Transcript Document 7754843

Gastrointestinal Bleeding
Rajeev Jain, M.D.
GI Bleeding
• Clinical Presentation
• Acute Upper GI Bleed
• Acute Lower GI Bleed
Core Principles in
GI Bleeding Management
• Assessment and stabilization of
hemodynamic status
• Determine the source of bleeding
• Stop active bleeding
• Treatment of underlying abnormality
• Prevent recurrent bleeding
GI Bleeding Management
Definitions
Hematemesis: bloody vomitus (bright red or
coffee-grounds)
Melena: black, tarry, foul-smelling stool
Hematochezia: bright red or maroon blood
per rectum
Occult: positive stool occult test
Symptoms of anemia: angina, dyspnea, or
lightheadedness
GI Bleeding Management
Patient Assessment
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Hemodynamic status
Localization of bleeding source
CBC, PT, and T & C
Risk factors
– Prior h/o PUD or bleeding
– Cirrhosis
– Coagulopathy
– ASA or NSAID’s
GI Bleeding Management
Initial Patient Assessment
Vital Signs
Blood Loss
Severity of GI
Bleed
Shock
20-25%
Massive
10-20%
Moderate
<10%
Minor
(resting hypotension)
Postural
(orthostatic hypotension)
Normal
GI Bleeding Management
Resuscitation
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2 large bore peripheral IV’s
Normal saline or LR
Packed RBCs
Correct coagulopathy
GI Bleeding Management
Location of Bleeding
• Upper
– Proximal to Ligament of Treitz
– Melena (100-200 cc of blood)
– Azotemia
– Nasogastric aspirate
• Lower
– Distal to Ligament of Treitz
– Hematochezia
Acute UGIB
Demographics
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Over 400,000 admissions annually
80% self-limited
Mortality 10-14%
Continued or recurrent bleeding - mortality 3040%
• Nonvariceal UGIB w/o complication*
– Mean LOS 2.7 days, $3402 (2008 $)
• Nonvariceal UGIB with complication*
– Mean LOS 4.4 days, $5632 (2008 $)
Adam V, Barkun A. Value Health. 2008;11:1-3.
Risk
Stratification
Scoring
Systems
Rockall Score
Blatchford Score
UGIB Risk Stratification – AIMS65
• Large clinical
database CareFusion
• 187 US hospitals
• Recursive partitioning
• 2004-5 29,222 pts to
derive risk score
• 2006-7 32,504 pts to
validate
• Albumin < 3.0 g/dL,
• INR > 1.5,
• Altered mental
status,
• Systolic blood
pressure 90 mm Hg
or lower, and
• Age older > 65
years.
Saltzman JR et al. Gastrointest Endosc 2011:1215-22.
UGIB Risk Stratification – AIMS65
Saltzman JR et al. Gastrointest Endosc 2011:1215-22.
Acute UGIB
Differential Diagnosis
Major Causes
• Peptic ulcer disease
– Gastric ulcer
– Duodenal ulcer
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Mallory-Weiss tear
Varices
Esophagitis
Dieulafoy’s lesion
Vascular anomalies
Malignancy
Minor Causes
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Post-procedural
Cameron’s lesions
Hemobilia
Hemorrhagic
gastropathy
• Aortoenteric fistula
Peptic Ulcer Disease
Forrest Class
Stigmata
IA
Arterial spurting
IB
Arterial oozing
IIA
Visible vessel
IIB
Adherent clot
IIC
Pigmented flat spot
III
Clean based
Forrest JA, Finlayson ND, Shearman DJ: Endoscopy in gastrointestinal bleeding. Lancet 1974; 2:394-7
Endoscopic Appearance
of Ulcers
Clean based ulcer
Nonbleeding visible vessel
Risk Stratification after
Endoscopy
Prognostic Features at Endoscopy in
Acute Ulcer Bleeding
Endoscopic Therapy of PUD
• Thermal
– Bipolar probe
– Monopolar probe
– Argon plasma
coagulator
– Heater probe
• Mechanical
– Hemoclips
– Band ligation
• Injection
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Epinephrine
Alcohol
Ethanolamine
Polidocal
Endoscopic Therapy of PUD
Laine and Peterson New Eng J Med 1994;331:717-27.
