GI bleeding

1. GI bleeding Mackay Memorial Hospital Department of Internal Medicine Division of Gastroenterology R4 陳泓達 97/6/22

2. GI Bleeding • UGI bleeding • Peptic ulcer disease • Variceal bleeding • LGI bleeding

3. UGI bleeding: 5 times more common than LGI bleeding. Men > Women Elderly persons. • Despite ongoing advances, fundamental principles are the same !!!!  immediate assessment and stabilization of hemodynamic status

4. Determine the source of bleeding • Stop active bleeding • Treat underlying abnormality • Prevent recurrent bleeding

7. Resuscitation In hemodynamically unstable… Set up two large-bore IV catheter Colloid solution (NS or lactated Ringer’s) • To restore vital sign !! ICU monitor is indicated Central venous monitoring F/U vital sign and urine output

8. History taking and physical examination UGI or LGI ? UGI  peptic ulcer disease or portal hypertension related (EV or GV)?

9. Differentiate LGI and UGI Melena – upper GI cause in 90% Hematochezia – upper GI cause in 10%

10. The intermediate patient Take more time…. Re-examine, Monitor vital signs, Re-check CBC, BUN

11. Transfusion ? • In hemodynamic unstable, any sign of poor tissue oxygenation, continued bleeding, persistent low Ht level(20-25%) • Maintain adequate perfusion • Target ?

12. Other Blood tests on the bleeding patient… INR, PTT – coagulopathy anyone?

13. “There is no single value of hemoglobin concentration that justifies or requires transfusion; an evaluation of the patient’s clinical situation should also be a factor in the decision.”Capital Health Guide to Blood Transfusion

14. You’ve decided to give blood… Options?

15. O neg Type Specific Full Cross Match – immediately available – 10 – 15 min. – 30 – 60 min.

16. What is in a unit of packed cells? 250 mL volume Contains citrate (anticoagulant), and preservative. 1 unit packed cells will increase the Hb concentration by approx. --? 0.5mg/dL

17. Massive Transfusion Greater than 1 blood volume( or 10 units ) transfused within 24 hours May dilute platelets and clotting factors

18. Dilution coagulopathy Monitor the patient for coagulopathy Follow the resuscitation (CBC, INR, PTT)

19. Treatment of dilution coagulopathy Plasma /FFP 10 – 15 mL / kg Usual adult dose 2 units. 5 –8 mL / kg dose for warfarin reversal

20. Treatment of dilution coagulopathy Platelets Keep the count greater than 50 ,000 in the bleeding patient 1 unit should increase platelet count by 5 ,000– 10, 000 / L Dose: 6 pack

21. Massive TransfusionWhat else can go wrong? Hypothermia Potassium Citrate toxicity (hypocalcemia)

22. Vomiting BloodHematemesis Upper GI Bleeding

23. Etiology Peptic Ulcer 50 % Gastritis 20% Esophageal varices 10% The rest: Tears, AVM, CA,etc 20%

24. More about bleeds…. 80 % of Non – variceal upper GI bleeds will stop spontaneously 60 % of variceal bleeds will stop spontaneously

25. What else can I do for GI bleeding, before endoscopy NG lavage Drug ABC Patient and family Agree ( Sign permit first)

26. Urgent Endoscopy ? Initial evaluation: 初始出血量是否大量 ? 出血量大者,rebleeding 機會也大 觀察重點: vital sign (tachycardia, orthostatic hypotension resting hypotension, shock), 吐血或 血便黑便的頻次與量, NG lavage的結果

27. NG lavage 15 – 20 % of upper GI bleeds have a negative aspirate Sensitivity 79%, Specificity 55% Cuellar et al, Arch of Int Med Jul 1990 • For endoscopic preparation • ( not contraindicated in patients with varices)

28. Endoscopy Diagnostic Therapeutic Prognostic

29. Endoscopic features and risk of re-bleeding 55 – 90% Active bleeding

30. Endoscopic features and risk of re-bleeding Non bleeding visible vessel 40 – 50 %

31. Endoscopic features and risk of re-bleeding Adherent clot 10 – 33%

32. Endoscopic features and risk of re-bleeding Flat spot 7 – 10 %

33. Endoscopic features and risk of re-bleeding Clean base 3 – 5%

34. Variceal bleeding Non-variceal bleeding

35. Drugs: Peptic ulcer bleeding Manipulation of gastric pH

36. Use of PPI’s Theory : raise gastric pH Better platelet activity Pepsinogen requires acid to become activated to pepsin Clots will form, clots not digested

37. High Risk Patients Elderly Co – Morbidity More severe bleeding (hemo-dynamically unstable, ongoing bleeding

38. Other helpful medication somatostatin / octreotide  associated with a reduced risk of continued bleeding and rebleeding in PUD

39. When endoscopic / pharmacological treatment fail… ◎ angiography  to localize bleeder and hemostasis generally reserved for patient: poor surgical candidates control of bleeding in an unstable patient awaiting surgery

40. Surgery • Hemodynamic instability despite vigorous resuscitation (more than a three unit transfusion) • Recurrent hemorrhage after initial stabilization (attempts at obtaining endoscopic hemostasis) • Shock associated with recurrent hemorrhage • Continued slow bleeding with a transfusion requirement exceeding three units per day.

41. Variceal Bleeding EGD finding: F1-4 Ls-m-i Cb / Cw Red color sign

43. After endoscopic treatment… Fail to achieve hemostasis or rebleeding • Balloon tamponade • Transjugular Intrahepatic Portosystemic Shunt (TIPS) • Surgery for shunt

44. Balloon Tamponade-Buy time Available in MMH S-B tube

45. McCormick. British Journal of Hospital Medicine. 43, Apr. 1990 Esophageal ballon Gastric ballon SB tube