Download GI Bleeds: The Basics EM Rounds 2009 Anatomy UGI vs. LGI

GI Bleeds: The
Basics
EM Rounds 2009
Anatomy
UGI vs. LGI defined by Ligament of
th
Treitz…located in 4 section of duodenum
Epidemiology
UGIB more common in men
LGIB more common in women
Ddx in adults
UGI:
 LGI:
PUD
Gastric erosions
75%
Varices
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Esophagitis
Duodenitis
UGI bleed
 Diverticulosis
80%
 Angiodysplasia
 Ca/polyps
 Rectal disease
(hemorrhoids, fistulas,
fissures)
 IBD
 Infectious

Ddx in peds
UGI:
Esophagitis
 LGI:
Anal fissure
 Infectious colitis
 IBD
 Polyps
 Intussusception

Gastritis
Ulcer
Varices
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Diagnosis
History:
Hematemesis, melena, hematochezia
Duration/amount of bleeding, previous
episodes, recent meds/Etoh/surgeries
s/s of blood loss
Physical:
Vitals—sustained tachycardia is most
sensitive
FOB?........
Resuscitation
Two large bore IV’s....foot IV’s don’t count!
Oxygen
2 liters crystalloid if hypotensive
Ddx bleeding
Melena:
Requires
>150ml blood
digested over
prolonged
period (~8h)
Pepto-bismol
(will not test
FOB positive)
Iron
Blueberries
 Hematochezia:
Only 5ml of blood required
to turn “toilet water bright
red”
 Beets

FOB testing
 False
False positives:
Red fruits/meats
Methylene blue
Chlorophyll
Iodide
Cupric sulfate
Bromide
negatives:
Rare!
 Bile
 Ingestion of Mg-containing
antacids
 Ascorbic acid

GIB investigations
CBC, INR/PTT, T+S, LFT’s
Remember, Hct lags behind clinical
picture, and is affected by hemodilution
Consider lytes, BUN, Cr
EKG
Upright CXR if suspect perf
UGIB management
GI—endoscopy
Gen Surg—operative (hemodynamically
unstable patients unresponsive to
conventional treatments)
or some suggest if > 5U blood in 1st 4
- 6 hrs...
Intervent Radiol—angio
UGIB and
endoscopy
Most accurate diagnostic tool
Identifies source in 78-95% of pts, when
performed within 12-24hrs post-UGIB
Allows for risk stratification (rebleeding and
mortality) as well as treatment (banding or
sclerosing of varices)
UGIB and
angiography
Detects location of UGIB in 2/3 of pts
Usually performed during active bleeding
Unstable vitals
Ongoing transfusion requirements
UGIB medications
PPI—pantoloc
Bolus 80mg then run @ 8mg/h x 72hrs
Role in pts with PUD as cause
Is an adjunct, not therapy for UGIB…still need
endoscopy
Somatostatin analogues—octreotide
Bolus 50ug then continuous infusion of 25 - 50ug/hr
Role in esophageal varices
Peptide analogue which causes splanchnic
vasoconstriction by direct effect on vascular smooth
Vasopressin ?
Has been used in pts with esophageal
variceal hemorrhages
No effect on overall mortality
High rate of complications (9% major, 3%
fatal)
Only role would be in exsanguinating pt,
with endoscopy or other measures
unavailable
SengstakenBlakemore tubes
Useful if esophageal
variceal bleeding
source
Linton tube if gastric
varices
High risk of
complications (14%
major, 3% fatal)
One of those lastditch efforts!
Insertion
techniques…
SB tubes…
Equipment:
Sterile Sengstaken-Blakemore
tube
Pair of scissors
50ml syringe
2 x rubber tipped artery
forceps

Precautions:

Balloon pressure should always
be <45mmHg
Pt should be intubated prior to
procedure
Keep scissors near bed at all
times (to cut tube prn if migrates
and causes resp distress)
Check tube placement by:


Water soluble lubricant
3 metres of white linen tape
Pressure gauge
Weight for traction
Pulley
PPE

• Aspirate and check pH
• Inject air and auscultate over stomach
• XR
SB tube
LGIB and scopes
Must r/o UGIB source first usually
If mild LGIB with no evidence of
hemorrhoids, then anoscopy /
proctosigmoidoscopy recommended
Absence of blood above rectum indicates
rectal source; however, blood above
rectum does not r/o rectal source
LGIB and
angiography
Does not usually diagnose cause of
bleeding, but identifies source in 40% of pts
Arterial embolization may be useful if
ongoing bleeding
Disposition
Very low risk (can be d/c’d home)
Low risk
Moderate risk
High risk
Very low risk
No comorbid disease
Normal vitals
Normal or trace FOB positive
+/- neg gastric aspirate
Normal (or near) Hgb/Hct
Good social situation
F/u within 24hrs
Understanding as to when to return…
Initial ED
stratification
Low Risk
Moderate Risk
Age <60
Age >60
Initial SBP ≥100 mm Hg
Initial SBP <100 mm Hg
Normal vitals for 1 hr
Mild ongoing tachycardia for 1 hr
No transfusion requirement
Transfusions required ≤4 U
No active major comorbid
diseases
Stable major comorbid diseases
No liver disease
Mild liver disease—PT normal or
near-normal
No moderate-risk or high-risk
clinical features
No high-risk clinical features
High Risk
Persistent SBP <100 mm Hg
Persistent moderate/severe tachycardia
Transfusion required >4 U
Unstable major comorbid diseases
Decompensated liver disease—i.e., coagulopathy,
ascites, encephalopathy
Final Stratification for Pt’s with UGIB after
endoscope combined with initial ED
stratification
Clinical Risk Stratification
Endoscopy
Low risk
hospitalization
Moderate risk
High risk
Low Risk
Immediate discharge[*]
24-hr patient stay[†]
Moderate Risk
High Risk
24-hr inpatient stay (floor)[†]
Close monitoring for 24 hr[‡];
≥48-hr
24–48 hr inpatient stay (floor)[†]
Close monitoring for 24 hr; ≥48hr hospitalization
Close monitoring for 24 hr; 48–72 Close monitoring for 24 hr; 48–72
hr hospitalization
hr hospitalization
Close monitoring ≥72-hr
hospitalization
So what does this
mean at FMC for
UGIB pts…
Low-risk pts:
Hold o/n in ED
until scoped
Consider
admission to
Hospitalist until
scoped
(depending on
GI suggestions)
 Med
risk pts:
Admit to
Hospitalist/Medicine until
scoped
 Scope immediately

 High
risk pts:
Scope immediately
 Admit to Medicine/ICU

Disposition LGIB pts
If not clearly due to hemorrhoids, fissures,
proctitis then should admit
Low risk: admit to Hospitalist with scoping
Med/High risk: admit to Medicine/ICU with
scoping +/- angio
Airway in GI Bleeds
Low threshold for capturing airway
Have suction (or two) ready
Extra hands
Follow the bubbles
Airway Rescue devices ready
Pearls
Elderly patients or those with underlying
CAD can present with ischemic chest pain
secondary to blood loss from GI bleed.
Don’t forget NSAID or EtOH hx
Correct coags ASAP
BUN is often elevated in UGI bleeds
secondary to absorption of blood from GI
tract and hypovolemia causing prerenal
Pearls
AAA repair and GI bleed need to r/o aortoenteric fistula
Fever and GI bleed consider aortoesophageal fistula
Resuscitate, resusciate, resuscitate