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Gastrointestinal Bleeding

Gastrointestinal Bleeding. Lisa N. Flemmons, ACNP-BC Vanderbilt University Medical Center Medical Intensive Care Unit. Objectives. Learn how to effectively evaluate and manage gastrointestinal bleeding in the critically ill patient

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Gastrointestinal Bleeding

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  1. Gastrointestinal Bleeding Lisa N. Flemmons, ACNP-BC Vanderbilt University Medical Center Medical Intensive Care Unit

  2. Objectives • Learn how to effectively evaluate and manage gastrointestinal bleeding in the critically ill patient • Distinguish upper gastrointestinal bleeding from lower and discuss possible etiologies • Understand diagnostic testing and therapeutic interventions • Review and discuss transfusion strategies in the gastrointestinal bleeding patient

  3. Epidemiology • Common and potentially fatal diagnosis accounting for ~30,000 admissions/year • Upper GIB accounts for 20,000 deaths/year • In our MICU, it is the 3rd most common diagnosis

  4. Distinguishing upper vs lower Upper GI bleed Lower GI bleed History Previous colon cancer Previous colon surgery Known diverticulosis Known hemorrhoids Symptoms Abdominal pain or can be painless Hematochezia Melena (less common) • History • Previous PUD • Alcoholism/liver dz varices • Retching/vomiting  Mallory Weiss tear • Medications such as anticoagulants, antiplatelets, NSAIDS → ulcers • Symptoms • Nausea/vomiting • Hematemesis • Melena • Rarely hematochezia (massive bleed)

  5. Evaluation and Assessment • ABCs of GIB • Airway and Access • Blood products • Correct Coagulopathy and Consultation • Drugs and Diagnostic testing

  6. Airway and Access • Ensure adequate airway • Hematemesis • Altered mental status • Shock • Needed for endoscopy • Adequate access • 2 large bore PIV vs CVC

  7. Blood Products • Crystalloid infusion while waiting on PRBC • Vasopressors are not a substitute for volume resuscitation • Each PRBC should increase PCV by ~3% per unit

  8. Transfusion goal

  9. Randomized 921 patients to either liberal or restrictive strategy • Liberal strategy transfusion trigger was Hgb <9 and restrictive strategy was 7 • The probability of survival at 6 weeks was higher in the restrictive-strategy group than in the liberal-strategy group (95% vs. 91%). • Further bleeding occurred in 10% of the patients in the restrictive-strategy group as compared with 16% of the patients in the liberal-strategy group and adverse events occurred in 40% as compared with 48%.

  10. 6 week survival rate in the 2 groups

  11. Correction of Coagulopathy • FFP transfusion • Synthetic liver dysfunction • Warfarin • Consider Vitamin K • Dilutional coagulopathy • Goal INR <1.5 • Platelet transfusion • in bleeding pt if less than 50K • Platelet dysfunction • Anti-platelet agents or uremia • Goal platelets >50, 000/mm³

  12. Correction of Coagulopathy • Transexamic acid • Synthetic derivative of aminoacid lysine that inhibits fibrinolysis or dissolution of the clot • Given as 1 gm loading dose followed by 1 gm IV infusion over 8 hrs

  13. Correction of Coagulopathy • Prothrombin Complex Concentrate • Non-activated concentrate of Vitamin K dependent factors (II, VII, IX, X) • Advantages compared to FFP: • small volume with rapid infusion time • no time delays for ABO blood typing and thawing • less risk of pathogen transmission, transfusion related ALI, add circulatory volume overload • less time to correct coagulopathy

  14. Consultation • Urgent gastroenterology consult • Consider surgical consult • Massive transfusion • Abdominal pain associated with GIB • Recurrent bleeding

  15. Diagnostics • Upper GIB→EGD (esophagogastroduodenoscopy) • Definitive test for diagnosis and treatment • Safe to perform once the airway is secure and pt is reasonably hemodynamically stable • Interventional options: epinephrine injection, cauterization, clipping, or banding of varices • May give 1 time dose of erythromycin 250 mg IV or Reglan 10 mg IVP to promote gastric emptying prior to procedure

  16. Large ulcer Status post cauterization

  17. Submucosal duodenal tumor 1.5 cm lesion s/p resection

  18. Site of resection: friable and oozing with visible vessel S/p epinephrine and cauterization

  19. Diagnostics continued • Lower GIB→colonoscopy • If slow bleed consider bowel prep overnight to allow for maximum visualization • If brisk bleed consider STAT colonscopy, tagged RBC scan, or angiography • Tagged RBC scan vs angiography • If upper and lower endoscopy fail to ID source then can consider video capsule or push enteroscopy

  20. Drugs Proton pump inhibitor BID Am J Health-Syst Pharm—Vol 62 Jun 1, 2005 1165

  21. Drugs • If hx of liver disease or ascites give SBP prophylaxis (quinolone, CTX, or bactrim) • Octreotide gtt for hx of liver disease or known varices • Hold beta blocker in the acute setting which will prevent/block reflex tachycardia

  22. Minnesota/Blakemore Tube A flexible tube consisting of an esophageal and gastric balloon that is inflated and is used as a temporizing measure to tamponade gastric and/or esophageal varices.

  23. Minnesota/Blakemore Tube Uses Cautions Necrosis if inflated too much or too long Nasal insertion can cause nose bleeds and sinusitis Can migrate upwards and compress trachea especially in shorter stature patients Perforate or tear esophagus during insertion • Should have experienced personnel assist with insertion • Maximum amt of time 24-72 hrs • Must be to traction (usually a football helmet) • KUB and CXR for confirmation of placement (keep in mind after transfer from OSH)

  24. Large esophageal varices with red wales sign Status post banding

  25. Transjugular Intrahepatic Portosystemic Shunt (TIPS) Increased pressure in PV forces blood to flow into smaller branches coming from abdominal organs that normally drain into the PV. These veins then enlarge and are referred to as varices

  26. 63 patients with cirrhosis and acute variceal bleeding randomly assigned within 24 hours after admission • 32 patients assigned to early TIPS group (within 72 hours) • 31 patients assigned to continuation of vasoactive drugs, NS- beta blockade, and long term EBL with insertion of a TIPS as rescue therapy if needed.

  27. Results • rebleeding or failure to control bleeding occurred in 14 patients in the pharmacotherapy–EBL group as compared with 1 patient in the early-TIPS group (P=0.001). • The number of days in the intensive care unit and the percentage of time in the hospital during follow-up were significantly higher in the pharmacotherapy–EBL group than in the early-TIPS group. • The 1-year actuarial survival was 61% in the pharmacotherapy–EBL group versus 86% in the early-TIPS group (P<0.001).

  28. References • CRASH-2 trial collaborators, Lancet 2010; 376; 23-32 • Garcia-Pagan et al, NEJM 2010; 362: 2370-9 • Lau JY, Sung JJ, Lee KKC, et al, NEJM 2000; 343: 310–316 • Marini, J.J., Wheeler, A.W. (2010). Critical care medicine: The essentials (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. • Rivkins, K., Lyakhovetskiy, A AJHP 2005; 62: 1164-1165 • Sarode, R., et al, Circulation 2013; 128: 1234-1243 • Villaneuva, C et al NEJM 2013; 368: 11-21

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