GI Bleeding Greg Rosenfeld St. Paul’s Hospital Gastroenterology July 14, 2015
Outline � Upper GI Bleeding � Presentation � Differential Diagnosis � Medical + Endoscopic Treatment � Peptic Ulcer Disease � Variceal Bleeding � Lower GI Bleeding � Differential Diagnosis � Investigation and Treatment
Additional Reference Management of Acute Bleeding from a Peptic Ulcer Ian M. Gralnek, M.D., M.S.H.S., Alan N. Barkun, M.D., C.M., M.Sc., and Marc Bardou, M.D., Ph.D. N Engl J Med 359;9 August 28, 2008
Upper GI Bleed � Proximal to Ligament of Treitz � Approximately 4 times as common as LGIB � Mortality rates from UGIB are 6-10% overall Fallah MA et al. Med Clin North Am 2000;84:1183-208
Ligam ent of Treitz
Epidemiology of Upper Gastrointestinal Bleeding � Incidence � 170 cases /100,000/year � 2 Male : 1Female � Mortality: � 5-10% � 0.6% if age <60 � 40% if rebleeding Rockall TA Gut 1996; 38: 316-21 Laine L. Gastroenterology 2002; 123: 632 Marshall JK. Am J Gastroenterol 1999; 94: 1841 Marshall JK. J Clin Gastroenterol 1999; 29: 165 Kupfer. Gastroenterol Clin North Am 2000; 29: 275
Case Summary: Hx: 84 year old male with hematemesis and melena stool for 24 hrs � Past medical history of hypertension, pacemaker for 3 rd degree AVB � Admitted for pacemaker change due to infection � On beta blocker, ASA � Non smoker, drinks “occasionally” PE: Hemodynamically stable � No stigmata of liver disease � Rectal: Melena
Outline your initial Management of this Man? 1. How would you localize the source of the bleed? 2. ie Is it upper or lower? 1.
Initial Management: ABC’s � Airway : Intubation ? � Massive upper GI bleed � Decreased mental status, unstable cardioresp � Circulation : 2 large bore IVs � ? Central line access � Resuscitate and Stabilize � Monitored Setting: BP/O 2 sat/EKG � (vital signs + Hb)
Hypovolemia � HR > 100 � BP < 100 � 30:20:10 Rule � Postural vitals: � HR > 30 � � BP Systolic > 20 mmHg and Diastolic > 10 mmHg � � When do you need to call ICU?
Resuscitation � ICU Consult: � Hemodynamic instability (shock) � Decrease in hematocrit > 6%, transfusion requirement > 2 units packed rbcs � Brisk active bleeding (hematemesis, bright red blood per NG tube, or hematochezia) � Correct Coagulopathy : � INR > 1.5, plts < 50 � FFP, cryoprecipitate, platelets � Dabigatran: ? PTT. Consider Octaplex
Secondary Management � Go back and get the details once the patient is stabilized � What are the history features you want to know? � Physical Exam?
History � Risks for UGIB : EtOH, NSAIDS, liver disease, prior PUD, prior bleeds, Prior HP � Previous investigations, recent CBC, Cardiorespiratory Hx, prior endoscopy � Family Hx: Gastric cancer � Duration of symptoms: CP, syncope, pre-syncope, SOB, Hx of melena, hematochezia � Meds: anticoagulation
UGIB: Presenting Symptoms Hematemesis - 40-50% � Melena - 70-80% � Hematochezia - 20% � Either hematochezia or melena: 90-98% � � Syncope – 14% � Presyncope – 43% � Dyspepsia - 18% � Epigastric pain - 40% � Heartburn - 20% Peter DJ et al. Emerg Med Clin North Am 1999;17:239-61 �
Physical Exam � Posturals, Resting HR, CardioResp exam � Stigmata of CLD � Stigmata of hereditary syndromes for risk of UGIB � RECTAL: colour of stool, rectal masses � When is FOB necessary?
Upper GI Bleed � Melena – 50-100 mL (blood in GIT >14 hrs) � Hematochezia – 1000 mL � ↑ BUN / Cr ratio � Stool color not reliable indicator of the location of bleeding � Hematochezia from upper GI bleeding: massive bleeding with shock and/or orthostasis
Management � ABC’s � History and Physical � What next? � Bloodwork – CBC, Xmatch, LFTs, INR, Bun, Cr, � IV PPI – 80 and 8 � ? Octreatide (50ug/hr) � Endoscopy?
Timing of Endoscopy � Early Endoscopy � But what is early? � < 24 hours � Early Endoscopy and risk classification � Safe and prompt D/C of low risk pts � Improves outcomes for high risk pts � Reduces use of resources for high and low risk pts. Barkun et al. , Ann Intern Med. 2010; 152: 101-113.
Goals of Management � Resuscitation � prevent shock/death � Stop the bleeding � Prevent recurrent bleeding � (risk highest in first 24 hours) � Treat underlying risk factors � Avoidance of precipitants
Outcome of UGI Bleeding: � 80% stop spontaneously � 20% continue to bleed or re-bleed � Bulk of resource consumption � Highest morbidity/mortality � 5-10% die … must identify early those at increased risk of rebleeding, morbidity, mortality to in order to optimize management and improve outcomes.
