Acute Gastrointestinal Bleeding

1
Acute Gastrointestinal Bleeding

• Rajeev Jain, M.D.

2
GI Bleeding

• Clinical Presentation
• Acute Upper GI Bleed
• Acute Lower GI Bleed

3
Case Presentation

• CC Melena
• HPI 54 yo man taking ibuprofen 200 mg po tid for
  the past 2 wks b/o acute LBP after lifting
  presents with 2 day h/o melena
• PMHx neg All NKDA SHx/FHx neg
• Vitals BP 105/75 P 90
• PE normal

4
Clinical Presentation

• Hematemesis bloody vomitus (bright red or
  coffee-grounds)
• Melena black, tarry, foul-smelling stool
• Hematochezia bright red or maroon blood per
  rectum
• Occult positive guaiac test
• Symptoms of anemia angina, dyspnea, or
  lightheadedness

5
Patient Assessment

• Hemodynamic status
• Localization of bleeding source
• CBC, PT, and T C
• Risk factors
• Prior h/o PUD or bleeding
• Cirrhosis
• Coagulopathy
• ASA or NSAIDs

6
Resuscitation

• 2 large bore peripheral IVs
• Normal saline or LR
• Packed RBCs
• Correct coagulopathy

7
Location of Bleeding

• Upper
• Proximal to Ligament of Treitz
• Melena (100-200 cc of blood)
• Azotemia
• Nasogatric aspirate
• Lower
• Distal to Ligament of Treitz
• Hematochezia

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Acute UGIBDemographics

• 10,000 - 20,000 deaths annually
• Mortality stable at 10
• 80 self-limited
• Continued or recurrent bleeding - mortality 30-40

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Acute UGIBPrognostic Indicators

• Cause of bleeding
• Severity of initial bleed
• Age of the patient
• Comorbid conditions
• Onset of bleeding during hospitalization

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Acute UGIBPrognostic Indicators
Tedesco et al. ASGE Bleeding Survey. Gastro Endo.
1981.
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Acute UGIBDifferential Diagnosis
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Acute UGIBDifferential Diagnosis

• Peptic ulcer disease
• Gastric ulcer
• Duodenal ulcer
• Mallory-Weiss tear
• Portal hypertension
• Esophagogastric varices
• Gastropathy
• Esophagitis

• Dieulafoys lesion
• Vascular anomalies
• Hemobilia
• Hemorrhagic gastropathy
• Aortoenteric fistula
• Neoplasms
• Gastric cancer
• Kaposis sarcoma

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Acute UGIBFinal Diagnoses of the Cause in 2225
Patients
Tedesco et al. ASGE Bleeding Survey. Gastro Endo.
1981.
14
Acute UGIBCauses in CURE Hemostasis Studies
(n948)
Savides et al. Endoscopy 199628244-8.
15
Acute UGIB
CORI Database University, VA,
private practices 20 months (12/99-7/01) 7822
EGDs for UGIB
BoonpongmaneeS. et al. Gastrointest Endosc
200459788-94.
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Endoscopic Appearanceof Ulcers
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Prognostic Features at Endoscopy in Acute Ulcer
Bleeding
Laine and Peterson New Eng J Med 1994331717-27.
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Endoscopic Therapy of PUD

• Thermal
• Bipolar probe
• Monopolar probe
• Argon plasma coagulator
• Heater probe
• Mechanical
• Hemoclips
• Band ligation

• Injection
• Epinephrine
• Alcohol
• Ethanolamine
• Polidocal

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Endoscopic Therapy of PUD
Laine and Peterson New Eng J Med 1994331717-27.
20
Adjuvant Medical Therapy of PUD

• Acid suppression (intragastric pH gt 4)
• Histamine 2 Receptor Antagonists (H2RAs)
• Ranitidine (Zantac)
• Famotidine (Pepcid)
• Proton Pump Inhibitors (PPIs)
• Pantoprazole (Protonix)
• Lansoprazole (Prevacid)
• Esomeprazole (Nexium)

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Bleeding PUD IV H2RAsMeta-Analysis

