Treatment of Acute Lower Gastrointestinal Bleeding

Experience of a Specialized Management Team

Eric J. Dozois, MD

Division of Colon & Rectal Surgery

Mayo ClinicRochester, Minnesota

Acute GI Bleeding

• Significant health problem:

• Morbidity

• Mortality

• Cost

• Disease of the Elderly:

• By 2050, 78 million Americans will be 65 years or older

Lower Gastrointestinal Bleeding (LGIB)Background

• Distinct entity from upper GI bleeding

• Spectrum of disease is broad

• Trivial hematochezia to massive hemorrhage and shock

Lower GI BleedBackground – Management Pathway

• Assessment of severity• Establishment of diagnosis• Appropriate use of resources• Control of bleeding• Prevention of rebleeding• Lower morbidity, mortality, cost

Acute Gastrointestinal BleedingManagement - Advances

• Growth of Therapeutic Endoscopy:*– Decrease length of hospitalization– Decrease transfusion requirements– Lowers need for surgical intervention– Reduced mortality

*Sacks et al JAMA 1990;264:494-9

Gastrointestinal Bleeding TeamMayo Clinic - Background

• Surgeons

• ER Physicians

• Radiologists

• Pharmacists

• ICU Physicians

1988

Mayo Clinic Gastrointestinal Bleeding Team

(GIBT)

Management of Acute GI BleedingMayo Clinic - Background

• Designed to satisfy the need for rapid and specialized endoscopic management of acute GI conditions, primarily GI bleeding

Mayo Clinic GI Bleed Team

• Rapid response, 24/7 service

• Response time for emergent endoscopy is < 30 minutes

• Involved until patient stabilized or surgery intervention

Members of Team

• 1 Staff Endoscopist (1 - wk rotation)

• 1-2 GI Fellows (1 - mo rotation)

• 1 Endoscopy nurse (1 - wk rotation)

• 1-2 full-time study coordinators

• Colorectal or General Surgeon

Mayo Clinic GI Bleed Team

• Scope of Practice:

• ER, clinic, hospital, OR

• All endoscopic emergencies– Food impaction

– Foreign body removal

– Colonic decompression (stents)

Early Assessment – High Risk Screening Criteria

• Historical Criteria:– Age > 65 years– Previous bleeding; identified site(s)– Major organ system disease, aortic graft

• Clinical Criteria:– SBP < 100, orthostatic drop > 20, HR > 100– Transfusion of > 4U/24hrs, 8U hospital stay– Re-bleed event > 2U

GIBT - Bowel Prep

• GoLYTELY:– 4 oz. Q 5 min. until effluent clear

OR

– 4 liter down NG tube over 2 hours

GIBT - Equipment

• Motorized, mobile unit

• State-of-the-art:

• DVD recording

• Accessories• Scopes

GIBT - Database

• Prospectively collected data on all patients

• Indications, findings, therapeutic modality, complications and outcome

• Enhances research productivity related to GI bleeding and other GI emergencies

Annual Procedure Volumes: 1999 - 2004

3357936253 37418 37410 38249

40669

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

1999 2000 2001 2002 2003 2004Years

No

. P

roce

du

res

Year-end 2005

> 42,000 Procedures

Extra procedures include PEG/PEJ, bedside NG-NJ tube placement, etc.

Bleeding Team Procedural Practice Trends

1527

0 0

1593

1419

1175

1090

10171069

1276

1359

1275

106143

234252

0

200

400

600

800

1000

1200

1400

1600

1800

2000 2001 2002 2003 2004 2005Year

# P

roce

du

res

Total Procedures

Bleed-related Procedures

Extra/other procedures

Bleeding Team Practice Trends

792

715743

938 936

873

296 302326 338

423402

0

100

200

300

400

500

600

700

800

900

1000

2000 2001 2002 2003 2004 2005

Year

# P

roce

du

res

Upper Endoscopies

Low er Endoscopies

Upper vs. Lower GI Bleeding (2005)

