Download GI Bleeding Jeopardy!

Document related concepts
no text concepts found
Transcript
GI Bleeding Jeopardy!
UGIB therapy
LGIB
Clinical stuff
General mgmt
Potpourri
10
10
10
10
10
20
20
20
20
20
30
30
30
30
30
40
40
40
40
40
50
50
50
50
50
These are your first 3 initial
management priorities given a 51y M
currently vomiting blood, has vomited
~1L blood with EMS
VS: 125, 88/57
A: maintaining
B: adequate
C: vomiting blood, VS as above
Brisk UGIB Management
1) Protection! – gown, gloves, face shield
2) Monitors, O2, IV x 2 (at least 18G)
3) Initial fluids?
• NS vs blood
• pRBC if ongoing vomiting or VS don’t improve
These are the top 3 medications you
might order for a patient with an UGIB
UGIB Pharmacotherapy
• Gastric acid suppression
• Pantoloc 80mg IV then 8mg/h infusion
• Somatostatin analogue
• Octreotide 50ug IV then 50ug/hr infusion
• Abx
• Ceftriaxone 1g IV
•What’s the point?
UGIB Pharmacotherapy
• PPI’s
• Improve clot formaion and breakdown
• Leontiadis GI et al. Cochrane rev Nov 2006
• re-bleeding risk (OR 0.49 (0.37-0.65))
• need for surgery (OR 0.61 (0.48-0.78))
• mortality in bleeding pts (OR 0.53 (0.31-0.91))
• No effect on overall mortality
• H2-blockers not shown to have same benefit
UGIB Pharmacotherapy
• Octreotide
• Causes splanchnic vasoconstriction
portal venous pressures
rebleeding
• Imperiale et al. Ann Intern Med 1997;127:1062-71
• Similar control of bleeding varices as EGD
• risk of continued bleeding in PUD (RR 0.53;)
UGIB Pharmacotherapy
• Antibiotics
In cirrhosis (Soares-Weiser et al. Cochrane rev, 2002):
• infectious complications (RR 0.40 (0.31-0.51))
• mortality (RR 0.66 (0.49-0.88))
• rebleeding
• No evidence that abx need to be started in the ED
This is the indication for using vasopressin
in UGIB, and its mechanism of action
UGIB Pharmacotherapy
• Vasopressin
• 20U IV over 20min then 0.2-0.4U/min
• Constricts mesenteric arterioles
• No mortality benefit (?mortality)
• Complication rate
• 9% major (myocardial, cerebral, bowel, limb ischemia)
• 3% fatal
• Indication
• Can try in exsanguinating patient with ?variceal
bleeding if EGD not available
This is what the acronym
“TIPS” stands for
Transjugular Intrahepatic Portosystemic Shunt
• Interventional radiology
• Connection between
• Hepatic vein
• Intrahepatic portion of portal vein
• Indication?
• Continued bleeding despite Rx/EGD
The rate of major complications from this
procedure is 15%, and the rate of fatal
complications is 3%
Linton tube
• Major complications
• Mucosal ulceration, tracheal compression, aspiration
pneumonia, esophageal/gastric rupture, asphyxiation
• Consider if exsanguinating patient with ?variceal
bleeding and EGD not immediately available
• Temporizing measure until EGD/surgery/TIPS
• Anything you need to do before putting it in?
• Need to secure A/W
The type of stool usually seen in LGIB
Stool – LGIB vs UGIB
• Hematochezia
• Usually LGIB (10% UGIB)
• Melena
• Need 200mL blood x 8hrs (70% UGIB)
These are 3 causes of false +ve
Hemoccult tests
FOB Testing
• False +ve
• Red fruits, meats, methylene blue, chlorophyll,
iodide, cupric sulfate, bromide
• What about iron? Pepto-Bismol?
• Not causes of false +ve
• False –ve?
• Bile, Mg-containing antacids, ascorbic acid
FOB Testing
• What about testing coffee ground emesis?
• Hemoccult are pH dependent
• Antacids/vitamin C cause false –ve
• False +ve with copper/iron salts
• +ve result can usually be trusted
This is the type of physician you will consult
and the urgency in the following patient with
hematemesis & hematochezia:
61y F
PMH: A.fib, NIDDM, HTN, AAA (repair 2y ago)
Rx: warfarin, metformin, glyburide
Hematochezia/hematemesis After AAA Repair
• ?Aortoenteric fistula
• STAT consult to vascular surgery!
• Incidence of up to 4% post-repair
• Usually presents as UGIB
• Aortoduodenal fistula
They are 3 investigation modalities that can
be used to help localize LGIB
LGIB Localization
• Scope
• Anoscopy
• Sigmoidoscopy/colonoscopy
• Angiography
• Requires 0.5cc/h bleeding
• ID’s site in 40%
• Radionuclide scan
• Technetium labeled RBC’s
• Need 0.1cc/h bleeding
These are the 3 main causes of painful
LGIB
Painful Rectal Bleeding
• Ischemic colitis
• Infectious colitis
• Inflammatory colitis
• 5 bacteria causing bloody colitis?
