GI Bleeding Greg Rosenfeld St. Pauls Hospital Gastroenterology - - PowerPoint PPT Presentation
GI Bleeding Greg Rosenfeld St. Pauls Hospital Gastroenterology July 14, 2015 Outline Upper GI Bleeding Presentation Differential Diagnosis Medical + Endoscopic Treatment Peptic Ulcer Disease Variceal Bleeding
Presentation Differential Diagnosis Medical + Endoscopic Treatment Peptic Ulcer Disease Variceal Bleeding
Differential Diagnosis Investigation and Treatment
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
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
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
Hx: 84 year old male with hematemesis and melena stool for 24 hrs
Past medical history of hypertension, pacemaker for 3rd 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
1.
Outline your initial Management of this Man?
2.
How would you localize the source of the bleed?
1.
ie Is it upper or lower?
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/O2 sat/EKG
(vital signs + Hb)
HR > 100 BP < 100 30:20:10 Rule
Postural vitals:
HR > 30
BP Systolic > 20 mmHg and
When do you need to call ICU?
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
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
Syncope – 14% Presyncope – 43% Dyspepsia - 18% Epigastric pain - 40% Heartburn - 20%
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?
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
ABC’s History and Physical What next?
Bloodwork – CBC, Xmatch, LFTs, INR, Bun, Cr, IV PPI – 80 and 8 ? Octreatide (50ug/hr)
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.
Resuscitation prevent shock/death Stop the bleeding Prevent recurrent bleeding (risk highest in first 24 hours) Treat underlying risk factors Avoidance of precipitants
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.
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
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
Variable`` 1 2 3 Age (yr) <60 60–79 >80 Shock No shock (HR <100; SBP >100) Tachycardia (HR >100; SBP >100) Hypotension (SBP <100) Co-morbidity Nil major Cardiac failure (e.g., IHD) Renal failure, liver failure, disseminated malignancy Diagnosis (Endoscopy) M-W tear, no lesion, no SRH* All other diagnosis including ulcer etc. Malignancy of upper GI tract Major Stigmata (Endoscopy) None or dark spot Blood in upper GI tract, adherent clot, visible or 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 TA. Gut 1996;38:316-21
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
IV PPI initiated in ER Bloodwork/Crossmatch:
Hb 110, BUN 17.1, Cr 99
Endoscopy:
4 clean based ulcers PLUS 2cm ulcer 2nd part of duodenum Adherent clot washed away No active bleeding
Forrest JA. Lancet 1974; 2: 394-7 Laine L, Peterson WL. NEJM 1994; 331: 717-27
2 0 4 0 6 0 8 0
Clean base Flat spot Adhere nt clot Active bleeding % w ith Rebleeding Non- bleeding visible vessel
5 1 0 2 2 4 3 5 5
Low -risk lesions High-risk lesions
Rate of Rebleeding by Forrest Classification
III IIc IIb IIa Ia/ b
Peptic ulcer disease — 55% Esophagogastric varices — 14% AV malformations — 6% Mallory-Weiss tears — 5% Tumors and erosions — 4% each Dieulafoy's lesion — 1%
CURE
14% Variceal 86% Non-variceal
55% Peptic ulcer 6% Angiodysplasia 5% MW tear 4% Neoplasm 4% Erosions 1% Dieulafoy
RUGBE
100% Non-variceal
56% Peptic ulcer
47% GU 42% DU
10% Erosions 9% Esophagitis 25% Other
MW tear, angiodysplasia,
Dieulafoy, neoplasm
Savides TJ. Endoscopy 1996; 28: 244-8 Barkun A. Am J Gastroenterol 2004; 99: 1238-9
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
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
Shock – hematochezia Cause of bleed: Varices, UGI cancer Older age, Co-morbid diseases Onset in hospital
Severe coagulopathy, Recurrent bleeding
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
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.
Varices are portosystemic collaterals formed
after pre-existing vascular channels have been dilated by portal hypertension.
Most common in the distal 2-5 cm of the
esophagus, as it contains superficial veins that lack support from surrounding tissues, a feature consistent with the occurrence of prominent bleeding at this site.