Risk of Recurrent Bleeding
after Endoscopic Therapy
Effect of Proton-Pump Inhibition
on Peptic Ulcer Bleeding
Gralnek et al. New Eng J Med 2008;359:928-37.
Management of PUD
after EGD in High Risk Pts
• Proton-pump inhibitor 80 mg IV bolus dose plus
continuous infusion for 72 hrs
• Admit to monitored bed or ICU setting
• Initiate oral intake of clear liquid diet 6 hrs after EGD
in pts with hemodynamic stability
• Transition to oral PPI after completing IV course
• Perform testing for H. pylori infection
• For selected patients, discuss need for NSAIDs and
antiplatelet therapy
Gralnek et al. New Eng J Med 2008;359:928-37.
Management of PUD
after EGD in Low Risk Pts
• Oral proton-pump inhibitor
• Initiate oral intake with a regular diet 6 hrs
after EGD in pts with hemodynamic stability
• Perform testing for H. pylori infection
• For selected patients, discuss need for
NSAIDs and antiplatelet therapy
• Consider early discharge in selected pts
Gralnek et al. New Eng J Med 2008;359:928-37.
Mallory-Weiss Tear
Esophageal Varices
Management of
Acute Variceal Bleeding
Suspected Variceal Bleeding
Octreotide 50 ug bolus, 50 ug/hr
Conservative blood volume resuscitation
Antibiotics
Endoscopy
Band ligation or sclerotherapy
Continue Octreotide for 5 days
Early rebleeding
Failure to control
TIPS or surgery
Antibiotic Prophylaxis in GI
Bleeding in Cirrhotic Patients
• Fluoroquinolones or amoxicillin +
clavulinic acid
• Meta-analysis 1
– Decrease rates of infection
• SBP, bacteremia
– Increased short-term survival
• RCT 2
– Reduction in early rebleeding
1.Bernard et al.Hepatology. 29(6):1655-61.1999.
2.Hou et al. Hepatology. 39(3):746-53.2004.
Variceal Band Ligation
Transjugular Intrahepatic
Portosystemic Shunt (TIPS)
IVC
Coronary Vein
Splenic Vein
Portal Vein
Aortoduodenal Fistula
Aorta
Duodenum
Fistula
Graft
Acute UGIB
Surgery
• Recurrent bleeding despite endoscopic
therapy
• > 6-8 units pRBCs
Management of Ulcer Bleeding: ACG
Guidelines
Initial Assessment and Risk Stratification
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Hemodynamic status should be assessed immediately upon presentation
and resuscitative measures begun as needed (Strong recommendation).
Blood transfusions should target Hgb ≥ 7 g / dl, with higher Hgbs targeted in
patients with clinical evidence of intravascular volume depletion or
comorbidities, such as coronary artery disease (Conditional
recommendation).
Risk assessment should be performed to stratify patients into higher and
lower risk categories and may assist in initial decisions such as timing of
endoscopy, time of discharge, and level of care (Conditional
recommendation).
Discharge from the ED without inpatient endoscopy may be considered in
patients with urea nitrogen < 18.2 mg / dl; Hgb ≥ 13.0 g / dl for men (12.0 g /
dl for women), systolic blood pressure ≥ 110 mm Hg; pulse < 100 beats /
min; and absence of melena, syncope, cardiac failure, and liver disease, as
they have < 1 % chance of requiring intervention (Conditional
recommendation).
