GI Bleeding Jeopardy!

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GI Bleeding Jeopardy!
UGIB therapy LGIB Clinical stuff General mgmt Potpourri
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These are your first 3 initial management
priorities given a 51y M currently vomiting
blood, has vomited 1L blood with EMS VS 125,
88/57 A maintaining B adequate C vomiting
blood, VS as above
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Brisk UGIB Management
1) Protection! gown, gloves, face shield 2)
Monitors, O2, IV x 2 (at least 18G) 3) Initial
fluids?

• NS vs blood
• pRBC if ongoing vomiting or VS dont improve

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These are the top 3 medications you might order
for a patient with an UGIB
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UGIB Pharmacotherapy

• Gastric acid suppression
• Pantoloc 80mg IV then 8mg/h infusion
• Somatostatin analogue
• Octreotide 50ug IV then 50ug/hr infusion
• Abx
• Ceftriaxone 1g IV
• Whats the point?

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UGIB Pharmacotherapy

• PPIs
• Improve clot formaion and ?breakdown
• Leontiadis GI et al. Cochrane rev Nov 2006
• ?re-bleeding risk (OR 0.49 (0.37-0.65))
• ?need for surgery (OR 0.61 (0.48-0.78))
• ?mortality in bleeding pts (OR 0.53 (0.31-0.91))
• No effect on overall mortality
• H2-blockers not shown to have same benefit

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UGIB Pharmacotherapy

• Octreotide
• Causes splanchnic vasoconstriction
• ??portal venous pressures??rebleeding
• Imperiale et al. Ann Intern Med 19971271062-71
• Similar control of bleeding varices as EGD
• ?risk of continued bleeding in PUD (RR 0.53)

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UGIB Pharmacotherapy

• Antibiotics
• In cirrhosis (Soares-Weiser et al. Cochrane rev,
  2002)
• ?infectious complications (RR 0.40 (0.31-0.51))
• ?mortality (RR 0.66 (0.49-0.88))
• ?rebleeding
• No evidence that abx need to be started in the
  ED

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This is the indication for using vasopressin in
UGIB, and its mechanism of action
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UGIB Pharmacotherapy

• Vasopressin
• 20U IV over 20min then 0.2-0.4U/min
• Constricts mesenteric arterioles
• No mortality benefit (??mortality)
• Complication rate
• 9 major (myocardial, cerebral, bowel, limb
  ischemia)
• 3 fatal
• Indication
• Can try in exsanguinating patient with ?variceal
  bleeding if EGD not available

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This is what the acronym TIPS stands for
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Transjugular Intrahepatic Portosystemic Shunt

• Interventional radiology
• Connection between
• Hepatic vein
• Intrahepatic portion of portal vein
• Indication?

• Continued bleeding despite Rx/EGD

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The rate of major complications from this
procedure is 15, and the rate of fatal
complications is 3
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Linton tube

• Major complications
• Mucosal ulceration, tracheal compression,
  aspiration pneumonia, esophageal/gastric rupture,
  asphyxiation
• Consider if exsanguinating patient with
  ?variceal bleeding and EGD not immediately
  available
• Temporizing measure until EGD/surgery/TIPS

• Anything you need to do before putting it in?

• Need to secure A/W

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The type of stool usually seen in LGIB
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Stool LGIB vs UGIB

• Hematochezia
• Usually LGIB (10 UGIB)
• Melena
• Need 200mL blood x 8hrs (70 UGIB)

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These are 3 causes of false ve Hemoccult tests
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FOB Testing

• False ve
• Red fruits, meats, methylene blue, chlorophyll,
  iodide, cupric sulfate, bromide
• What about iron? Pepto-Bismol?

• Not causes of false ve

• False ve?

• Bile, Mg-containing antacids, ascorbic acid

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FOB Testing

• What about testing coffee ground emesis?

• Hemoccult are pH dependent
• Antacids/vitamin C cause false ve
• False ve with copper/iron salts
• ve result can usually be trusted

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This is the type of physician you will consult
and the urgency in the following patient with
hematemesis hematochezia 61y F PMH A.fib,
NIDDM, HTN, AAA (repair 2y ago) Rx warfarin,
metformin, glyburide
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Hematochezia/hematemesis After AAA Repair

• ?Aortoenteric fistula
• STAT consult to vascular surgery!
• Incidence of up to 4 post-repair
• Usually presents as UGIB
• Aortoduodenal fistula

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They are 3 investigation modalities that can be
used to help localize LGIB
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LGIB Localization

• Scope
• Anoscopy
• Sigmoidoscopy/colonoscopy
• Angiography
• Requires 0.5cc/h bleeding
• IDs site in 40
• Radionuclide scan
• Technetium labeled RBCs
• Need 0.1cc/h bleeding

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These are the 3 main causes of painful LGIB
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Painful Rectal Bleeding

• Ischemic colitis
• Infectious colitis
• Inflammatory colitis

• 5 bacteria causing bloody colitis?

