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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 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 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 DEFINITIONS Upper vs. Lower GI bleed UGIB = proximal to ligament of Treitz LGIB = distal to ligament of Treitz Ligament of Treitz GOALS OF CARE Stabilize patient’s hemodynamics Assess patient, determine source of bleed Stop any active bleeding Treat underlying cause Prevent recurrence PRESENTATION “The patient has been vomiting blood” Usually indicates upper GI source Can include: bright red blood coffee ground emesis clots 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 INITIAL ASSESSMENT Is the patient hemodynamically stable? Replace intravascular volume History, physical exam Nasogastric intubation Lab evaluation Floor vs. ICU 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 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 INITIAL ASSESSMENT – HISTORY Age Previous bleeding Comorbidities CAD heart failure AAA repair liver disease Previous endoscopies (look at reports!) Associated symptoms risk, mortality increase with age pain retching anorexia, weight loss nausea/vomiting early satiety dysphagia epistaxis, hemoptysis Medication history – NSAIDs, warfarin, ASA, Plavix 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” 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 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 INITIAL EVALUATION – LABS CBC H+H, including BASELINE Platelets BUN/Cr ratio see increased BUN in UGIB due to absorbed blood proteins ratio usually > 20:1 Coags goal platelet count? Renal function panel how often to check? goal H+H? may take up to 72 hrs to equilibrate goal INR < 1.5 reverse with FFP, vitamin K unless contraindicated LFTs Iron studies 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 Medications epistaxis hemoptysis ASA, NSAIDs (gastric irritation) Exogenous peroxidase activity red meat consumption fruits (grapefruit, cantaloupe, figs) uncooked vegetables (broccoli, cauliflower, radish, cucumber, carrot) 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 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 UPPER GI BLEED Other Erosions Neoplasm MalloryWeiss Tear AVM PUD Esophageal Varices (Other includes Dieulafoy’s lesion, GAVE, foreign body, etc.) 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 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 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 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 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 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 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 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 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 Thank you! Enjoy your time in Cleveland!
