GI bleeding

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GI bleeding

• Never forget the general principle of internal
  medicine.
• Airway, Breathing, Circulation
• Stabilize vital sign and aggressive
  resuscitation.
• Well explanation to the family.
• Acquire thorough history and past medical
  history.
• Differential diagnosis of GI bleeding
• UGI LGI
• Make the diagnosis by yourself!
• Arrange adequate diagnostic procedure.
• Emperical treatment

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• ?????????? dizziness , fainting, tachycardia,
  cold sweating, shock, abdominal fullness, poor
  appetite, cons. change
• ????,??vital sign???????? (occult bleeding or
  overt bleeding)
• Orthostatic hemodynamic change 10 to 20 blood
  loss
• Drop in systolic pressure gt 10 mmHg, raise in
  pulse rate gt15/min
• Supine hypotension greater than 20 blood loss
• ?? UGI or LGI ???? medical treatment or surgical
  treatment
• GI bleeding vs Non-GI bleeding ?? vs. ?? vs.
  internal bleeding

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Study in GI bleeding

• Digital exam for collect stool
• NG aspiration for DDx UGI and LGI
• PES Panendoscopy or EGD( esophago-gastro-duodenos
  copy) should be perform early in the clinical
  course after vital sign stable or management.
• Colonoscopy/ rigid sigmoidscopy
• RBC scan only in Taipei MMH gt0.1cc/min or 6
  cc/hour
• Angiography gt0.5cc/min or 30 cc/hour
• Enteroscopy or capsule endoscopy
• Surgery

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Why the GI bleeding patient need NPO

• Not every GI bleeding patient should NPO
• Prepare for emergency study or management
• Avoid aspiration

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GI bleeding ????

• Again and again Check vital sign
• Evaluate NPO or not
• If NPO, IVF supply
• Arrange laboratory study
• CBC, PT, PTT, Blood group and cross match, liver
  and renal function.
• Blood product Whole blood vs. pack RBC, FFP vs.
  FP, ????(ex.6HES)
• Medication
• How to arrange the study NG irrigation, Blood
  sampling, PES, Angiography, Colonofiberscope, RBC
  scan

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Vital sign for GI bleeding

• Orthostatic hypotension drop SBP over 10 mmHg,
  rise in pulse rate over 15 beat/min blood loose
  10-20
• Supine hypotension more than 20
• Shock index SBP/HRlt1 which hint blood loose over
  25
• If the patient got Inderal using, the tachycardia
  may be disappear ( pacemaker also cover the risk
  sign)

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IVF supply in GI bleeding

• Large-bore IV line ( 14-16 gauge catheter) is
  better than central line. Isotonic solution (NS),
  LR can be initiated plus plasma expander ( ex 5
  hetastarch or 6 HES)
• The IVF amount is dependent on hemodynamic
  condition, other CV/renal condition, age
• The IVF content is dependent on underline
  disease ( DM, LC, Uremia, CHF)
• Some drug add in the IVF( KCL, HRI, st-B..) or
  the IVF is for therapy (PPI or H2RA for PUD
  pitression/glypression, sandostadin in EV/GV)

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Blood product using in UGI bleeding

• When transfusion is indicated bleeding is
  massive, ongoing, or severe enough that colloid
  infusion alone is not adequate for tissue
  oxygenation. ( keep Ht over 25-30)
• The unit is different in Taiwan( 1 unit is about
  250cc but not 500cc)
• Whole blood is better than pack RBC if the
  patient got no risk for fluid overload ( ex. CHF,
  uremia..)
• Keep platelet over 50000, and correct the PT with
  vit K, PTT with FFP(also for massive transfusion)
• Add Bena/Decadron in allergy patient and Lasix
  avoid fluid overload, Sincal after massive
  transfusion

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UGI bleeding

• Differential diagnosis of Variceal and
  Non-variceal bleeding
• History of liver cirrhosis with/without variceal
  bleeding
• Massive hematemesis
• Signs of liver cirrhosis Spider nevi,
  Gynecomastia, Splenomegaly, Ascites, Jaundice
• Lab data suggest liver cirrhosis
  Hypoalbuminemia, PT prolonged, Mild impaired
  liver function (GOTgtGPT) with hyperbilirubinemia,
  
• History of alcohol abuse.