Acute esophageal variceal bleeding constitutes a life-
threatening emergency.
Treatment is aimed at resuscitating the patient, correcting
coagulopathy, administration of Abx, controlling the bleeding, and preventing complications.
A combination of endoscopic therapy and
pharmacologic therapy of variceal bleeding may be superior to pharmacologic treatment alone & able to control bleeding in up to 90% of cases at intial treatment.
Start ASAP and continue for up to 5 days Choice of agents with evidence:
Somatostatin Octreotide Terlipressin Vasopressin plus nitroglycerin
Antibiotics have been shown to reduce mortality and
bacterial infections in patients with variceal bleeds
Bleeding cannot be controlled in approx 10% of patients, defined
by any of the following three factors:
(1) transfusion of four units of red blood cells or more
to maintain the hematocrit value between 25% and 30%;
(2) inability to increase the systolic blood pressure by
20 mm Hg or to greater than 70 mm Hg; or
(3) persistence of a heart rate greater than 100 beats
per minute.
Uncontrolled bleeding = 2 sessions of
endoscopic treatment in 24 hours
Balloon tamponade (Blakemore) Salvage therapy
TIPPS or Surgical Shunt
Hx: 80 year old male on a cruise to Alaska with sudden onset hematochezia followed by melena stool for 24 hrs
Past medical history of hypertension, MI, CAD and CKD On beta blocker, ASA, Plavix Non smoker, drinks “occasionally”
PE: Hemodynamically stable
No stigmata of liver disease Rectal: Maroon Colour stool
Transfused 2 U PRBC on the cruise Hgb 8857 given 4 U PRBC in ER but still has
bloody stool
Hgb now 78 How would you manage this man?
ABC’s Transfusion (evidence of ongoing brisk bleeding) EGD – no blood nor pathology to suggest upper
source
Colonoscopy
Maroon blood but unable to get beyond Splenic Flexure Repeat after prep – no source found
Distal to ligament of Treitz 11% of patients with hematochezia: from an
upper GI source
Clues hemodynamic instability, elevated
BUN, NGT aspirate bloody Melena – can be seen with proximal lower
GI bleeding (Right colon, distal small bowel)
Intermittent – up to 85% stop spontaneously LGIB frequency: increases 200-fold from 3rd to 9th decades of
life
Massive bleed usually age >60:
Mortality 30% 0.7% admissions to hospital
Diverticulosis — 33%
Diverticulosis — 33% Cancers/polyps — 19%
Diverticulosis — 33% Cancers/polyps — 19% Colitis/ulcers (IBD, infectious, ischemic, radiation) — 18%
UC
Diverticulosis — 33% Cancers/polyps — 19% Colitis/ulcers (IBD, infectious, ischemic, radiation) — 18% Angiodysplasia — 8%
Pre-treatment Post-treatment with APC
Diverticulosis — 33% Cancers/polyps — 19% Colitis/ulcers (IBD, infectious, ischemic, radiation) — 18% Angiodysplasia — 8% Miscellaneous (post-polypectomy, aorto-colonic fistula, stercoral
ulcer, anastomotic bleeding) — 8%
Painless
Diverticula Angiodysplasia Neoplasms
Painful
Ischemia Inflammatory Bowel Disease Infectious (E. coli, Campylobacter, Shigella etc) Hemorrhoids/Fissures
Age < 60:
Diverticula Neoplasms IBD
Age > 60:
Diverticula Neoplasms Angiodysplasia
Colonoscopy – Difficult to localize during active bleeding CT angiography
Detects rate of ≥ 1.0 mL/min Variable sensitivity with high specificity
RBC scan
Sensitive (80-90%) Detects ≥ 0.1 to 0.5 mL/min Relatively low specificity Poor localization
Resuscitate and stabilize Colonoscopy +/- EGD Angiography (+/- CT) – If unable to
RBC scan – If unable to localize @ colonoscopy Surgery – Last resort if ongoing hemorrhage with no answers
from the above investigations