1. Rebecca Burton-MacLeod Feb 15th, 2007 Emerg Med Resident Rounds
GI Bleeds
Rebecca Burton-MacLeod
Feb 15th, 2007
Emerg Med Resident Rounds

2. Overview
Anatomy
Upper GI bleeds
Lower GI bleeds

3. Anatomy
UGI vs. LGI defined by Ligament of Treitz…located in 4th section of duodenum

4. UGI vs. LGI ? Melena and hematemesis means UGI bleed, right?
Hematochezia—10-15% of pts will be UGI presentation

5. Ddx in adults UGI: LGI: PUD UGI bleed Diverticulosis Gastric erosions
Varices
Mallory-Weiss tear
Esophagitis
Duodenitis
LGI:
UGI bleed
Diverticulosis
Angiodysplasia
Ca/polyps
Rectal disease (hemorrhoids, fistulas, fissures)
IBD
Infectious
75%
80%

6. Ddx in adults
No identifiable source found for GIB in 10% of patients

7. Elderly and LGIB Tips from EMR…
Don’t rely on the color of stool to determine the bleeding site. Colors change as transit times vary and blood products break down. • All that bleeds bright red is not a hemorrhoid. Unless it’s bleeding before your eyes, look for another diagnosis. • Elderly patients may not manifest orthostatic changes from blood loss as readily as their younger counterparts.  • The initial hemoglobin may not be a reliable indicator of the volume of blood lost, as the volume may be contracted.  • Look for other systemic causes if your investigation of the abdominal structures turns up negative and the patient still has abnormal vitals, especially if the rectal bleeding has ceased. • Order typed blood products. • Peritoneal signs may take up to 20 hours to manifest. • Perform a digital exam and anoscopy on a patient with anorectal bleeding.

8. Case
78M presents with hematemesis and hematochezia x 2hrs. States he has had increasing episodes over last 30min. Feeling presyncopal.
PMHx: HTN, CAD, AAA repair 3mos ago
O/e: HR 110, BP 100/70; pale, clammy
Any thoughts?

9. Ddx in peds UGI: LGI: Esophagitis Anal fissure Gastritis
Ulcer
Varices
Mallory-Weiss tear
LGI:
Anal fissure
Infectious colitis
IBD
Polyps
Intussusception

10. Case
47M brought in with hematemesis…EMS reports just vomited 1-2L of BRB. He reports this is his third episode in last 1hr
Feeling weak, pale. Says he thinks he’s going to vomit again…
HR 132, BP 86/62
Plan?

11. Case cont’d Monitors, supplemental O2 2 x 18G IVs CBC, INR/PTT, T+S
2L bolus IV N/S with monitoring vitals
Consider PRBC if ongoing vomiting, vitals fail to improve
Consult GI ASAP

12. Diagnosis History: Physical: Hematemesis, melena, hematochezia
Duration/amount of bleeding, previous episodes, recent meds/Etoh/surgeries
s/s of blood loss
Physical:
Vitals—sustained tachycardia is most sensitive
Don’t forget the DRE…and good ol’ FOB testing!

13. Case
56F who presents c/o abdo pain and “black stool”. Epigastric pain x1day. No emesis. 1x episode of black stool this a.m. No previous hx
PMHx: HTN
Meds: HCTZ, pepto-bismol (used last nite for epigastric pain)
O/E: HR 82, BP 140/80. exam unremarkable except black stool on DRE (FOB negative)
Any thoughts?

14. Ddx bleeding Melena: Hematochezia:
Requires >150ml blood digested over prolonged period (~8h)
Pepto-bismol
Iron
Blueberries
Hematochezia:
Only 5ml of blood required to turn “toilet water bright red”
Beets

15. FOB testing False positives: False negatives: Red fruits/meats
Methylene blue
Chlorophyll
Iodide
Cupric sulfate
Bromide
False negatives:
Rare!
Bile
Ingestion of Mg-containing antacids
Ascorbic acid

16. HOB testing
What about pt with “coffee ground emesis” appearing vomitus…any role for HOB testing?

17. Case
2day-old post SVD, no complications. Discharged home earlier today. At home, had a bloody BM (parents bring the diaper just to show you!)
Pt exams well. Normal vitals.
Any investigations?