Laine & Jensen Am J Gastroenterol 2012; 107:345–360
Management of Ulcer Bleeding: ACG Guidelines
Pre-endoscopic interventions
• Intravenous infusion of erythromycin (250 mg ~ 30 min before
endoscopy) should be considered to improve diagnostic yield and
decrease the need for repeat endoscopy. However, erythromycin
has not consistently been shown to improve clinical outcomes
(Conditional recommendation).
• Pre-endoscopic intravenous PPI (e.g., 80 mg bolus followed by 8 mg
/ h infusion) may be considered to decrease the proportion of
patients who have higher risk stigmata of hemorrhage at endoscopy
and who receive endoscopic therapy. However, PPIs do not improve
clinical outcomes such as further bleeding, surgery, or death
(Conditional recommendation).
• If endoscopy will be delayed or cannot be performed, intravenous
PPI is recommended to reduce further bleeding (Conditional
recommendation).
• Nasogastric or orogastric lavage is not required in patients with
UGIB for diagnosis, prognosis, visualization, or therapeutic effect
(Conditional recommendation).
Laine & Jensen Am J Gastroenterol 2012; 107:345–360
Management of Ulcer Bleeding: ACG Guidelines
Timing of endoscopy
• Patients with UGIB should generally undergo endoscopy
within 24 h of admission, following resuscitative efforts to
optimize hemodynamic parameters and other medical
problems (Conditional recommendation).
• In patients who are hemodynamically stable and without
serious comorbidities endoscopy should be performed as
soon as possible in a non-emergent setting to identify the
substantial proportion of patients with low-risk endoscopic
findings who can be safely discharged (Conditional
recommendation).
• In patients with higher risk clinical features (e.g., tachycardia,
hypotension, bloody emesis or nasogastric aspirate in
hospital) endoscopy within 12 h may be considered to
potentially improve clinical outcomes (Conditional
recommendation).
Laine & Jensen Am J Gastroenterol 2012; 107:345–360
Management of Ulcer Bleeding: ACG Guidelines
- Endoscopy
• Stigmata of recent hemorrhage should be recorded as they predict risk
of further bleeding and guide management decisions. The stigmata, in
descending risk of further bleeding, are active spurting, non-bleeding
visible vessel, active oozing, adherent clot, fl at pigmented spot, and
clean base (Strong recommendation).
• Endoscopic therapy should be provided to patients with active spurting
or oozing bleeding or a non-bleeding visible vessel (Strong
recommendation).
• Endoscopic therapy may be considered for patients with an adherent
clot resistant to vigorous irrigation. Benefi t may be greater in patients
with clinical features potentially associated with a higher risk of
rebleeding (e.g., older age, concurrent illness, inpatient at time bleeding
began) (Conditional recommendation).
• Endoscopic therapy should not be provided to patients who have an
ulcer with a clean base or a fl at pigmented spot (Strong
recommendation).
Laine & Jensen Am J Gastroenterol 2012; 107:345–360
Management of Ulcer Bleeding: ACG Guidelines
- Endoscopy
• Epinephrine therapy should not be used alone. If used, it should be
combined with a second modality (Strong recommendation).
• Thermal therapy with bipolar electrocoagulation or heater probe and
injection of sclerosant (e.g., absolute alcohol) are recommended
because they reduce further bleeding, need for surgery, and mortality
(Strong recommendation).
• Clips are recommended because they appear to decrease further
bleeding and need for surgery. However, comparisons of clips vs. other
therapies yield variable results and currently used clips have not been
well studied (Conditional recommendation).
• For the subset of patients with actively bleeding ulcers, thermal therapy
or epinephrine plus a second modality may be preferred over clips or
sclerosant alone to achieve initial hemostasis (Conditional
recommendation).
Laine & Jensen Am J Gastroenterol 2012; 107:345–360
Management of Ulcer Bleeding: ACG
Guidelines - Therapy after initial endoscopy
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After successful endoscopic hemostasis, intravenous PPI therapy with 80 mg
bolus followed by 8 mg/h continuous infusion for 72 h should be given to
patients who have an ulcer with active bleeding, a non-bleeding visible vessel,
or an adherent clot (Strong recommendation).
