Acute Gastrointestinal BleedingNaveed Ahmad M.D

November 2012

QUESTION 1

Endotracheal intubation for airway protection in the management of acute Upper GI bleeding should be considered:

A. in all cirrhotic patients B. in all patients with UGI bleeding C. in patients with altered mental status and ongoing

hematemesis D. in patients with stable COPD E. in all patients unless it delays urgent endoscopy

QUESTION 2

A 73 year old man presents with several episodes of hematemesis. Examination shows signs of orthostatic hypotension and melena. What is the first priority in caring for this patient?

A. Nasogastric tube placement and gastric lavage. B. Resuscitation with adequate IV access and

appropriate fluid and blood product infusion. C. Intravenous infusion of H2-receptor antagonists to

stop the bleeding. D. Urgent upper endoscopy. E. Urgent surgical consultation.

QUESTION 3.

A 58 year old female patient presents to the ED with a 24-hour history of several bloody bowel movements. She denies any abdominal pain but complains of light headedness. She is found to be hypotensive with systolic blood pressure of 90mmHg supine. Hb 7gm/dl. Resuscitative measures are instituted. What is the most appropriate next step?

A. Nasogastric tube placement B. Flexible sigmoidoscopy C. Colonoscopic examination D. Tagged RBC scan E. Angiography

Intraluminal blood loss anywhere from oropharynx to anus

Upper : above ligament of Treitz

Lower Below the ligament of Treitz

Incidence

Annual rate of hospitalization for any type of GIB in US 350/100,000

Annually, approximately 100,000 patients are admitted to US hospitals

UGIB 50%, Lower GIB 40%, 10% obscure bleeding.

Mortality rates from UGIB are 6-10% overall

The incidence of UGIB is 2-fold greater in males than in females, in all age groups; however, the death rate is similar in both sexes

Signs

Hematemesis : blood in vomitus (UGIB)

Hematochezia : bloody stools (LGIB or rapid UGIB)

Melena : Black Tarry stools from digested blood (Usually UGIB but can be anywhere including right colon)

Etiologies (UGIB)

Source Prevalence (%)

Duodenal Ulcer 24.3

Gastric Erosions 23.4

Gastric Ulcer 21.3

Esophagogastric Varices 10.3

Mallory-Weiss tear 7.2

Esophagitis 6.3

Erosive Duodenitis 5.8

Etiologies (UGIB)

Oropharyngeal bleeding and epistaxis

Immunocompetent host : GERD/Barrett’s/XRT

Immunocompromised host : CMV,HSV, Candida

Vascular Malformations (5%) Dieulafoy’s Lesion (superficial ectatic artery in cardia ->

sudden massive UGIB) AVMs (isolated or with Osler-Weber-Rendu syndrome) Aorto-enteric fistula (AAA or aortic graft erodes into 3rd

portion of duodenum;presents with herald bleed) Vasculitis

Neoplastic disease (esophageal or gastric)

Etiologies (LGIB)

Source Prevalence (%)

Diverticulosis 17 – 44

Colonic Angiodysplasia 2 – 30

Ischemic Colitis 9 – 21

Malignancy 4 – 14

Hemorrhoids/Anorectal 4 – 11

Postpolypectomy 6

Unknown 8 - 12

Clinical Manifestations

UGIB>LGIB: Nausea, vomiting, hematemesis, coffee ground emesis, epigastric pain, vasovagal reaction, syncope, melena

LGIB>UGIB: Diarrhea, tenesmus,BRBPR or maroon stools

Work Up

History : Acute or chronic GIB, number of episodes, most recent episode, hematemesis, vomiting prior to hematemesis, melena, hematochezia, abdominal pain, use of NSAIDs, anti coagulants, alcohol abuse, cirrhosis, prior GI or aortic surgery

Physical Exam

Tachycardia at 10% volume loss Orthostatic hypotension at 20% loss Shock at 30% volume loss Pallor, talengectesia (ETOH,cirrhosis, OWR Synd) Chronic liver disease: jaundice,spider angiomata,

gynecomastia, testicular atrophy, palmer erythema, caput medusae

Localized abdominal tenderness or peritoneal signs, masses, signs of prior surgery

Rectal Exam: appearance of stools, hemorrhoids, anal fissure

Lab Studies

Hct: maybe normal before equiliberation which may take 24 hours, decreased 2-3%-> loss of 500cc blood.

