approach to management of acute gi bleeddaumed.com/123/year 6/medicine/week 5/gi...
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Approach to Management of acute GI BleedDr. Bara AlMakadma
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Definition and Classification: • Intraluminal Blood Loss anywhere from the
oropharynx to the anus
• Upper = above the ligament of Treitz
• Lower = below the ligament of Treitz
• “Severe” GIB ➔ requires hospitalization: defined as:
• having associated shock,
• orthostatic hypotension,
• decreased Hct by 6% (or Hb by 2g/dL),
• or requiring transfusion of >= 2u pRBCs.
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Abbreviations
UGIB: upper GI bleeding
LGIB: lower GI bleeding
NSAID: non-steroidal anti inflammatory
ASA: aspirin (acetyl salicylic acid)
N/V: nausea/ vomiting
EtOH: ethanol
UOP: urine output
HCT: hematocrit
MCV: mean corpuscular volume
FFP: fresh frozen plasma
SBP: systolic blood pressure
H/O (h/o, or H/o): history of
LAN: lymphadenopathy
EGD: endogastroduodenoscopy
IR interventional radiology
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Clinical Manifestations
• Hematemesis: blood in vomitus (UGIB)
• Coffee-ground emesis: blood exposed to gastric acid (UGIB)
• Melena: black, tarry stools from digested blood (usually UGIB, but can be from R. colon)
• Hematochezia: bloody or maroon-colored stools (LGIB) or rapid UGIB)
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Initial ManagementApproach
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Assess severity
Vital signs including orthostatic changes,
JVP
Tachycardia: can be masked by beta blocker use ➔ suggests 10% volume loss,
Orthostatic hypotension: 20% volume loss
Sock: > 30% volume loss
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History
• Prior GIB
• Tempo of current bleed (how strong is it)
• Specific bleeding manifestations (such as ones outlined in clinical manifestations)
• Prior GI signs and symptoms• Abdominal pain• Changes in bowel habits• Weight loss• N/V
• NSAID/ASA use
• EtOH use
• Anticoagulation, antiplatelet drugs
• H/o or risk factors for cirrhosis
• Radiation
• Prior GI or aortic surgery
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Physical Examination• Localizable abdominal tenderness
• Peritoneal signs
• Masses
• LAN
• Prior surgery signs
• Signs of liver disease
• Hepatosplenomegaly
• Ascites
• Jaundice
• Telangiectasias
• Rectal examination: masses, hemorrhoids, anal fissures and
• stool appearance, color, and stool for occult blood
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Resuscitation
Placement of 2 large-bore (18-gauge or larger) intravenous
lines
Volume replacement: NS or LR to achieve
normal VS, UOP, and mental status
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Lab studies
Hct (may be normal in first 24 hours of acute GIB before equilibration
2-3% decrease ➔ 500 mL blood loss
low MCV ➔ Fe deficient and chronic blood loss
Plt, PT, PTT
BUN/Cr (ratio > 36 in UGIB because GI resorption of blood +/- prerenal azotemia)
LFTs
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Transfuse
Blood sample for type and cross match
Use O-negative if emergent; for UGIB (esp. with
portal HTN)
transfuse with more
restrictive Hb goal (e.g. 7
g/dL)
or > 8 g/DL if CAD
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Reverse coagulopathy
FFP and Vitamin K to normalize PT
Platelets to keep count
above 50,000
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From the moment of Triage
Alert endoscopist Consider ICU if unstable vital signs or poor end organ perfusion (signs of shock)
Intubation for emergent EGD if:
Ongoing hematemesis
Shock
Poor respiratory status
Changes in mental status
Out-patient management can be considered if all of the following conditions are met: SBP > 110, HR <100, Hb >=13, 12 (male and female respectively), BUN <18, no melena, no syncope, no heart failure, no liver disease
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Diagnostic Studies
Approach
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Nasogastric tube
• Can aid localization: by observing whether it is fresh blood or coffee grounds ➔ active vs recent bleed UGIB
• Nonblood gastric material ➔ does not exclude UGIB (about 15% are missed)
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Diagnostic studies for UGIB
• EGD within 24 hours
• If severe bleed ➔ increase your diagnostic and treatability yield by gastric lavage and
• erythropoietin 250 mg IV 30 minutes prior to endoscopy ➔ significantly accelerates correction of anemia after acute bleed
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Diagnostic studies of LGIB
• Colonoscopy: identifies cause in > 70%
• If severe, colonoscopy within 12 hours
• Colon has to be “prepared” – to have a clear field of vision: i.e. cleared of fecal matter: therefore:
• consider rapid purge with polyethylene glycol electrolyte solution (a laxative a.k.a. PEG) solution to be given 6-8L over 4 to 6 hours
• If hematochezia is associated with orthostasis: you have tobe concerned for brisk UGIB ➔ and exclude UGIB with an EGD first.
• If no yield: consider push enteroscopy • Capsule
• Anoscope
• Conclusion: endoscopy in combination with urgent colonoscopy results in diagnosis in more than 95% of patients
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Imaging
• If too unstable for endoscopy or recurrent bleeding: consider interventional radiology procedure
• Note the advent of endoscopic ultrasound
• Otherwise: surgery
• Tagged RBC scan: can identify general luminal location if bleeding rate more than 0.04 mL/min
• Arteriography: can localize exact vessel if bleeding rates >= 0.5 mL/min and allows for IR treatment
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Last Resort diagnostic study (that is naturally also a chance for immediate
treatment)
Emergent exploratory laparotomy is the last resort if no localization by all previous studies and life-threatening
bleed
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Upper GI bleed by Etiology
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UGIB causes; Treat the cause
• PUD: 20-67% of cases
• Erosive gastropathy : 4-31% of cases
• Erosive esophagitis : 5-18% of cases
• Esophageal or gastric varices: 4-20% of cases
• Portal HTN gastropathies:
• Vascular causes:
• Angioectasia AVMs, HHT, Dieulafoy’s lesion
• Gastric antral vascular ectasia (GAVE)
• Aortoenteric fistula: life threatening potential
• Malignancy: 2-8% of cases
• Mallory-Weiss tear 4-12% of cases
• Cameron’s lesions
• Post-sphincterotomy bleeding
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LGIB causes; Treat the cause
• Diverticular bleed (30%)
• Polyp? Tumor (20%)
• Colitis (20%)
• Anorectal disorders (20%)
• Vascular (<10%)
• Meckel’s diverticulum
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OBSCURE GIB
Definition: continued bleeding despite negative EGD and negative colonoscopy. manifested as:
Melena
Hematochezia
Seen in 5% of patients.
Etiologies:
Dieulafoy’s lesion
GAVE
Small bowel angiodysplasia
Ulcer or cancer
Crohn’s disease
Aortoenteric fistula
Meckel’s diverticulum
Hemobilia
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How to diagnose obscure GIB
• MONITOR: as soon as bleeding becomes active ➔ while the patient is bleeding repeat EGD with push enteroscopy and/or colonoscopy
• If still negative: video capsule to evaluate the small intestines
• If still negative consider Tc pertechnetate scan (Meckel’s scan), enteroscopy (single balloon, double balloon
• Tagged RBC scan and arteriography
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References
• (NEJM 2013:368:11)
• (Lancet 2009:373:42)
• Pocket Medicine
• (AmjGauro 2006:101:121)
• (AmJGostro 2015:110:1265 & 2016:111:755)
• (Gostro 2007:133:1694;CIE 2010:72:471)
• Kumar
• Google images