1. Gastrointestinal Bleeding Lisa N. Flemmons, ACNP-BC Vanderbilt University Medical Center Medical Intensive Care Unit

2. Objectives Learn how to effectively evaluate and manage gastrointestinal bleeding in the critically ill patient Distinguish upper gastrointestinal bleeding from lower and discuss possible etiologies Understand diagnostic testing and therapeutic interventions Review and discuss transfusion strategies in the gastrointestinal bleeding patient

3. Epidemiology Common and potentially fatal diagnosis accounting for ~30,000 admissions/year Upper GIB accounts for 20,000 deaths/year In our MICU, it is the 3 rd most common diagnosis

4. Distinguishing upper vs lower Upper GI bleed – History Previous PUD Alcoholism/liver dz  varices Retching/vomiting  Mallory Weiss tear Medications such as anticoagulants, antiplatelets, NSAIDS → ulcers – Symptoms Nausea/vomiting Hematemesis Melena Rarely hematochezia (massive bleed) Lower GI bleed – History Previous colon cancer Previous colon surgery Known diverticulosis Known hemorrhoids – Symptoms Abdominal pain or can be painless Hematochezia Melena (less common)

5. Evaluation and Assessment ABCs of GIB 1.Airway and Access 2.Blood products 3.Correct Coagulopathy and Consultation 4.Drugs and Diagnostic testing

6. Airway and Access Ensure adequate airway – Hematemesis – Altered mental status – Shock – Needed for endoscopy Adequate access – 2 large bore PIV vs CVC

7. Blood Products Crystalloid infusion while waiting on PRBC Vasopressors are not a substitute for volume resuscitation Each PRBC should increase PCV by ~3% per unit

8. Transfusion goal

9. Randomized 921 patients to either liberal or restrictive strategy Liberal strategy transfusion trigger was Hgb <9 and restrictive strategy was 7 The probability of survival at 6 weeks was higher in the restrictive-strategy group than in the liberal-strategy group (95% vs. 91%). Further bleeding occurred in 10% of the patients in the restrictive-strategy group as compared with 16% of the patients in the liberal-strategy group and adverse events occurred in 40% as compared with 48%.

11. 6 week survival rate in the 2 groups

12. Correction of Coagulopathy FFP transfusion – Synthetic liver dysfunction – Warfarin Consider Vitamin K – Dilutional coagulopathy – Goal INR <1.5 Platelet transfusion – in bleeding pt if less than 50K – Platelet dysfunction Anti-platelet agents or uremia – Goal platelets >50, 000/mm³

13. Correction of Coagulopathy Transexamic acid – Synthetic derivative of aminoacid lysine that inhibits fibrinolysis or dissolution of the clot – Given as 1 gm loading dose followed by 1 gm IV infusion over 8 hrs

14. Correction of Coagulopathy Prothrombin Complex Concentrate – Non-activated concentrate of Vitamin K dependent factors (II, VII, IX, X) – Advantages compared to FFP: 1.small volume with rapid infusion time 2.no time delays for ABO blood typing and thawing 3.less risk of pathogen transmission, transfusion related ALI, add circulatory volume overload 4.less time to correct coagulopathy

15. Consultation Urgent gastroenterology consult Consider surgical consult – Massive transfusion – Abdominal pain associated with GIB – Recurrent bleeding

16. Diagnostics Upper GIB→EGD (esophagogastroduodenoscopy) – Definitive test for diagnosis and treatment – Safe to perform once the airway is secure and pt is reasonably hemodynamically stable – Interventional options: epinephrine injection, cauterization, clipping, or banding of varices – May give 1 time dose of erythromycin 250 mg IV or Reglan 10 mg IVP to promote gastric emptying prior to procedure

17. Large ulcerStatus post cauterization

18. Submucosal duodenal tumor 1.5 cm lesions/p resection

19. Site of resection: friable and oozing with visible vessel S/p epinephrine and cauterization

20. Diagnostics continued Lower GIB→colonoscopy – If slow bleed consider bowel prep overnight to allow for maximum visualization – If brisk bleed consider STAT colonscopy, tagged RBC scan, or angiography Tagged RBC scan vs angiography If upper and lower endoscopy fail to ID source then can consider video capsule or push enteroscopy

21. Drugs Proton pump inhibitor BID Am J Health-Syst Pharm—Vol 62 Jun 1, 2005 1165

22. Drugs If hx of liver disease or ascites give SBP prophylaxis (quinolone, CTX, or bactrim) Octreotide gtt for hx of liver disease or known varices Hold beta blocker in the acute setting which will prevent/block reflex tachycardia

23. Minnesota/Blakemore Tube A flexible tube consisting of an esophageal and gastric balloon that is inflated and is used as a temporizing measure to tamponade gastric and/or esophageal varices.

24. Minnesota/Blakemore Tube Uses Should have experienced personnel assist with insertion Maximum amt of time 24-72 hrs Must be to traction (usually a football helmet) KUB and CXR for confirmation of placement (keep in mind after transfer from OSH) Cautions Necrosis if inflated too much or too long Nasal insertion can cause nose bleeds and sinusitis Can migrate upwards and compress trachea especially in shorter stature patients Perforate or tear esophagus during insertion

25. Large esophageal varices with red wales signStatus post banding

26. Transjugular Intrahepatic Portosystemic Shunt (TIPS) Increased pressure in PV forces blood to flow into smaller branches coming from abdominal organs that normally drain into the PV. These veins then enlarge and are referred to as varices

27. 63 patients with cirrhosis and acute variceal bleeding randomly assigned within 24 hours after admission – 32 patients assigned to early TIPS group (within 72 hours) – 31 patients assigned to continuation of vasoactive drugs, NS- beta blockade, and long term EBL with insertion of a TIPS as rescue therapy if needed.

28. Results – rebleeding or failure to control bleeding occurred in 14 patients in the pharmacotherapy–EBL group as compared with 1 patient in the early-TIPS group (P=0.001). – The number of days in the intensive care unit and the percentage of time in the hospital during follow-up were significantly higher in the pharmacotherapy–EBL group than in the early-TIPS group. – The 1-year actuarial survival was 61% in the pharmacotherapy–EBL group versus 86% in the early-TIPS group (P<0.001).

29. References CRASH-2 trial collaborators, Lancet 2010; 376; 23-32 Garcia-Pagan et al, NEJM 2010; 362: 2370-9 Lau JY, Sung JJ, Lee KKC, et al, NEJM 2000; 343: 310–316 Marini, J.J., Wheeler, A.W. (2010). Critical care medicine: The essentials (4 th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Rivkins, K., Lyakhovetskiy, A AJHP 2005; 62: 1164-1165 Sarode, R., et al, Circulation 2013; 128: 1234-1243 Villaneuva, C et al NEJM 2013; 368: 11-21