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