18. GIB investigations CBC, INR/PTT, T+S Consider lytes, BUN, Cr EKG
Remember, Hct lags behind clinical picture, and is affected by hemodilution
Consider lytes, BUN, Cr
EKG
Upright CXR if suspect perf

19. Case
78M presents to ED with hx of melena x3days…wife convinced him to come get it checked. Slightly dizzy.
PMHx: Afib, diverticulosis
Meds: metoprolol, warfarin
O/e: HR 72 BP 118/69, obvious melena stool on DRE. Exam otherwise unremarkable.
Thoughts ?
Investigations ?

20. Case cont’d
Blwk:
Hgb 117, Plt 450
INR >9
Reverse INR?
Vit K?
FFP?

21. Role of CT ? Not indicated in UGIB cases
Sensitivity for identifying mesenteric ischemia is 64-82%
Identification of other colonic pathology is 75% sensitive
specificity 96%
NPV 96%

22. Case
58M with hx of CAD. Presents with 2x episodes of melena yest and 1x episode hematemesis after breakfast this a.m. C/o epigastric pain which radiates into his chest, SOB, dizziness. No previous episodes
O/E: HR 92 BP 120/80
You order CBC, INR/PTT, T+S, EKG

23. EKG

24. Case cont’d His labs are still pending What do you want to do?
One of your colleagues walks by and eyeballs the EKG and says “wow, that patient needs ASA, b-blocker, heparin, cardiology consult STAT”…what do you think?

26. UGIB and NG tubes Any role for NG tube insertion?
May aid in ruling out LGIB in pt with hematochezia
Otherwise, 10% of established UGIB will have negative NGT aspirates…so NOT useful!
Lots of false negatives (ex: bleeding in duodenum or bleeding already stopped)
Bottomline…not very useful…

27. UGIB management GI—endoscopy Gen Surg—operative Intervent Radiol—angio
Melena, Cuba

28. UGIB and endoscopy Most accurate diagnostic tool
Identifies source in 78-95% of pts, when performed within 12-24hrs post-UGIB
Allows for risk stratification (rebleeding and mortality) as well as treatment (banding or sclerosing of varices)

29. When to scope ? Most authors suggest within 12-24hrs Lin et al (1996):
Large RCT (n=124pts) showed that endoscopy within 12h is safe and effective
Leads to dec transfusion requirements
Dec length of hospital stay
Dec costs

30. UGIB and angiography Detects location of UGIB in 2/3 of pts
Usually performed during active bleeding
Unstable vitals
Ongoing transfusion requirements

31. UGIB and surgery Mortality for pts undergoing surgery for UGIB is 23%
Hemodynamically unstable pts, not responsive to medical/transfusion mgmt, endoscopy unavailable
Consider if >5U PRBC given over first 6h or when 2U PRBC required q4h after replacing initial losses—and still unstable!

32. UGIB medications PPI—pantoloc Somatostatin analogues—octreotide
Bolus 80mg then 8mg/h x 72hrs
Role in pts with PUD as cause
Is an adjunct, not therapy for UGIB…still need endoscopy
Somatostatin analogues—octreotide
Bolus 40ug then continuous infusion
Role in esophageal varices
Peptide analogue which causes splanchnic vasoconstriction by direct effect on vascular smooth muscle

33. Pantoloc ?

34. Octreotide ?
Multicenter RCT of octreotide vs. injection sclerotherapy for acute variceal hemorrhage
N=150
No significant differences in control of bleeding, re-bleeding, and mortality
Octreotide felt to be as effective as injection sclerotherapy
Jenkins SA, et al. A multicentre randomised trial comparing octreotide and injection sclerotherapy in the mgmt and outcome of acute variceal hemorrhage. GUT