• E. coli
• Campylobacter
• Yersinia
• Salmonella
• Shigella
• C. difficile

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These are 3 risk factors for poor outcome in UGIB
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• Risk factors for poor outcome (UGIB)
• Age gt 60y
• Coagulopathy
• Liver failure
• Cardiac disease
• Severe bleeding

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The 3 of these are responsible for 75 of all UGIB
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Differential diagnosis of UGIB

• Esophageal/gastric varices
• PUD
• Gastritis/gastric erosions

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• Esophagitis
• Mallory-Weiss tear
• Gastric CA
• Aortoenteric fistula
• Angiectasias
• Osler-Weber-Rendu syndrome

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Differential diagnosis of UGIB

• 10 of GIB patients have no identifiable source

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The 2 of these are responsible for 80 of all LGIB
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Differential diagnosis of LGIB

• Diverticulosis
• Angiodysplasia

• Infectious colitis
• Ischemic colitis
• Radiation colitis
• Anorectal varices
• Aortoenteric fistula
• Perianal disease
• Hemorrhoids
• Fissure
• Trauma

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• Malignancy
• UGIB
• Polyps
• IBD

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These are 4 things that could be the cause of
your patients dark stools
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DDx Melena

• UGIB
• High LGIB
• Swallowed blood (epistaxis, etc)
• Iron
• Bismuth (Pepto-Bismol)
• Food products (eg. blueberries)

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The utility of postural vital signs and capillary
refill in predicting hypovolemia
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Physical Exam Skills

• Postural vital signs
• ?HR by 20bpm sustained
• 98 specific for significant blood loss in GIB
• ?sBP by 20mmHg
• 97 specific for significant blood loss in GIB
• CR gt 2-3sec
• 10 SN for significant hypovolemia

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These are the investigations you order for the
patient with a brisk UGIB
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UGIB investigations

• CBC, TS, INR/PTT
• Lytes, BUN, Cr
• ALT, ALP, bili, GGT
• ECG?

• CAD hx, age gt 50, CP, SOB, hypotension

• CXR?

• If ?aspiration or ?perforation

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They are the 3 specialties that you might have to
consult with a GIB (other than ICU)
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HELP!

• GI
• Scope
• Interventional radiology
• TIPS
• Angiography
• General surgery

• Anyone else?

• Vascular surgery

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This is the likely source of bleeding (UGIB vs
LGIB) in the following patient 72y M, PMH HTN,
OA, A.fib Meds ? Hematochezia x 5 episodes over
90min VS 112, 81/40, 22, 370
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Hematochezia Shock

• Hematochezia shock UGIB
• Rapid transit

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This is the utility of NG tube insertion in the
patient with blood per rectum
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NG tube in patient with bloody stools?

• If ve blood
• UGIB
• LGIB oral/nasal mucosal bleed

• If ve blood
• UGIB bleeding stopped, duodenal blood
• 10 of UGIB have ve NG aspirate
• LGIB

• Bottom line
• Not diagnosticnot helpful

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This is the expected rise in Hb and Hct for 2U
pRBC
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Transfusion Facts

• 1U pRBC (if no ongoing bleeding)
• ?Hb by 10mmol/L
• ?Hct by 3

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They are 3 risk factors for ischemic colitis
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Painful Rectal Bleeding

• Risk factors for ischemic colitis?

• Dysrhythmia
• CAD
• Heart failure
• Prolonged hypotension
• Marathon running

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They are 2 potential future diagnostic modalities
for GIB
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Future Diagnosis

• CT/MRI reconstruction endoscopy
• Wireless capsule endoscopy

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These are the GIB patients you can send home from
the ED
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Disposition

• Very low risk (d/c home)
• No comorbidities
• N VS
• N/trace FOB
• NG aspirate ve if done
• Home support in place
• Understand symptoms sig bleed
• Easy access to ED
• F/U within 24h

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Risk Stratification
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Risk Stratification
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They are the 2 potential causes of an increased
BUN in the GIB patient
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Increased BUN

• Prerenal azotemia
• Digested blood

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It is much more likely to be your diagnosis in a
patient with hematochezia and a history of
cirrhosis (and its not brisk UGIB)
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Liver Disease and LGIB

• Anorectal variceal bleeding
• Superior hemorrhoidal veins and middle/inferior
  hemorrhoidal veins

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• Rules
• Teams decide how much to wager
• Each team pick one skilled participant
• Participants leave the room for setup of Final
  Jeopardy!

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• Task
• Race to fill the Linton tube with 600cc air
• Opposing team counts ccs