1. GI Bleeding Jeopardy! UGIB therapyLGIBClinical stuffGeneral mgmtPotpourri 10 20 30 40 50

2. These are your first 3 initial management priorities given a 51y M currently vomiting blood, has vomited ~1L blood with EMS VS: 125, 88/57 A: maintaining B: adequate C: vomiting blood, VS as above

3. Brisk UGIB Management 1) Protection! – gown, gloves, face shield 2) Monitors, O 2, IV x 2 (at least 18G) 3) Initial fluids? NS vs blood pRBC if ongoing vomiting or VS don’t improve

4. These are the top 3 medications you might order for a patient with an UGIB

5. Gastric acid suppression Pantoloc 80mg IV then 8mg/h infusion Somatostatin analogue Octreotide 50ug IV then 50ug/hr infusion Abx Ceftriaxone 1g IV What’s the point? UGIB Pharmacotherapy

6. PPI’s Improve clot formaion and  breakdown Leontiadis GI et al. Cochrane rev Nov 2006  re-bleeding risk (OR 0.49 (0.37-0.65))  need for surgery (OR 0.61 (0.48-0.78))  mortality in bleeding pts (OR 0.53 (0.31-0.91)) No effect on overall mortality H 2 -blockers not shown to have same benefit UGIB Pharmacotherapy

7. Octreotide Causes splanchnic vasoconstriction   portal venous pressures   rebleeding Imperiale et al. Ann Intern Med 1997;127:1062-71 Similar control of bleeding varices as EGD  risk of continued bleeding in PUD (RR 0.53;) UGIB Pharmacotherapy

8. Antibiotics In cirrhosis (Soares-Weiser et al. Cochrane rev, 2002) :  infectious complications (RR 0.40 (0.31-0.51))  mortality (RR 0.66 (0.49-0.88))  rebleeding No evidence that abx need to be started in the ED UGIB Pharmacotherapy

9. This is the indication for using vasopressin in UGIB, and its mechanism of action

10. Vasopressin 20U IV over 20min then 0.2-0.4U/min Constricts mesenteric arterioles No mortality benefit (?  mortality) Complication rate 9% major (myocardial, cerebral, bowel, limb ischemia) 3% fatal Indication Can try in exsanguinating patient with ?variceal bleeding if EGD not available UGIB Pharmacotherapy

11. This is what the acronym “TIPS” stands for

12. Transjugular Intrahepatic Portosystemic Shunt Interventional radiology Connection between Hepatic vein Intrahepatic portion of portal vein Indication? Continued bleeding despite Rx/EGD

13. The rate of major complications from this procedure is 15%, and the rate of fatal complications is 3%

14. Linton tube Major complications Mucosal ulceration, tracheal compression, aspiration pneumonia, esophageal/gastric rupture, asphyxiation Consider if exsanguinating patient with ?variceal bleeding and EGD not immediately available Temporizing measure until EGD/surgery/TIPS Anything you need to do before putting it in? Need to secure A/W

15. The type of stool usually seen in LGIB

16. Stool – LGIB vs UGIB Hematochezia Usually LGIB (10% UGIB) Melena Need 200mL blood x 8hrs (70% UGIB)

17. These are 3 causes of false +ve Hemoccult tests

18. FOB Testing False +ve Red fruits, meats, methylene blue, chlorophyll, iodide, cupric sulfate, bromide What about iron? Pepto-Bismol? Not causes of false +ve False –ve? Bile, Mg-containing antacids, ascorbic acid

19. FOB Testing What about testing coffee ground emesis? Hemoccult are pH dependent Antacids/vitamin C cause false –ve False +ve with copper/iron salts +ve result can usually be trusted

20. This is the type of physician you will consult and the urgency in the following patient with hematemesis & hematochezia: 61y F PMH: A.fib, NIDDM, HTN, AAA (repair 2y ago) Rx: warfarin, metformin, glyburide

21. Hematochezia/hematemesis After AAA Repair ?Aortoenteric fistula STAT consult to vascular surgery! Incidence of up to 4% post-repair Usually presents as UGIB Aortoduodenal fistula

22. They are 3 investigation modalities that can be used to help localize LGIB

23. LGIB Localization Scope Anoscopy Sigmoidoscopy/colonoscopy Angiography Requires 0.5cc/h bleeding ID’s site in 40% Radionuclide scan Technetium labeled RBC’s Need 0.1cc/h bleeding

