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GI BLEEDING

GI BLEEDING. Brad Martin, MD c/o Jason De Roulet, MD July 18, 2012. OBJECTIVES. Define some common terms associated with GI bleeds Review the ways patients commonly present with GI bleeds Review how to assess patients presenting with GI bleed

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GI BLEEDING

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  1. GI BLEEDING Brad Martin, MD c/o Jason De Roulet, MD July 18, 2012

  2. OBJECTIVES • Define some common terms associated with GI bleeds • Review the ways patients commonly present with GI bleeds • Review how to assess patients presenting with GI bleed • Identify the most common causes of both upper and lower GI bleeds • Identify key information to have available when calling a GI consult • Review the medical and endoscopic treatments for both upper and lower GI bleeds

  3. DEFINITIONS • Acute GI bleed • < 3 days duration • hemodynamic instability • requires blood transfusion • Overt vs. occult • overt = visible blood (melena, bright red blood, coffee grounds) • occult = only detected by lab tests

  4. DEFINITIONS • Upper vs. Lower GI bleed • UGIB = proximal to ligament of Treitz • LGIB = distal to ligament of Treitz Ligament of Treitz

  5. GOALS OF CARE • Stabilize patient’s hemodynamics • Assess patient, determine source of bleed • Stop any active bleeding • Treat underlying cause • Prevent recurrence

  6. PRESENTATION • “The patient has been vomiting blood” • Usually indicates upper GI source • Can include: • bright red blood • coffee ground emesis • clots

  7. PRESENTATION • “The patient has had bloody stools” • need to determine stool characteristics, especially color, consistency, and frequency • melena = black, tarry stool (melena ≠ dark, formed stool!) • usually indicates upper GI bleed, although ~5% can be from small bowel or proximal colon • only need around 50cc of blood to get melena • adjective is melenic, not melanotic • hematochezia = BRBPR or clots • usually indicates lower GI bleed, although can be brisk upper bleed • brown stool, formed stool usually not aggressive bleed

  8. INITIAL ASSESSMENT • Is the patient hemodynamically stable? • Replace intravascular volume • History, physical exam • Nasogastric intubation • Lab evaluation • Floor vs. ICU

  9. INITIAL ASSESSMENT – STABLE? • Is the patient orthostatic? • requires loss of 20% of blood volume • “dizzy when I get up” • Is the patient in shock? • requires loss of 40% of blood volume • hypotensive, tachycardic, pallor

  10. INITIAL ASSESSMENT – RESUSCITATION • Establish good access • 2 large bore (ideally 18-gauge peripheral IVs) • in MICU, may place triple-lumen or Cordis • Replace intravascular volume • if hypotensive and/or orthostatic, give NS boluses • if anemic, give PRBCs • may need FFP and/or platelets if massive GI bleed

  11. INITIAL ASSESSMENT – HISTORY • Age • risk, mortality increase with age • Previous bleeding • Comorbidities • CAD • heart failure • AAA repair • liver disease • Previous endoscopies (look at reports!) • Associated symptoms • pain • retching • anorexia, weight loss • nausea/vomiting • early satiety • dysphagia • epistaxis, hemoptysis • Medication history – NSAIDs, warfarin, ASA, Plavix

  12. INITIAL ASSESSMENT – PHYSICAL • Vital signs: tachycardia? hypotension? hypoxia? • Gen: distress? alert + oriented? • HEENT: pallor, blood in nares or mouth • Abd: distension, tenderness • Rectal – visualize the stool! • BRB, melena, maroon, brown, no stool in vault • “The ER said it was heme positive”

  13. INITIAL ASSESSMENT – NG TUBE • Nasogastric intubation, NG lavage • confirm NGT is in stomach (KUB) • inject 250cc NS, then draw 250cc back or place to wall suction • can be repeated for up to total of 2L • stop when fluid is clear (or when reach 2L) • Contraindications • facial trauma, nasal bone fracture • known esophageal abnormalities (strictures, diverticuli) • ingestion of caustic substances, esophageal burns • generally, esophageal varices are NOT a contraindication to NG tube placement

  14. INITIAL ASSESSMENT – NG TUBE • Interpretation of aspirate: • bright red, clots = active UGIB • coffee grounds = slow bleeding, may have stopped, localizes to upper GI source • clear = indeterminate (NOT a guarantee that the bleeding has stopped) • bilious = bleeding has stopped

  15. INITIAL EVALUATION – LABS • CBC • H+H, including BASELINE • how often to check? • goal H+H? • may take up to 72 hrs to equilibrate • Platelets • goal platelet count? • Renal function panel • BUN/Cr ratio • see increased BUN in UGIB due to absorbed blood proteins • ratio usually > 20:1 • Coags • goal INR < 1.5 • reverse with FFP, vitamin K unless contraindicated • LFTs • Iron studies

