Download Gastrointestinal Bleeding AKA: “My poop looks purple”

Gastrointestinal Bleeding
Why is GI bleeding important?
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Mortality rates from upper GI bleeding
vary from 3.5% to 7% in the U.S.
Mortality rates for lower GI bleeding is
reported at 3.6%
If new GI bleed in hospital, mortality
can be 25%
Billions of dollars spent for >300,000
hospitalizations per year
Why is GI bleeding important
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Complications
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Integrilin
Heparin, etc.
Iatrogenic causes
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NSAIDS
Aspirin
Coumadin
Approach to GI Bleeding
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Identify the Clinical Setting
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ER vs. Ward vs. MICU vs. CCU vs. Clinic
Clinical presentation – i.e.
history/assessment
Resuscitation
Labs
Localize Bleed
Definitive therapy
Resuscitation
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Key component to GI Bleed
Identify stumbling blocks
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Pt with sign comorb. – CHF, valvular hrt
dz, etc.
Review setting where res. should occur
Access
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Should be automatic – 2 large bore IVs
Resuscitation cont.
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Mention on size:
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Poiseuille’s law
Triple Lumen: two
18 g, one 16 g with
length 20 cm
Central line: 8F with
10 cm length
Short and wide will
get the job done
Resuscitation cont.
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Fluid of choice
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Isotonic fluid – Normal Saline or Ringer’s
are both good choices
Patients with active bleeding and a
coagulopathy (INR>1.5) or
thrombocytopenia (<50,000) should be
transfused with FFP and platelets,
respectively
Resuscitation cont.
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Frequent vitals checks and gauging
initial status
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Orthostatics, pulse, hypoxia, symptoms
(agitation, lightheadedness, etc.)
Vitals:
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Normal BP: minor blood loss <10% of volume
+ orthostatics: mod blood loss 10-20% of vol.
Resting hypotension: SEVERE BLOOD LOSS
>20-25%
HPI
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Goal is to help identify likely source and
potential etiologies
Also to identify those patients most at
risk – i.e. who will crump on the way to
the unit
Focus on the details – how much, how
long, pain, meds, etc.
HPI – cont.
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Upper GI bleed commonly presents with
hematemesis (vomiting blood or coffee-ground
material) or melena (black, sticky maladorous stool)
 5x more likely to be an upper source
 Defined as bleeding occurring proximal to the
ligament of trietz
Melena: at least 50 cc of blood loss – typically
upper source, but cecal bleeds can be
melanic
If pt is vomiting BRB – GET NERVOUS!!!
HPI – cont.
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Bleeding from a lower GI source refers to
blood loss originating from a sight distal to
the ligament of Treitz.
Lower GI bleeding typically presents with
hematochezia (passage of maroon or bright
red blood from the rectum)
Up to 11% of patients with hematochezia
may have an upper source
Patient’s history
Important historical features include:
1.
Age: elderly are more likely to bleed from
diverticula, ischemic colitis, malignancy and
younger patients are more likely bleeding
from PUD, esophagitis, varices
2.
Prior bleeding
3.
Known GI disease: diverticulosis, IBD, PUD,
portal hypertension
4.
Previous surgery
Patient’s history cont.
5.Medications: coumadin, heparin, NSAIDs,
aspirin
6.Abdominal pain: PUD, mesenteric ischemia
7.Change in bowel habits, weight loss, anorexia
8.Other comorbid conditions: CKD, coagulation
d/o
9.Previous retching: Mallory-Weiss
Lab’s and Rad’s
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CBC – may be normal
LFTs, coags – screening tool and
identifying synthetic dysfunction
Chemistry or P2 – watch BUN – will
tend to trend up if upper
CXR / AAS – specific clinical
presentations – looking for catastrophe
– free air – mediastinum or abdomen
Bedside Studies
“Never trust anyone’s lavage” – Todd Sheer
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NG Lavage – were the money is made (90%
sensitive for UGI)
 Blood (18% mortality) – GET NERVOUS
 Coffee grounds (10% mortality) – likely not
actively bleeding
 Clear (6% mortality) – could have bled and
stopped
 Bilious – rules out upper bleed
Bedside Studies cont.
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Proctoscope
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Typically performed by general surgery and
for hematochezia
Looking for obvious ulcerations, fissures,
etc. - limited exam as only 10-20 cm
observed and messy!
Diagnostic Studies and
Therapeutics
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EGD
Colonoscopy
Tagged RBC scan
Angiography
Surgery
Further Evaluation and
Therapy
EGD:
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Can be performed at the bedside
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Has high diagnostic accuracy, is therapeutic
and associated with low morbidity
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Should be performed early in the course
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Patient must be hemodynamically stable
Further Evaluation and
Therapy
Colonoscopy:
 Advantages include precise localization
of bleeding and potential therapeutic
intervention.
 Early colonoscopy has been associated
with reduced length of hospital stay
Further Evaluation and
Therapy
Radionuclide Imaging with TRBC scan:
 Noninvasive modality
 Detects bleeding that is occurring at a
rate of 0.1 to 0.5 ml/m.