Risk Stratification � Clinical parameters ( Blatchford ) � Blood urea nitrogen � Hemoglobin � Systolic blood pressure � Pulse � Presence of melena � Syncope � Hepatic disease, and cardiac failure � Score 0 to 14: risk of requiring endoscopic intervention increases with higher score Blatchford et al. Lancet . 2000 Oct 14;356(9238):1318-21
Blatchford Scoring System � No endoscopic findings � Identifies patients at low and high risk of needing an intervention � Transfusion or � Surgery or � Endoscopic therapy Blatchford O. Lancet 2000; 356: 1318-21
Rockall Scoring System for Severity of Acute UGIB Variable`` 0 1 2 3 Age (yr) <60 60–79 >80 No shock Tachycardia Hypotension Shock (HR <100; (HR >100; (SBP <100) SBP >100) SBP >100) Renal failure, Cardiac failure liver failure, Co-morbidity Nil major (e.g., IHD) disseminated malignancy M-W tear, Diagnosis All other diagnosis Malignancy of no lesion, including ulcer etc. upper GI tract (Endoscopy) no SRH* Blood in upper GI Major Stigmata None or tract, adherent dark spot clot, visible or (Endoscopy) spurting vessel Score <2 ( low risk ) � excellent prognosis (1 in 744 patients) Score >8 � high risk of death Rockall TA. Gut 1996; 38: 316-21 Vreeburg EM. Gut 1999: 44: 331-5
Rockall Score: Risk of Rebleed and Death % Rockall TA. Gut 1996;38:316-21
Rockall Score � Clinical: � Age � Pulse > 100 bpm � BP < 100 � Comorbidity: CHF, CAD, renal/liver disease, disseminated malignancy � Endoscopic Diagnosis: � High risk Stigmata, blood in upper GI tract Rockall et al. Lancet 1996; 347:1138-40
Case Sum m ary: IV PPI initiated in ER Bloodwork/Crossmatch: � Hb 110, BUN 17.1, Cr 99 Endoscopy: � 4 clean based ulcers PLUS � 2cm ulcer 2 nd part of duodenum � Adherent clot washed away � No active bleeding
Rate of Rebleeding by Forrest Classification 8 0 Low -risk High-risk % w ith Rebleeding lesions lesions 5 5 6 0 4 3 4 0 2 2 2 0 1 0 5 0 Clean Flat Adhere Non- Active base spot nt clot bleeding bleeding visible vessel III IIc IIb IIa Ia/ b Forrest JA. Lancet 1974; 2: 394-7 Laine L, Peterson WL. NEJM 1994; 331: 717-27
Causes of UGI Bleeding � Peptic ulcer disease — 55% � Esophagogastric varices — 14% � AV malformations — 6% � Mallory-Weiss tears — 5% � Tumors and erosions — 4% each � Dieulafoy's lesion — 1% Jutabha R et al. Med Clin North Am. 1996;80(5):1035 �
Source of UGI Bleeding CURE RUGBE � 14% Variceal � 100% Non-variceal � 56% Peptic ulcer � 86% Non-variceal � 47% GU � 55% Peptic ulcer � 42% DU � 6% Angiodysplasia � 10% Erosions � 5% MW tear � 9% Esophagitis � 4% Neoplasm � 4% Erosions � 25% Other � 1% Dieulafoy � MW tear, angiodysplasia, Dieulafoy, neoplasm Savides TJ. Endoscopy 1996; 28: 244-8 Barkun A. Am J Gastroenterol 2004; 99: 1238-9
Summary � Most patients will have visible signs of blood loss � Stool color not a reliable indicator of location of bleeding � Most common cause of UGI bleed is Peptic Ulcer disease: incidence may be declining � ABC’s � Stabilize before Endoscopy � Medical Management: Pantoloc or Octreotide
Summary � Risk Stratification: Blatchford and Rockall � Forrest Classification: Endoscopic Stigmata � Evidence for IV Proton Pump Inhibitors � After Ulcer with high risk stigmata x 72 hrs � Lau et al. NEJM 2000 � Before Endoscopy to downstage Ulcer � Lau et al. NEJM 2007
High Risk Patients � Shock – hematochezia � Cause of bleed: Varices, UGI cancer � Older age, Co-morbid diseases � Onset in hospital � Severe coagulopathy, Recurrent bleeding
Case Summary
Case Summary
Had Enough Yet?
Variceal Hemorrhage
Natural History � 10 – 30% of all UGIB’s. � Occurs in 40% of cirrhotics & in as many as 60% of pts with cirrhosis & ascites. � Varices – Portosystemic collaterals, usually in distal esophagus.
� The risk of death with acute variceal bleeding is 5% to 8% at one week and about 20% at six weeks. � Patients who rebleed early, have a MELD score >18, require >4 units of packed red blood cell transfusions, and in whom renal failure develops have the highest risk of death.
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