  16. THE STOOL GUAIAC • Stool guaiac is a great tool for colon cancer screening • It is NOT a test for acute GI bleed • Causes of false-positives include: • Trauma • Extraintestinal blood loss • epistaxis • hemoptysis • Medications • ASA, NSAIDs (gastric irritation) • Exogenous peroxidase activity • red meat consumption • fruits (grapefruit, cantaloupe, figs) • uncooked vegetables (broccoli, cauliflower, radish, cucumber, carrot)

  17. INITIAL EVALUATION - TRIAGE • What necessitates a MICU admission? • Hemodynamic instability despite adequate volume resuscitation • NG lavage does not clear with 2L • History of cirrhosis, concern for variceal bleed • Continued bleeding • Be concerned when: • Age > 60 • Multiple comorbidities • Coagulopathy (i.e. Plavix, warfarin, cirrhosis) • Known portal hypertension • Hematemesis is bright red blood • History of AAA repair in the past

  18. DETERMINING THE SOURCE • History is crucial • NSAIDs, postprandial epigastric pain (ulcer?) • hypotension preceding BRBPR (mesenteric ischemia?) • retching or recurrent vomiting (Mallory-Weiss?) • history of cirrhosis (variceal bleed?) • Stool exam • NG lavage • 11% of patients initially suspected of LGIB actually have UGIB

  19. UPPER GI BLEED (Other includes Dieulafoy’s lesion, GAVE, foreign body, etc.)

  20. LOWER GI BLEED • Differential diagnosis: • Diverticulosis (up to 42%) • Ischemia (up to 18%) • Hemorrhoids, fissures (up to 16%) • UGI or small bowel bleed (up to 13%) • Neoplasia (up to 11%) • Other (IBD, infectious colitis, post-polypectomy) • Unknown cause in up to 23% of cases

  21. CALLING A GI CONSULT • Presentation • PMHx, especially if h/o liver disease • NG lavage results • RECTAL EXAM!!-Stool characteristics • Vital signs, hemodynamics, orthostatics • Labs • Previous endoscopy reports • Have a differential

  22. MEDICAL THERAPY FOR UGIB • PUD: • PPI bolus of 80mg, then drip at 8mg/hr • has been shown to accelerate resolution of bleeding and decrease need for therapy during EGD • Varices • Octreotide 50-100mcg bolus, then 50mcg/hr drip • If pt has ascites, will need antibiotics for 7 days for SBP prophylaxis • norfloxacin 400mg BID • Bactrim DS BID

  23. ENDOSCOPIC THERAPY FOR UGIB • PUD • epinephrine injection • bipolar cautery • hemoclip • Varices • endoscopic band ligation • >90% success • 30% rebleeding rate • TIPS for hemorrhage refractory to banding • also used for gastric varices

  24. UGIB ADMISSION • NPO after midnight • Call GI fellow first thing the next morning (8am) • If patient cannot consent, make sure medical decision maker is identified and have phone numbers available

  25. TREATMENT OF LGIB • No medical treatments • Diverticular bleeds stop on their own 75% of the time • Bleeds due to angiodysplasia stop spontaneously around 85% of the time • If pt continues to bleed • CT angiography to localize bleed • can often be accompanied by embolization to stop the bleeding • requires > 0.5cc per minute of blood loss • Tagged RBC scan • can detect bleeding at > 0.1cc per minute • unreliable localization, high false positive rate

  26. TREATMENT OF LGIB • Usually no need for emergent colonoscopy • If stable but continued bleeding can do “rapid purge” (GoLYTELY 4L given quickly) and colonoscopy can be done in 6-12 hours • Colonoscopy reveals cause in > 70% of cases • Tools used include • epinephrine injection • cautery • hemoclip • surgery

  27. LGIB ADMISSION (ON THE FLOOR) • Clear liquid diet the day prior to endoscopy • 1 gallon GoLYTELY started the afternoon/evening before procedure • Goal is for stool to be CLEAR

  28. SUMMARY • A detailed history is crucial in diagnosing GIB • It is also very important to characterize the emesis and/or stool to aid in diagnosis • Stool guaiac testing is not indicated in acute GIB • Most important step is assessing hemodynamic (in)stability and resuscitating with NS and/or blood if needed • In most cases, the patient will need endoscopy, but you can help to improve outcomes with specific medical treatments

  29. Thank you! Enjoy your time in Cleveland!

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