N = 726

Upper GI n=456 (65%)

Lower GI n=200 (25%)

Unknown n=70 (9%)

All GI Bleeding Etiologies - 2005

• PUD 29%• Gastroesophageal varices 7%• Vascular ectasias 6%• Diverticular bleeding 6%• Postpolypectomy 4%• Colonic ulcers 4%• Ischemia 3%• Mallory-Weiss tear 3%• Malignancy 0.8%• Anastomotic site 0.7%• Dieulafoy 0.1%

Causes of LGI Bleeding - 2005

• Diverticular 21%• Ulcers/erosions 15%

• NSAID, infection, idiopathic

• Ischemic colitis 12%• Post-polypectomy 11%• Vascular ectasias 8%• Malignancy 2%• Anastomotic site 2%

Lower GI BleedRisk Factors for Mortality*

• Age > 70 years• Vital organ disease (*heart, liver, lungs)

• History of Cancer

• Shock

• Re-bleeding (> 4 units/event)

• Hospitalized patients*With permission from CJ Gostout, MD

Lower GI BleedRisk Factors for Re-bleeding

• Bleeding > 24 hours• Hemodynamic instability• Hemoglobin , 10 g/dL• Anticoagulation/coagulation disorder• Cirrhosis• Transfusion > 4 U per resuscitation event• Undiagnosed prior major bleeding

*With permission from CJ Gostout, MD

GIBT – Complications

• Study Period 1989 - 2000

• No. of Cases 10,520

• Complications 230

Gostout et al. AJG 2001;96:3452

Complication Rate 2.19%

GIBT – ComplicationsGostout et al. AJG 2001;96:3452

Iatrogenic bleeding 24.3%Perforation 20.0%Hypoxia 9.6%Hypotension 9.6%Mucosal tears 8.0%Arrhythmias 6.1%Aspiration 3.0%Death 2.0%

GIBT - Technical Expertise

• Injection:• Epi, sclerosants, cyanoacrylate glue

• Thermal:• Heat probe, Bipolar electrocoagulation

• Mechanical:• Clipping, Banding, Cryotherapy

Endoscopic Management LGIB

• Principles:– If active bleeding, inject epinephrine

(1:10,000) to slow or stop bleeding

– Epinephrine is generally a temporary solution and used as an adjunct to definitive therapy (e.g., clipping or thermal coagulation)

Endoscopic Management LGIB

• Principles:– If feasible, clipping generally preferred in

the colon due to perceived increased safety relative to thermal techniques

– Clipping and thermal coagulation techniques are equally effective for most bleeding colonic lesions

Indications for Clips

• Mallory-Weiss Tear• Peptic Ulcer Disease• Dieulafoy lesion• Post-polypectomy bleeding• Diverticular bleeding• Angioectasias*

(*APC or contact thermal modality preferred)

Raju GS et al. Gastrointest Endosc 2004;59:267

Vascular Ectasia

Non-Bleeding Bleeding

CoaptiveCoagulation

APC(preferred)

EpinephrineInjection

CoaptiveCoagulation

APC(preferred)

Clipping not optimal for vascular ectasias

Diverticular & Postpolypectomy Bleeding

AngiographicEmbolization

CoaptiveCoagulation

Clipping(preferred)

EpinephrineInjection

CoaptiveCoagulation

Clipping

failed failed

failed failed

Anastomotic Site Bleed

Stigmata Active Bleed

CoaptiveCoagulation

Clipping(preferred)

EpinephrineInjection

CoaptiveCoagulation

Clipping(preferred)

Conclusions

Mayo Clinic GI Bleed Team

• Organized, highly skilled team

• Delivers immediate and advanced endoscopic therapy to patients with acute GI bleeding

• Should improved outcomes

Mayo GIBT – Future Research

• How will the presence of the GIBT effected:

• Mortality, Morbidity, Cost

• Transfusion requirements

• Need for surgical intervention

• Length of hospital stay