24. These are the 3 main causes of painful LGIB

25. Ischemic colitis Infectious colitis Inflammatory colitis Painful Rectal Bleeding 5 bacteria causing bloody colitis? E. coli Campylobacter Yersinia Salmonella Shigella C. difficile

26. These are 3 risk factors for poor outcome in UGIB

27. Risk factors for poor outcome (UGIB) Age > 60y Coagulopathy Liver failure Cardiac disease Severe bleeding

28. The 3 of these are responsible for 75% of all UGIB

29. Esophageal/gastric varices PUD Gastritis/gastric erosions Differential diagnosis of UGIB 75% Esophagitis Mallory-Weiss tear Gastric CA Aortoenteric fistula Angiectasias Osler-Weber-Rendu syndrome

30. Differential diagnosis of UGIB 10% of GIB patients have no identifiable source

31. The 2 of these are responsible for 80% of all LGIB

32. Diverticulosis Angiodysplasia Differential diagnosis of LGIB Malignancy UGIB Polyps IBD Infectious colitis Ischemic colitis Radiation colitis Anorectal varices Aortoenteric fistula Perianal disease Hemorrhoids Fissure Trauma 80%

33. These are 4 things that could be the cause of your patient’s dark stools

34. DDx Melena UGIB High LGIB Swallowed blood (epistaxis, etc) Iron Bismuth (Pepto-Bismol) Food products (eg. blueberries)

35. The utility of postural vital signs and capillary refill in predicting hypovolemia

36. Physical Exam Skills Postural vital signs  HR by 20bpm sustained 98% specific for significant blood loss in GIB  sBP by 20mmHg 97% specific for significant blood loss in GIB CR > 2-3sec 10% SN for significant hypovolemia

37. These are the investigations you order for the patient with a brisk UGIB

38. UGIB investigations CBC, T&S, INR/PTT Lytes, BUN, Cr ±ALT, ALP, bili, GGT ECG? CAD hx, age > 50, CP, SOB, hypotension CXR? If ?aspiration or ?perforation

39. They are the 3 specialties that you might have to consult with a GIB (other than ICU)

40. HELP! GI Scope Interventional radiology TIPS Angiography General surgery Anyone else? Vascular surgery

41. This is the likely source of bleeding (UGIB vs LGIB) in the following patient: 72y M, PMH: HTN, OA, A.fib; Meds: ? Hematochezia x 5 episodes over 90min VS: 112, 81/40, 22, 37 0

42. Hematochezia + Shock Hematochezia + shock = UGIB Rapid transit

43. This is the utility of NG tube insertion in the patient with blood per rectum

44. NG tube in patient with bloody stools? If +ve blood UGIB LGIB + oral/nasal mucosal bleed If –ve blood UGIB + bleeding stopped, duodenal blood 10% of UGIB have –ve NG aspirate LGIB Bottom line Not diagnostic…not helpful

45. This is the expected rise in Hb and Hct for 2U pRBC

46. Transfusion Facts 1U pRBC (if no ongoing bleeding)  Hb by 10mmol/L  Hct by 3%

47. They are 3 risk factors for ischemic colitis

48. Painful Rectal Bleeding Risk factors for ischemic colitis? Dysrhythmia CAD Heart failure Prolonged hypotension Marathon running

49. They are 2 potential future diagnostic modalities for GIB

50. Future Diagnosis CT/MRI reconstruction “endoscopy” Wireless capsule endoscopy

51. These are the GIB patients you can send home from the ED

52. Disposition Very low risk (d/c home) No comorbidities N VS N/trace + FOB NG aspirate –ve if done Home support in place Understand symptoms sig bleed Easy access to ED F/U within 24h

53. Risk Stratification

56. They are the 2 potential causes of an increased BUN in the GIB patient

57. Increased BUN Prerenal azotemia Digested blood

58. It is much more likely to be your diagnosis in a patient with hematochezia and a history of cirrhosis (and it’s not brisk UGIB)

59. Liver Disease and LGIB Anorectal variceal bleeding Superior hemorrhoidal veins and middle/inferior hemorrhoidal veins

61. Rules: Teams decide how much to wager Each team pick one skilled participant Participants leave the room for setup of Final Jeopardy!

62. Task: Race to fill the Linton tube with 600cc air Opposing team counts cc’s