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Treatment of variceal bleeding

• The most important of all
• STABILIZED THE VITAL SIGN.
• WELL EXPLAIN TO THE FAMILY on critical, 1/3
  mortality in each episode.
• Pharmacological treatment
• Glypressin (Terlipressin) 1 amp iv stat and
  q6h.
• Sandostadin 2 amp iv drip stat and 12 amp in 500
  c.c. D5W run 24 hours
• Pitressin 20 amp in 480 c.c. D5W or NS (conc.
  0.8IU/ml), run 12 cc/hr to 54 cc/hr (0.2IU/min to
  0.9IU/min), side-effect chest pain, peripheral
  cyanosis combine nitrate--- Seldom used in
  recently years

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Treatment of variceal bleeding

• Endoscopic treatment highly operator dependent,
  high failure rate in acute bleeding, once the
  procedure succeeded, the outcome is good.
• Esophageal varices band ligation
• Gastric varices Scleosing therapy
• SB tube trachea intubation first, the effect is
  not good.

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• TIPS -- transjugular intrahepatic portosystemic
  shunt
• Operation Shunt surgery
• Precipitating factors of variceal bleeding ---
  treat the precipitating factor
• SBP
• Sepsis
• Impending hepatic failure

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Peptic ulcer disease

• Etiology of peptic ulcer disease
• Mucosal defensive factor
• Mucosal barrier to ion diffusion
• Two component mucous barrier
• Bicarbonate, Phospholipids
• Local mucosal blood flow
• Prostaglandins, EGF
• Intrinsic mechanism that inhibit gastric
  secretion.

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Peptic ulcer disease

• Etiology of peptic ulcer disease
• Aggressive factors
• Gastric acid and pepsin
• NSAIDs
• H. Pylori
• Free radical

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Typical symptoms of PUD

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• ?? ????????????
• ??? ????????, ??????
• ??? ??????????

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Diagnosis of PUD

• Esophagogastroduodenalscopy (EGD)
• Gastric ulcer and duodenal ulcer
• Description of PUD in EGD
• Stage A1, A2, H1, H2, Scar
• Size the risk of recurrent bleeding increased
  if greater than 2 cm
• Location antrum, body, fundus, anterior wall,
  posterior wall, great curvature side, lesser
  curvatyre side
• SRH (Stigmata of recent hemorrhage)
• Gastritis and Erosion.

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Risky sign in the PES description of UGI bleeding

• Varix RCS ( red color sign) which hint bleeding
  red-whale marking, cherry-red spot, active
  bleeding CbgtCw,F3gt2gt1
• Ulcer A1-2(active), H1-2(healing) and
  S1-2(scaring) active bleeding vs SRH (stigmata
  of recent bleeding)
• Bleeding with unknown cause

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Medication/Management in UGI bleeding PUD

• PPI ( losec/nexium, takepron, pariet,) losec
  1Amp NS 50-100 cc drip over 10 min st and q12h
  the 1 qd
• H2RA (zantac , tazac, famox) Zantac 3 Amp
  500cc IVF run 20cc/hr then 1 bid
• Sukit/gelfos 1pk q1h x4-6 times
• Sucrate gel 1Pk bid or ulsanic 1 qid (avoid
  using with antiacid, H2RA or PPI)
• Therapeutic endoscopy with bosmin injection, heat
  probe, hemoclip, laser..
• Sometimes, surgical intervention still indicated

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Medication/Management in UGI bleeding Surgical
intervention in PUD or other Dx

• Hypovolemic shock can not control by medical
  treatment
• Massive transfusion over 4-6U/8U(2000cc) in 24
  hours or over 10U(2500-5000cc) overall
• Recurrent or intractable bleeding after
  non-surgical treatment
• Risk factor for OP over 60y/o, transfusion over
  5 unit, shock, hematemesis with hypotension,
  coagulopathy, large ulcer over 2 cm, emergency
  Op, co morbid illness, rebleeding within 72 hours

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• ?????????????????????(critical)?????????,????????
  ?????????
• ?????????????
• ???????(ex. Severe pancreatitis, hepatic failure,
  hypovolemic shock..)??????ICU??( ex. SB tube,
  plasmaphrosis)
• ????????
• Call GI CR for emergent endoscopy!
• ??????on call CR ???, ????CR, ???VS, ????

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Low GI bleeding

• Hemorrhoid, anal fistula, angiodysplasia,
  radiation proctitis/colitis, aortoenteric
  fistula, tumor
• Urgent colonoscopy difficult due to poor
  preparation
• Consult Proctologist for the surgical
  intervention
• Fortunately, most common LGI bleeding may stopped
  spontaneously.

