gi bleeding
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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 ofTreitz
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 risk, mortality increase with age
Previous bleeding Comorbidities
CAD heart failure AAA repair liver disease
Previous endoscopies (look at reports!) Associated symptoms
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
how often to check? goal H+H? may take up to 72 hrs to equilibrate
Platelets goal platelet count?
Renal function panel BUN/Cr ratio
see increased BUN in UGIB due to absorbed blood proteins ratio usually > 20:1
Coags 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
epistaxis hemoptysis
Medications 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 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!
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