 Accuracy rates range from 24 to 91%
 Clinical utility of this test is for
screening before arteriography
Further Evaluation and
Therapy
Angiography
 Requires active blood loss of 1 to 1.5 ml/m
 100% specific but sensitivity varies from 3047%
 If an active lesion is found, intraarterial
vasopressin can be infused causing
vasoconstriction and cessation of bleeding
 Complications such as intrarterial thrombosis,
embolization and renal failure occur in 11%
of patients
Further Evaluation and
Therapy
Surgery:
 General indications for surgery are:
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Transfusion requirements that exceed 4-6
units over 24 hours or 10 units overall
More than two to three recurrent bleeding
episodes from the same source
Upper GI Bleed
UGIB in 2225 Patients
(Silverstein, et al, Gastrointest
Endo)
1.
2.
3.
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6.
7.
Gastric/Duodenal Ulcer
Gastric Erosions
Varices
Mallory-Weiss Tear
Esophagitis
Neoplasm
Other
45%
23%
10%
7%
6%
3%
6%
PUD
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Dr. Robin Warren and Professor Barry
Marshall – fought the battle to prove h.
pylori was associated with PUD
Marshall swallowed a culture or h. pylori
Koch would be proud:
PUD cont.
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Other risk factors: NSAIDS and stress
Initial approach: high dose PPI
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Capozza: “High dose PPI is as good as
endoscopy initially in stopping the bleed”
IV pantoprazole: 80 mg bolus then 8 mg/hr
drip
Definitive therapy: endoscopy with
injection versus thermal coagulation
Later that night….
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Re-bleeding:
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Active arterial bleeding 90%
Non-Bleeding visible vessel
50%
Adherent clot 25-30%
Oozing without visible vessel
10-20%
Flat Spot 7-10%
Clean ulcer base 3-5%
Mallory-Weiss Tear
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A mucosal tear at
the
gastroesophageal
junction
Bleeding ceases
spontaneously in
almost all instances
Consider PPI for 1-2
weeks to promote
healing
Mallory-Weiss
Esophageal Varices
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Variceal hemorrhage requires an ICU
admission
Consider endotracheal intubation in patients
who are thought to be actively bleeding for
airway protection
Start Octreotide infusion immediately (50 to
100 mcg bolus followed by infusion at 25-50
mcg/hour)
Endoscopy with variceal ligation or banding is
the therapy of choice
Esophageal Varices
TIPS (transjugular intrahepatic
portosystemic shunt)
 A radiologic procedure where a metal
stent is placed between the hepatic
veins and portal vein
 Indication for TIPS: intractable bleeding
unresponsive to variceal ligation or
sclerotherapy
Uncommon Causes of Upper
GI bleed
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Gastric antral vascular ectasia
Portal hypertensive gastropathy
Hemobilia
Hemosuccus pancreaticus
Aortoenteric Fistulas
Upper GI tumors
Dieulafoy’s lesion
Cameron lesions
Final Diagnosis in Major Lower
GI Bleeding
Diverticulosis
Angiodysplasia
Undetermined
Neoplasia
Colitis
Other
43%
20%
12%
9%
9%
7%
Management of Lower GI
Bleed
Acute Hematochezia
Eval and Res.
NGT aspiration
Bile and NO
BLOOD
colonoscopy
All other
negative
EGD
UGI
source
Treat as
appropriate
Source identified
Negative Exam
Treat as appropriate
Has hematochezia
ceased?
YES
Not possible due to
severity of bleeding
no
Arteriography versus
nuc med scan
Surgical consultation
Small bowel
studies
Diverticular Bleeding
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Occurs in only 3% of patients with
diverticulosis
75% of diverticula occur in the left side of the
colon
Source of diverticular bleed is right sided 5090% of the time
Acute, painless hematochezia
Self-limited 70-80% of the time
Colonoscopy is diagnostic and therapeutic
Angiodysplasia
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Dilated, tortuous submucosal vessels
May be the most frequent cause of
acute lower GI bleed in patients over 65
Painless hematochezia
Self limited
Colonoscopy is diagnostic and
therapeutic
Ischemic Colitis
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Common entity in the elderly
Usually caused by low flow states and small
vessel disease rather than large vessel
occlusion
Most commonly occurs at splenic flexure,
descending or sigmoid colon
Typically presents with mild, crampy
abdominal pain localized to LLQ
May see “thumb printing” on plain films
Most cases resolve with supportive care
References
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Shields, W. “GI Bleed (what I learned from Patrick)”
July, 2003.
Uptodate, of course
Zuccaro, G. Management of the Adult Patient with
Acute Lower Gastrointestinal Bleeding. Am J Gastro
1998;93:1202-08.
Barkun, A. et al. Consensus Recommendations for
Managing Patients with Nonvariceal Upper
Gastrointestinal Bleeding. Ann Internal Med.
2003;139:843-857.