• E. coli
• Campylobacter
• Yersinia
• Salmonella
• Shigella
• C. difficile
These are 3 risk
factors for poor
outcome in UGIB
Risk factors for poor outcome (UGIB)
• Age > 60y
• Coagulopathy
• Liver failure
• Cardiac disease
• Severe bleeding
The 3 of these are responsible for 75%
of all UGIB
Differential diagnosis of UGIB
• Esophageal/gastric varices
• PUD
75%
• Gastritis/gastric erosions
• Esophagitis
• Mallory-Weiss tear
• Gastric CA
• Aortoenteric fistula
• Angiectasias
• Osler-Weber-Rendu syndrome
Differential diagnosis of UGIB
• 10% of GIB patients have no identifiable
source
The 2 of these are responsible for 80%
of all LGIB
Differential diagnosis of LGIB
• Diverticulosis
• Angiodysplasia
• Malignancy
• UGIB
• Polyps
• IBD
80%
• Infectious colitis
• Ischemic colitis
• Radiation colitis
• Anorectal varices
• Aortoenteric fistula
• Perianal disease
• Hemorrhoids
• Fissure
• Trauma
These are 4 things that could be the
cause of your patient’s dark stools
DDx Melena
• UGIB
• High LGIB
• Swallowed blood (epistaxis, etc)
• Iron
• Bismuth (Pepto-Bismol)
• Food products (eg. blueberries)
The utility of postural vital signs and
capillary refill in predicting
hypovolemia
Physical Exam Skills
• Postural vital signs
• HR by 20bpm sustained
• 98% specific for significant blood loss in GIB
• sBP by 20mmHg
• 97% specific for significant blood loss in GIB
• CR > 2-3sec
• 10% SN for significant hypovolemia
These are the investigations you order for
the patient with a brisk UGIB
UGIB investigations
• CBC, T&S, INR/PTT
• Lytes, BUN, Cr
• ±ALT, ALP, bili, GGT
• ECG?
• CAD hx, age > 50, CP, SOB, hypotension
• CXR?
• If ?aspiration or ?perforation
They are the 3 specialties that you might
have to consult with a GIB (other than ICU)
HELP!
• GI
• Scope
• Interventional radiology
• TIPS
• Angiography
• General surgery
• Anyone else?
• Vascular surgery
This is the likely source of bleeding
(UGIB vs LGIB) in the following patient:
72y M, PMH: HTN, OA, A.fib; Meds: ?
Hematochezia x 5 episodes over 90min
VS: 112, 81/40, 22, 370
Hematochezia + Shock
• Hematochezia + shock = UGIB
• Rapid transit
This is the utility of NG tube insertion in
the patient with blood per rectum
NG tube in patient with bloody stools?
• If +ve blood
• UGIB
• LGIB + oral/nasal mucosal bleed
• If –ve blood
• UGIB + bleeding stopped, duodenal blood
• 10% of UGIB have –ve NG aspirate
• LGIB
•Bottom line
• Not diagnostic…not helpful
This is the expected rise in Hb and Hct
for 2U pRBC
Transfusion Facts
• 1U pRBC (if no ongoing bleeding)
• Hb by 10mmol/L
• Hct by 3%
They are 3 risk factors for ischemic
colitis
Painful Rectal Bleeding
• Risk factors for ischemic colitis?
• Dysrhythmia
• CAD
• Heart failure
• Prolonged hypotension
• Marathon running
They are 2 potential future diagnostic
modalities for GIB
Future Diagnosis
• CT/MRI reconstruction “endoscopy”
• Wireless capsule endoscopy
These are the GIB patients you can send
home from the ED
Disposition
• Very low risk (d/c home)
• No comorbidities
• N VS
• N/trace + FOB
• NG aspirate –ve if done
• Home support in place
• Understand symptoms sig bleed
• Easy access to ED
• F/U within 24h
Risk Stratification
Risk Stratification
They are the 2 potential causes of an
increased BUN in the GIB patient
Increased BUN
• Prerenal azotemia
• Digested blood
It is much more likely to be your diagnosis
in a patient with hematochezia and a
history of cirrhosis
(and it’s not brisk UGIB)
Liver Disease and LGIB
• Anorectal variceal bleeding
• Superior hemorrhoidal veins and
middle/inferior hemorrhoidal veins
Rules:
• Teams decide how much to wager
• Each team pick one skilled participant
• Participants leave the room for setup of
Final Jeopardy!
Task:
• Race to fill the Linton tube
with 600cc air
• Opposing team counts cc’s