1. Management of Gastrointestinal Bleeding in 2015 WITH SPECIAL FOCUS ON GI BLEEDING IN PATIENTS WITH LEFT VENTRICULAR ASSIST DEVICES (LVAD)

2. Gastrointestinal Bleeding is a Common Medical Condition  250K-500K hospital admissions per year  UGI bleeding incidence is 100/100,000 adults Incidence increases 20-30 fold from the third to ninth decade of life  LGI bleeding incidence 20/100,000 adults  Overwhelmingly disease of the elderly  GI bleeding stops spontaneously in 80%

3. Costs  Average hospital costs exceed $5000 per admission  Most of this for hospital bed and ICU stays rather than physician fees, blood products, diagnostic tests and medications  Goal is to reduce hospital admission and LOS in order to reduce costs

4. Morbidity Data  Majority will receive blood transfusions  2-10% require urgent surgery to arrest the bleeding  Average LOS 4-7 days  Mortality rates for UGI bleeding 2-15%  Mortality for patients who develop bleeding after admission to hospital for another reason is 20-30%

5. Causes of acute upper gastrointestinal bleeding Common Gastric ulcer Duodenal ulcer Esophageal varices Mallory-Weiss tear Less common Gastric erosive/gastropathy Esophagitis Cameron lesions Dieulafoy lesion Telangiectasias Portal hypertensive gastropathy Gastric antral vascular ectasia (watermelon stomach) Gastric varices Neoplasms Rare Duodenitis, esophageal ulcer, aortoenteric fistula, Crohn's disease, hemobilia, pancreatic disease

6. Causes of acute lower gastrointestinal bleeding Common Colonic diverticula Angioectasia Less common Colonic neoplasms (including post polypectomy bleeding) Inflammatory bowel disease Colitis Ischemic Radiation Unspecified (infectious or non specific) Hemorrhoids Small bowel source Upper gastrointestinal source Rare Dieulatory lesion, Colonic ulcerations, Rectal varices

8. Facts about UGI bleeding  Hematemesis occurs 25% of the time  Melena alone occurs 25% of the time--require 50cc -100cc of blood to have melena  Hematochezia occurs only 15% in a massive UGI bleed  Elevated BUN out of proportion to the creatinine is a good marker for an UGI bleed  NGT may miss an active bleeding duodenal ulcer bleed

9. Facts about Lower GI bleeding  Frank red blood indicates a brisk LGI bleed  Melena can mean a right sided bleed  Most lower GI bleeding is self limited  Lower GI bleeding is mostly painless  Diverticulosis is the main cause for significant LGI bleeding

10. Assessment of Patient with Acute GI Bleeding  Assess hemodynamics and resuscitate  Keep Hgb >= 7 gm/dL  Assess level of risk  Timing of endoscopy  Timing of discharge  Level of care  Possible discharge from ED based on certain criteria:  BUN <18.2 mg/dL  Hgb > 13 mg/dL (M)/ 12 mg/dL (F)  SBP > 110 mm Hg and HR < 100  absence of melena, syncope, cardiac failure, and liver disease  <1% of need for intervention

11. Glascow-Blatchford Bleeding Score

14. Endoscopic Clipping

15. Endoscopic Banding

16. Argon Plasma Coagulator

17. Watermelon Stomach (GAVE- gastric antral vascular ectasia)

18. Treatment of GAVE

19. Bleeding Ulcer

20. Bleeding Colonic Diverticulum

22. CT Angiography

23. Angiography

24. Congestive Heart Failure and Ventricular Assist Devices  500, 000 new cases a year  Interagency Registry For Mechanical Circulatory Support (INTERMACS)--1400+ LVAD were placed between 2006 and 2009. That number is rising  At Medstar Washington Hospital Center we placed over 70 devices in 2014 and we are projecting more in 2015  It is clear LVAD are becoming a mainstay for advanced heart failure

25. Major Causes of Mortality after VAD Placement  Cardiac Failure 22%  Infection 16%  CNS 14%  Multi-organ failure 10%  Respiratory failure 5%  GI bleed 1%

26. Mechanisms for GI bleeding in LVAD patients  Use of antiplatelet therapy and anticoagulation  Acquired Von Willebrand Syndrome  fragmentation of high-molecular-weight multimers of vWF by the shear forces of the HVAD  chronic low pulse pressure  intestinal hypoperfusion from reduced pulse pressure leads to regional hypoxia, vascular dilation, and subsequent angiodysplasia  Similar situation seen in Aortic Stenosis

27. Gastrointestinal Bleeding in Recipients of the HeartWare Ventricular Assist System Daniel J. Goldstein, MD,* Keith D. Aaronson, MD, et al., JACC: Heart Failure, Vol 3, No 4, April 15, 2015:303- 313  Looked at 382 patients enrolled over 30 center b/w 2008-2012  Average age was 53 yrs old, predominantly male (70%)  Majority were 96% NYHA Heart Failure  15% of the patients had GI bleeding (59 of the 382)  Clinical characteristics—high BMI, diabetic, ischemic etiology of HF, elevated creatinine  Most GI bleeds occurred after 30 days of implantation  Mean INR at presentation was 2.2  34% of the bleeding patients had 2 or more GI bleeding events  At 1 year, 84 % had no further bleeding

28.  The most common lesion was an AVM  Second was an ulcer  Most common lesion site was the small bowel then stomach  LVAD support was longer in patients with GI bleed  No deaths related to GI bleeding  Incidence of GI bleeding was 16% or.27 GIB/yr  Survival doesn’t seem to be affected by GI bleeding