Platelet count, PT,PTT BUN/Cr (ratio>36 in UGIB due to GI resorption of blood and prerenal azotemia)

LFTs

NG tube: Useful for localization (presence of non-boody bile in lavage excludes active bleeding proximal to ligament of Treitz), can also clear GI contents prior to EGD and detect continued bleeding

Glasgow-Blatchford Score

Admission risk marker Score component value

Blood Urea

≥6·5 <8·0 2

≥8·0 <10·0 3

≥10·0 <25·0 4

≥25 6

Haemoglobin (g/L) for men

≥12.0 <13.0 1

≥10.0 <12.0 3

<10.0 6

Haemoglobin (g/L) for women

≥10.0 < 12.0 1

<10.0 6

Systolic blood pressure (mm Hg)

100–109 1

90–99 2

<90 3

Other markers

Pulse ≥100 (per min) 1

Presentation with melaena 1

Presentation with syncope 2

Hepatic disease 2

Cardiac failure 2

scores of 6 or more were associated with a greater than 50% risk of needing

an intervention

Rockall Score

A score less than 3 carries good prognosis but total score more than 8 carries high risk of mortality

Diagnostic Studies

UGIB EGD (potentially therapeutic) LGIB

(r/o UGIB)

Stable. Spontaneously stops- colonoscopy diagnostic in 70% cases also potentially therapeutic

Stable, ongoing bleeding- colonoscopy or Bleeding scan (Tc tagged RBC/albumin) detects rates >0.1 ml/min, localization difficult

Unstable, arteriography bleeding rates >0.5ml/min, potentially therapeutic

Ex Lap

RBC scan

Angiogram

Treatment

IV access with 2 large bore (18 gauge or larger) IV lines Vol resuscitiation (saline, Ringer’s) Transfusion therapy Correct Coagulopathies NG/Prokinetics Airway management Consult GI and Surgery service as needed

Peptic Ulcer Disease

Pharmacologic therapy High Dose PPI therapy (Pantoprazole 80 mg IV bolus

followed by 8gm/hr infusion)

Endoscopic therapy (Injection, Thermal, Laser)

Arteriography with embolization

Surgery if endoscopic and pharmacologic therapy fails

Varices

Pharmacologic Octreotide 50 microgram IVB 50microgram/hr

infusion (84% success; Lancet 1993) Non Selective Beta Blocker therapy (once stable)

Non Pharmacologic EVL has replaced sclerotherapy (>90% success) Balloon Temponade (Sengstaken-Blakemore) TIPS if Endoscopy fails

Mallory-Weiss TearUsually stops spontaneously, endoscopic

therapy if active

Esophagitis/GastritisPPI, H2- Antagonists

Diverticular Disease

Usually stops spontaneoulsy

Endoscopic therapy

Arterial vasopressin or embolization

Surgery

Angiodysplasia

Endoscopic therapy Arterial vasopressin Surgery Hormonal therapy

Risks of Rebleeding without Endoscopic Intervention

0

10

20

30

40

50

60

70

80

90

Activebleeding

NBVV Clot Pigmentedspot

Clean base

Summary

Acute GI bleeding remains a important cause for morbidity, hospital admissions and mortality

Early and prompt resuscitation is the key to management

Diagnostic and therapeutic modalities are ever improving

Thank you

QUESTION 1

Endotracheal intubation for airway protection in the management of acute Upper GI bleeding should be considered:

A. in all cirrhotic patients B. in all patients with UGI bleeding C. in patients with altered mental status and ongoing

hematemesis D. in patients with stable COPD E. in all patients unless it delays urgent endoscopy

QUESTION 2

A 73 year old man presents with several episodes of hematemesis. Examination shows signs of orthostatic hypotension and melena. What is the first priority in caring for this patient?

A. Nasogastric tube placement and gastric lavage. B. Resuscitation with adequate IV access and

appropriate fluid and blood product infusion. C. Intravenous infusion of H2-receptor antagonists to

stop the bleeding. D. Urgent upper endoscopy. E. Urgent surgical consultation.

QUESTION 3.

A fifty-eight year old female patient presents to the emergency department with a 24-hour history of several bloody bowel movements. She denies any abdominal pain but complains of light headedness. She is found to be hypotensive with systolic blood pressure of 90mmHg supine. Hb 7gm/dl. Resuscitative measures are instituted. What is the most appropriate next step?

A. Nasogastric tube placement B. Flexible sigmoidoscopy C. Colonoscopic examination D. Tagged RBC scan E. Angiography