35. Vasopressin ?
Has been used in pts with esophageal variceal hemorrhages
No effect on overall mortality
High rate of complications (9% major, 3% fatal)
Only role would be in exsanguinating pt, with endoscopy or other measures unavailable

36. Sengstaken-Blakemore tubes
Useful if esophageal variceal bleeding source
Linton tube if gastric varices
High risk of complications (14% major, 3% fatal)
One of those last-ditch efforts!
Insertion techniques…

37. SB tubes… Equipment: Precautions: Sterile Sengstaken-Blakemore tube
Pair of scissors
50ml syringe
2 x rubber tipped artery forceps
Water soluble lubricant
3 metres of white linen tape
Pressure gauge
Weight for traction
Pulley
PPE
Precautions:
Balloon pressure should always be <45mmHg
Pt should be intubated prior to procedure
Keep scissors near bed at all times (to cut tube prn if migrates and causes resp distress)
Check tube placement by:
Aspirate and check pH
Inject air and auscultate over stomach XR

38. Insertion…
Any takers ?

39. SB tube

40. Sengstaken vs. Linton tubes ?
RCT of SB vs. LN tubes in pts with known esophageal/gastric varices
N=79
Primary hemostasis in 86% of pts
If esophageal varices as cause, SB more effective at permanent hemostasis (52 vs. 30%)
If gastric varices as cause, LN tube much more effective (50 vs. 0%)
Teres J et al. Esophageal tamponade for bleeding varices. Controlled trial between the Sengstaken-Blakemore tube and the Linton-Nachlas tube. Gastro 1978.

41. LGIB and scopes Must r/o UGIB source first usually
If mild LGIB with no evidence of hemorrhoids, then anoscopy / proctosigmoidoscopy recommended
Absence of blood above rectum indicates rectal source; however, blood above rectum does not r/o rectal source

42. LGIB and angiography
Does not usually diagnose cause of bleeding, but identifies source in 40% of pts
Arterial embolization may be useful if ongoing bleeding

43. Disposition
Very-low risk
Low risk
Medium risk
High risk

44. D/c home if: No comorbid disease Normal vitals
Normal or trace FOB positive
+/- neg gastric aspirate
Normal (or near) Hgb/Hct
Good social situation
F/u within 24hrs
Understanding as to when to return…

45. Initial ED stratification
Low Risk
Moderate Risk
High Risk
Age <60
Age >60
Initial SBP ≥100 mm Hg
Initial SBP <100 mm Hg
Persistent SBP <100 mm Hg
Normal vitals for 1 hr
Mild ongoing tachycardia for 1 hr
Persistent moderate/severe tachycardia
No transfusion requirement
Transfusions required ≤4 U
Transfusion required >4 U
No active major comorbid diseases
Stable major comorbid diseases
Unstable major comorbid diseases
No liver disease
Mild liver disease—PT normal or near-normal
Decompensated liver disease—i.e., coagulopathy, ascites, encephalopathy
No moderate-risk or high-risk clinical features
No high-risk clinical features

46. Stratification with initial and endoscopy findings
Clinical Risk Stratification
Endoscopy
Low Risk
Moderate Risk
High Risk
Low risk hospitalization
Immediate discharge[*]
24-hr inpatient stay (floor)[†]
Close monitoring for 24 hr[‡]; ≥48-hr
Moderate risk
24-hr patient stay[†]
24–48 hr inpatient stay (floor)[†]
Close monitoring for 24 hr; ≥48-hr hospitalization
High risk
Close monitoring for 24 hr; 48–72 hr hospitalization
Close monitoring ≥72-hr hospitalization

47. So what does this mean at FMC for UGIB pts…
Low-risk pts:
Hold o/n in ED until scoped
Consider admission to Hospitalist until scoped (depending on GI suggestions)
Med risk pts:
Admit to Hospitalist/Medicine until scoped
Scope immediately
High risk pts:
Admit to Medicine/ICU

48. Disposition LGIB pts
If not clearly due to hemorrhoids, fissures, proctitis then should admit
Low risk: admit to Hospitalist with scoping
Med/High risk: admit to Medicine/ICU with scoping +/- angio