• Duodenal ulcer no benefit
• Gastric ulcer mild benefit
• Mortality
• ARR 3 NNT 33
• Surgery
• ARR 7 NNT 14
• Rebleeding
• ARR 7 NNT 14

• Caveats
• Tolerance develops within 24 hrs
• More potent acid suppression available

Levine JE et al. Aliment Pharmacol Ther
2002161137-42.
22
Adjuvant Medical Therapy of PUD
739 patients admitted with GI bleeding
472 patients required no endoscopic treatment
267 received endoscopic treatment
27 patients not included comorbid or no consent
120 patients received IV omeprazole 80 mg
bolus then 8 mg/hr for 72 hours
120 patients received placebo
Lau et al. New Eng J Med 2000343310-316.
23
Adjuvant Medical Therapy of PUD
Lau et al. New Eng J Med 2000343310-316.
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Bleeding PUD PO/IV PPIsMeta-Analysis

• Reduction in
• Rebleeding NNT 4-17
• Surgery NNT 6-25
• No change in mortality
• PPIs add to endoscopic therapy but do not
  supplant endoscopic therapy

Estimates from pooled ORs
Leontiadis, GI et al. BMJ 2005330568-75.
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Mallory-Weiss Tear
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Esophageal Varices
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Variceal Band Ligation
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Variceal Band Ligation
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MEDICAL THERAPYAcute Variceal Bleeding

• Vasopressin/Glypressin
• Nonselective vasoconstrictor
• 50 efficacy in controlling bleeding
• 25 vasospastic side effects
• Octreotide
• Cyclic octapeptide analog of somatostatin
• Longer acting than somatostatin
• Equivalent to sclerotherapy and improves
  endoscopic results

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TIPS
Coronary Vein
IVC
Splenic Vein
Portal Vein
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Aortoduodenal Fistula
Aorta
Duodenum
Fistula
Graft
32
Acute BleedingChanges Before and After 2 Liter
Bleed
45
45
27
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Acute UGIB Surgery

• Recurrent bleeding despite endoscopic therapy
• gt 6-8 units pRBCs

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Case Presentation

• CC Hematochezia
• HPI 74 yo woman presents with 6 hour history of
  painless maroon blood per rectum
• PMHx CAD, Chol, AFib, CABG, L-CEA
• Meds ASA, coumadin, digoxin, lovastatin
• Vitals BP 105/75 P 90
• PE irreg rhythm, maroon blood on DRE

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Acute LGIBDifferential Diagnosis
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Acute LGIBDifferential Diagnosis

• Diverticulosis
• Colitis
• IBD (UCgtgtCD)
• Ischemia
• Infection
• Vascular anomalies
• Neoplasia
• Anorectal
• Hemorrhoids
• Fissure

• Dieulafoys lesion
• Varices
• Small bowel
• Rectal
• Aortoenteric fistula
• Kaposis sarcoma
• UPPER GI BLEED

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Acute LGIBDiagnoses in pts with hemodynamic
compromise.
Zuccaro. ASGE Clinical Update. 1999.
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Diverticulosis
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Diverticular Bleeding
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Urgent Colonoscopy for the Diagnosis and
Treatment of Severe Diverticular Hemorrhage

• 121 pts with severe bleeding (gt4 hrs after
  hospitalization)
• 1st 73 pts no colonoscopic tx
• Last 48 pts eligible for colonoscopic tx
• Colonoscopy w/in 6-12 hrs

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Urgent Colonoscopy for the Diagnosis and
Treatment of Severe Diverticular Hemorrhage
Jensen DM, et al. New Eng J Med 200034278-82.
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Hemorrhoids
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Bleeding AVM
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Radiation Proctitis
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Acute LGIBMeckels Diverticulum

• Incidence 0.3 - 3.0
• Etiology Incomplete obliteration of the
  vitelline duct.
• Pathology 50 ileal, 50 gastric, pancreatic,
  colonic mucosa
• Complications
• Painless bleeding (children, currant jelly)
• Intussusception

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Acute LGIBEvaluation
Zuccaro. ASGE Clinical Update. 1999.
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Acute LGIBKey Points

• Resuscitation
• UGI source
• Most bleeding ceases
• Colonscopy - early
• No role for barium studies
• 5 Mortality