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Ileus

• Very dangerous diagnosis when new patient arrive
  with this diagnosis
• Paralytic vs Mechanical
• NPO in most cases
• IVF supply
• Overlapping with acute abdomen
• Series F/U the same kind x ray film

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Nausea and vomiting(1)

• Bowel obstruction or pregnancy must exclude
  first. Besides, extra-abdominal problem ( IICP,
  metabolic problem..)also need exclude.
• The vomitus also help for identified the
  obstruction level by color
• NG decompression amount is another key for
  evaluate the degree for obstruction

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Nausea and vomiting (2)

• Novamin( proclorperazine) ADR- drowsiness, acute
  dystonic reaction, EPS, postural hypotension..
• Dopamine antagonist - primperan (metoclopramide-
  EPS is notorious ADR) and motilium (domperidone).
  Cisparide is not approve in FDA now
• Ondansteron (zofran) and Granisetron ( kytril)
  are 5HT3 (serotonin) receptor inhibitor for C/T

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Diarrhea(1)

• The definition of diarrhea include the BM
  increase over 3 times per day and the amount
  increase
• Acute diarrhea vs chronic diarrhea 2 week
• NPO is the first step in DDx the secretary and
  osmotic diarrhea (but IVF supply also indicated
  after NPO especially in DM patient)
• Stool study stool OB, pus cell and culture when
  infectious diarrhea is suspected esp. in
  bacterial infection). PMC need special agar for
  culture. Ameba and parasite ova in chronic
  diarrhea also need considered.

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Diarrhea (2)

• Drug may be the most common cause of diarrhea in
  hospital( senokot, MgO, antacids, digitalis,
  quinidine, colchicine, antibiotic..)
• PMC( pseudomembranous colitis)must be carefully
  monitor when antibiotic using
• Parasite still need consider esp. in MMH Taitung
  branch.
• Most AGE is caused by virus and self-limiting.
• Diarrhea in cancer patients post radiotherapy is
  dangerous.

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Diarrhea (3)

• Review the drug sheet
• Evaluate the risky sign BM over 6 times, bloody
  stool or tenesmus, fever, severe abd pain,
  dehydration
• Hydration by enteral feeding if possible
• Symptomatic treatment with Kaopetin 15-20 cc/
  Tannalbin for loose stool, Anti-muscarinics (
  buscopan-scopolamine, trancolon-mepenzolate,
  bentyl-dicyclomine, esperan-oxapium), Smooth
  muscle relaxant ( Spasmonal-alverine,
  Cospanon-Flopropione, Duspatalin-Mebeverine)
• Imodium 2 st
• Codeine and Morphine
• Antibiotic in Infectious diarrhea after stool
  culture and study FQ and sulfa drug

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PMC or AAC

• Pseudomenbranous colitis or antibiotic-associated
  colitis
• C. difficle is not the only cause
• Cleocin is most notorious drug. PCN and Cepha got
  most patient!
• Dx scope , toxin, culture( in anaerobic
  condition)
• Tx stop antibiotic, symptomatic control, oral
  antibiotic ( metronidazole, vancomycine), IV
  antibiotic may be the last choice. Inferon Berna
  enema

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Constipation(1)

• Medication also the main cause of constipation (
  Calcium channel blocker, opiates,
  anticholinergic, iron, barium sulfate)
• Besides, old age and several disease (DM,
  hypothyroidism, scleroderma, myotonic
  dystrophy..) patient also got constipation
  tendency
• Intestinal obstruction must exclude first

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Constipation (2)

• Fiber supplementation Konsyl or Normacol
• Emollient laxative Mineral oil
• Stimulant cathartics Castor oil, Anthraquinones
  ( senokot 1-2 qhs), Bisacodyl ( dulcolax 1-2
  qhs or supp)
• Osmotic cathartic Mg citrate, lactulose..
• Fleet enema

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TPN

• Indication ???,???,???
• Time not over 7 days NPO
• How to order gradually increase the dose and
  concentration
• How to calculate the water amount
• How to calculate the calori demand
• How to calculate the protein demand
• How to calculate the fat supply
• How to supply the trace element, Vit

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TPN(2)

• Complication of TPN
• Mechanical problem caused by CVP insertion
• Chemical problem BS, electrolyte balance..
• Infection problem
• Other problem GB stasis and stone, LFT
  impairment, drug interaction

