical features include: 1. Age: elderly are more likely to bleed from diverticula, ischemic colitis, malignancy and younger patients are more likely bleeding from PUD, esophagitis, varices 2. Prior bleeding 3. Known GI disease: diverticulosis, IBD, PUD, portal hypertension 4. Previous surgery

14. Patient’s history cont. 5.Medications: coumadin, heparin, NSAIDs, aspirin 6.Abdominal pain: PUD, mesenteric ischemia 7.Change in bowel habits, weight loss, anorexia 8.Other comorbid conditions: CKD, coagulation d/o 9.Previous retching: Mallory-Weiss

15. Lab’s and Rad’s CBC – may be normal LFTs, coags – screening tool and identifying synthetic dysfunction Chemistry or P2 – watch BUN – will tend to trend up if upper CXR / AAS – specific clinical presentations – looking for catastrophe – free air – mediastinum or abdomen

16. Bedside Studies “Never trust anyone’s lavage” – Todd Sheer NG Lavage – were the money is made (90% sensitive for UGI) Blood (18% mortality) – GET NERVOUS Coffee grounds (10% mortality) – likely not actively bleeding Clear (6% mortality) – could have bled and stopped Bilious – rules out upper bleed

17. Bedside Studies cont. Proctoscope Typically performed by general surgery and for hematochezia Looking for obvious ulcerations, fissures, etc. - limited exam as only 10-20 cm observed and messy!

18. Diagnostic Studies and Therapeutics EGD Colonoscopy Tagged RBC scan Angiography Surgery

19. Further Evaluation and Therapy EGD: Can be performed at the bedside Has high diagnostic accuracy, is therapeutic and associated with low morbidity Should be performed early in the course Patient must be hemodynamically stable

20. Further Evaluation and Therapy Colonoscopy: Advantages include precise localization of bleeding and potential therapeutic intervention. Early colonoscopy has been associated with reduced length of hospital stay

21. Further Evaluation and Therapy Radionuclide Imaging with TRBC scan: Noninvasive modality Detects bleeding that is occurring at a rate of 0.1 to 0.5 ml/m. Accuracy rates range from 24 to 91% Clinical utility of this test is for screening before arteriography

22. Further Evaluation and Therapy Angiography Requires active blood loss of 1 to 1.5 ml/m 100% specific but sensitivity varies from 30- 47% If an active lesion is found, intraarterial vasopressin can be infused causing vasoconstriction and cessation of bleeding Complications such as intrarterial thrombosis, embolization and renal failure occur in 11% of patients

23. Further Evaluation and Therapy Surgery: General indications for surgery are: Transfusion requirements that exceed 4-6 units over 24 hours or 10 units overall More than two to three recurrent bleeding episodes from the same source

24. Upper GI Bleed

25. Final Diagnosis of the Cause of UGIB in 2225 Patients (Silverstein, et al, Gastrointest Endo) 1. Gastric/Duodenal Ulcer45% 2. Gastric Erosions23% 3. Varices10% 4. Mallory-Weiss Tear7% 5. Esophagitis6% 6. Neoplasm3% 7. Other6%

26. PUD Dr. Robin Warren and Professor Barry Marshall – fought the battle to prove h. pylori was associated with PUD Marshall swallowed a culture or h. pylori Koch would be proud:

27. PUD cont. Other risk factors: NSAIDS and stress Initial approach: high dose PPI Capozza: “High dose PPI is as good as endoscopy initially in stopping the bleed” IV pantoprazole: 80 mg bolus then 8 mg/hr drip Definitive therapy: endoscopy with injection versus thermal coagulation

28. Later that night…. Re-bleeding: Active arterial bleeding 90% Non-Bleeding visible vessel 50% Adherent clot 25-30% Oozing without visible vessel 10-20% Flat Spot 7-10% Clean ulcer base 3-5%

29. Mallory-Weiss Tear A mucosal tear at the gastroesophageal junction Bleeding ceases spontaneously in almost all instances Consider PPI for 1-2 weeks to promote healing

30. Mallory-Weiss

31. Esophageal Varices Variceal hemorrhage requires an ICU admission Consider endotracheal intubation in patients who are thought to be actively bleeding for airway protection Start Octreotide infusion immediately (50 to 100 mcg bolus followed by infusion at 25-50 mcg/hour) Endoscopy with variceal ligation or banding is the therapy of choice

32. Esophageal Varices TIPS (transjugular intrahepatic portosystemic shunt) A radiologic procedure where a metal stent is placed between the hepatic veins and portal vein Indication for TIPS: intractable bleeding unresponsive to variceal ligation or sclerotherapy

34. Uncommon Causes of Upper GI bleed Gastric antral vascular ectasia Portal hypertensive gastropathy Hemobilia Hemosuccus pancreaticus Aortoenteric Fistulas Upper GI tumors Dieulafoy’s lesion Cameron lesions

35. Final Diagnosis in Major Lower GI Bleeding Diverticulosis43% Angiodysplasia20% Undetermined12% Neoplasia9% Colitis9% Other7%

37. Management of Lower GI Bleed Acute Hematochezia Eval and Res. NGT aspiration Bile and NO BLOOD All other EGD UGI source Treat as appropriate negative colonoscopy

38. Source identifiedNegative Exam Not possible due to severity of bleeding Treat as appropriate Has hematochezia ceased? no YES Small bowel studies Arteriography versus nuc med scan Surgical consultation

39. Diverticular Bleeding Occurs in only 3% of patients with diverticulosis 75% of diverticula occur in the left side of the colon Source of diverticular bleed is right sided 50- 90% of the time Acute, painless hematochezia Self-limited 70-80% of the time Colonoscopy is diagnostic and therapeutic

40. Angiodysplasia Dilated, tortuous submucosal vessels May be the most frequent cause of acute lower GI bleed in patients over 65 Painless hematochezia Self limited Colonoscopy is diagnostic and therapeutic

41. Ischemic Colitis Common entity in the elderly Usually caused by low flow states and small vessel disease rather than large vessel occlusion Most commonly occurs at splenic flexure, descending or sigmoid colon Typically presents with mild, crampy abdominal pain localized to LLQ May see “thumb printing” on plain films Most cases resolve with supportive care

42. References Shields, W. “GI Bleed (what I learned from Patrick)” July, 2003. Uptodate, of course Zuccaro, G. Management of the Adult Patient with Acute Lower Gastrointestinal Bleeding. Am J Gastro 1998;93:1202-08. Barkun, A. et al. Consensus Recommendations for Managing Patients with Nonvariceal Upper Gastrointestinal Bleeding. Ann Internal Med. 2003;139:843-857.