Patients with ulcers that have flat pigmented spots or clean bases can receive
standard PPI therapy (e.g., oral PPI once daily) (Strong recommendation).
Routine second-look endoscopy, in which repeat endoscopy is performed 24 h
after initial endoscopic hemostatic therapy, is not recommended (Conditional
recommendation).
Repeat endoscopy should be performed in patients with clinical evidence of
recurrent bleeding and hemostatic therapy should be applied in those with
higher risk stigmata of hemorrhage (Strong recommendation).
If further bleeding occurs after a second endoscopic therapeutic session,
surgery or interventional radiology with transcathether arterial embolization is
generally employed (Conditional recommendation).
Laine & Jensen Am J Gastroenterol 2012; 107:345–360
International Consensus on Nonvariceal
Upper Gastrointestinal Bleeding:
Postdischarge ASA and NSAIDs
• In patients with previous ulcer bleeding who require
an NSAID, it should be recognized that treatment
with a traditional NSAID plus PPI or a COX-2 inhibitor
alone is still associated with a clinically important risk
for recurrent ulcer bleeding.
• In patients with previous ulcer bleeding who require
an NSAID, the combination of a PPI and a COX-2
inhibitor is recommended to reduce the risk for
recurrent bleeding from that of COX-2 inhibitors
alone.
Barkun AN, et al. Ann Intern Med. 2010;152:101-113.
International Consensus on Nonvariceal
Upper Gastrointestinal Bleeding:
Postdischarge ASA and NSAIDs
• In patients who receive low-dose ASA and develop
acute ulcer bleeding, ASA therapy should be
restarted as soon as the risk for cardiovascular
complication is thought to outweigh the risk for
bleeding.
• In patients with previous ulcer bleeding who require
cardiovascular prophylaxis, it should be recognized
that clopidogrel alone has a higher risk for rebleeding
than ASA combined with a PPI.
Barkun AN, et al. Ann Intern Med. 2010;152:101-113.
Acute LGIB
Differential Diagnosis
• Diverticulosis
• Colitis
– IBD (UC>>CD)
– Ischemia
– Infection
• Vascular anomalies
• Neoplasia
• Anorectal
– Hemorrhoids
– Fissure
• Dieulafoy’s lesion
• Varices
– Small bowel
– Rectal
• Aortoenteric fistula
• Kaposi’s sarcoma
• UPPER GI BLEED
Acute LGIB
Diagnoses in pts with hemodynamic compromise.
DIAGNOSES
Diverticulosis
Vascular anomalies
Colitis
Neoplasia
Anorectal
Upper GI sites
% OF TOTAL
40
30
21
14
10
10
Zuccaro. ASGE Clinical Update. 1999.
Diverticulosis
Diverticular Bleeding
Hemorrhoids
Bleeding AVM
Radiation Proctitis
Acute LGIB
Meckel’s Diverticulum
• Incidence
• Etiology
0.3 - 3.0 %
Incomplete obliteration of
the vitelline duct.
• Pathology 50% ileal, 50% gastric,
pancreatic, colonic mucosa
• Complications
– Painless bleeding (children, currant jelly)
– Intussusception
Acute LGIB
Evaluation
Study
Colonoscopy
Arteriography
Yield
%
Comments
69-80 Therapeutic
40-78
1 ml/min,
risks
Tagged RBC Scan 20-72 Localization
Zuccaro. ASGE Clinical Update. 1999.
Acute LGIB
Key Points
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Resuscitation
UGI source
Most bleeding ceases
Colonoscopy
No role for barium studies
SUMMARY
GI Bleeding Management
• Assessment and stabilization of
hemodynamic status
• Determine the source of bleeding
• Stop active bleeding
• Treatment of underlying abnormality
• Prevent recurrent bleeding