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Complication of hepatic insufficiency

• Fulminant hepatic failure
• Hepatic encephalopathy
• Hepato-pulmonary syndrome
• Hepato-renal syndrome
• Portal hypertension
• Ascites
• SBP
• Coagulopathy

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Hepatic failure

• How to identified the hepatic failure?
• PT is more important than AST/ALT
• Bilirubin also very important parameter
• Hypoglycemia and hypocholesterol also risky sign
• Cons. Level must evaluate carefully and closely
• The NH3 level is not parallel to cons. Level
• Very high mortality if no chance for liver
  transplant
• The Child-Turcott-Pugh score ( A 2.8-3.5, A
  slightly, Bil 2-3, Encephalopathy 1-2, PT 4-6)
  A 5,6 B 7-9 C 10-15

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Hepatic encephalopaghy ( HE)

• Correct the precipitating factor azotemia,
  tranquilizer, opioid, sedative-hyponotic, GI
  bleeding, hypokalemia, alkalosis, constipation,
  infection, diarrhea, porto-systemic shunt
• Medication lactulose po and enema Neomycine po
  and enema, Metronidazole po, BCAA chain supply
  (aminopoly-H)
• The possibility of intra-cranial lesion must
  exclude ( ex. ICH, SDH, brain tumor)

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Hepato-pulmonary sndrome

• Intra-pulmonary shunt increase
• Hypoxia
• Prove by angiography or contrast heart echo.

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Hepato-renal syndrome

• Similar to pre-renal azotemia
• Difficult in DDx
• Check Urine Na
• Also caused by peripherial arteriol dilatation
• Acute vs. Chronic
• The kidney is normal !!

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Portal HTN

• PE caput medusa, hemorrhoid
• Normal portal presssure 7 mmHg ( about 10 cm
  H2O)
• Portal HTN over 10 mmHg ( got S/S if over 12-15
  mmHg)
• EV or GV bleeding (dependent on which collateral
  circulation)

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Ascites and SBP

• Aldactone is the first choice for diuretic in LC
  related ascites
• Any LC patient with fever, abdominal pain need
  screen the SBP
• Neutrophile over 250/ul
• E coli, KP and Strep pneumoniae
• Empiric antibiotic 3rd cephalosporine or 1st
  aminoglycoside ( risk for renal toxicity)
• Norfloxcin 400 mg qd can reduce the recurrence
  for SBP

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Coagulopathy

• PT prolong
• Thrombocytopenia
• PTT prolong if the condition worsen or
  complication

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Pancreatitis

• Lab data can not complete exclude or include all
  cases
• CT is most sensitive diagnosis tool in severe
  pancreatitis
• Hydration is the key point for treatment
• Biliary pancreatitis is more common in Taiwan and
  female patient.
• Alc related pancreatitis is most common cause in
  USA and increase in Taiwan
• Hypertriglycemia vs. DM vs. pancreatitis

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Pancreatitis (2)

• Biliary pancreatitis need drainage ASAP
• Ranson criteria and APACHE II if Ranson over 3
  point or APACHE over 5, the patient got severe
  pancreatitis
• Identified the severe vs mild pancreatitis
  clinical course (CV, chest, GI, nephro
  complication), scoring system, CT staging

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Ranson criteria

• On admission Alcoholic (Non-alcoholic)
• WBC gt16000 (18000)
• Blood sugar gt200 (220)
• LDH gt350 (400)
• AST gt250 (440)
• Age gt55 (70)
• During the first 48 hours of admission
• Fall in hematocrit gt10 (10)
• Serum calcium lt8 mg/dl (8 mg/dl)
• Base deficit gt4 mEq/L (5 mEg/L)
• Increase in BUN gt5 mg/dl (2 mg/dl)
• Fluid sequestration gt6L (6L)
• Arterial PO2 lt60 mmHg (60 mmHg)

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Pancreatitis (3)

• Nature course
• Acute renal failure and M. acidosis
• Lung complication (ARDS..)
• Ileus and GI bleeding
• 2nd infection of necrotic tissue (2week)
• Pseudocyst (6weeek)

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Acute cholangitis vs cholecystitis

• Comparison of the triade
• RUQ pain fever leucocytosis
• RUQ pain fever jaundice (Charcot triade)
• shock cons change (Raynold pentade)

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Thank You for Your Attention!