Upper GI Bleed:

1
Upper GI Bleed Clinical Case Presentation
Lisa Philipose 4 / 25/ 06
2
History

• CC 79 y.o. white male presents via EMS to the
  Bayview E.D. with two days of loose black tarry
  stools.
• HPI On the morning PTA, patient felt weak and
  light-headed, so wife called EMS. VS in the
  field were HR136 BP 82/48 RR18 O2sat 98
  on RA D-stick150.
• 600 cc bolus was administered by EMS and BP
  increased to 107/61 and HR decreased to 96.

3
History

• ROS Pt denies N/V/D/C, and denies
  chest/abdominal/ back/flank/rectal pain.
• PMH HTN, DM, no h/o bleeding d/o no h/o GI
  disorders
• Last colonoscopy 3 yrs ago reported normal per
  patient.
• PSH None
• Meds Lisinopril, Metformin, Glucophage, HCTZ,
  ASA
• All NKDA
• SH No h/o tobacco/alcohol/illicits

4
Physical

• Vital Signs
• T 98.8 HR 104 RR 18 BP 127/89 O2 Sat 98,
  RA
• Gen Pale, smiling, NAD
• HEENT Moist mucus membranes
• Lungs CTAB
• CV RRR, no M/R/G
• Abdomen Nontender, nondistended, BS
• Rectal Grossly heme positive with black tarry
  foul smelling stool, one small external
  hemorrhoid-not ruptured, inflamed, or bleeding
• Extremities No swelling/tenderness, 2DP pulses
• Neuro Alert and oriented, nonfocal

5
E.D. course

• Two large bore IVs in place- 1L NS bolus followed
  by NS infusion
• Patient placed on O2 and cardiac monitor.
• EKG Normal sinus rhythm
• Hemocue 8.9 g/dl
• Labs sent CBC (hgb9.4), CMP, TS, coags,
  cardiac enzymes
• CXR normal. No free air under diaphragm
• Rectal exam grossly positive
• NG lavage 300 cc clear output?NG d/c
• Protonix 40mg IV

6
E.D. course

• Orthostatics
• Lying(77, 132/77)
• Sitting (73,120/70)
• Standing (95,114/62) pt reports
  lightheadedness
• Repeat CBC (hgb8.4) and CE
• 1 unit PRBCs given
• VS stable
• Pt admitted for observation and inpatient
  endoscopy
• GI team aware

7
Laboratory Data
WBC 9310 w/ nl diff Hgb9.4?8.4 Hct
26.5?24 Platelets226 Coags normal Blood Type
A CE X 2 negative UA normal
Na 135 K 4.5 Cl 103 CO2 22 BUN 77 Cr
1.6 Glucose 120 Extended panel normal
8
Differential Diagnosis

• Upper GI bleed
• Lower GI bleed
• Slow bleed from right colon
• Bleeding from small bowel
• Other causes of black stools
• Iron pills
• Licorice
• Bismuth (Pepto-Bismol)
• Blueberries

Melena
9
Upper GI Bleed

• Location Proximal to ligament of Treitz
• Incidence 100 per 100,000 population
• Symptoms
• -Melena (70-80)
• (gt60 ml blood in gut for 8 hrs)
• -Hematemesis (45-50)
• -Presyncope (40)
• -Hematochezia (15-20)
• -Syncope (15)
• 80 bleeds stop spontaneously

UGI bleed has 10 mortality
10
Etiologies of UGI

• Peptic ulcer disease (risk factors HP, NSAIDs,
  stress, gastric acid)
• Esophageal varices
• Mallory Weiss-tears
• Esophagitis
• Gastric/esophageal tumor
• Gastritis
• Aortoenteric fistula
• Lymphoma
• Vascular lesions Dieulafoy, angiodysplasia
• Coagulopathy
• Anticoagulant use

11
Approach to UGI Bleed in ED

• 1.Assess hemodynamic stability (Shock?)
• - ABCs
• 2. Clinical assessment/ Resuscitation
  (Transfuse?)
• - 1st use crystalloid, use pRBCs if gt2-3L
  crystalloids needed or signs of ischemia on EKG
• -O2
• -CXR, EKG
• - Foley, labs
• - Place NGT confirm UGI source,
• assess rapidity of bleeding/ need for endoscopy
• -involve consultants early if needed
• -acid suppression therapy (PPI decreases risk of
  acute rebleed)
• 3. Risk stratify (Endoscopy? Inpatient or
  outpatient?)
• 4. Diagnose

12
Risk Assessment Clinical Lancet 2000

• Triage for Outpatient management
• Pts with low risk of requiring intervention such
  as endoscopic therapy or transfusion
• Factors
• -BUN lt6.5 Hgbgt13(men), gt12 (women)
• -SBPgt110 HRlt100

13
Risk Assessment Clinical

• Triage for Inpatient management
• -unknown/suspected variceal bleed
• -hemodynamic instability
• -ongoing symptoms of bleeding/ recurrent bleeding
• -comorbidity req. hospitalization (angina)
• -mental impairment or noncompliance
• -coagulopathy
• -anemia requiring transfusion

14
Role of Endoscopy
Urgent endoscopy generally performed
for -unstable patients, continued
bleeding -diagnostic and therapeutic Elective
Endoscopy -for stable admitted
patients Endoscopic Prognostic Factors (NEJM
1994) Finding Incidence() Re-bleed
() 1.Active bleeding 8 85-100 2.Visible
vessel 17-50 18-55 3.Adherent clot 18-26 24-41 4
.Dark spots 12-18 5-9 5.Clean-based 10-36 0-1

15
Non-variceal UGIBThe Controversy of Endoscopic
Triage in the ED

• Risk of re-bleeding is difficult to assess
  clinically
• Is endoscopic triage a solution?
• -Perform urgent endoscopy on all patients with
  acute UGI bleed before admission/triage? better
  health outcomes? More cost effective?
• -identify high-risk patients early even if
  clinically silent
• -discharge low risk patients

16
110 patients upper GI bleed (nonvariceal) and
stable VS randomized
Prospective RCT
Early endoscopy in ED 46(26/56) with low risk
lesions d/cd from ED per GI recs without adverse
outcome 8 pts upgraded (ward?IMC?ICU) based on
unexpected high risk endoscopic lesions Median
LOS 1 days Median cost 2,068
Endoscopy within 2 days of admission (control
group) Median LOS 2 days Median cost 3,662
Assess clinical outcomes and costs prospectively
for next 30 days
17
The other side

• -Randomized multicenter trial of nonvariceal UGI
  bleed (2004)
• -no difference in LOS or clinical outcomes
• -difference in study 40 were recommended for
  d/c based on endoscopy findings, however only 9
  patients actually d/cd from ED (vs 46 in Lee
  study)
• -mimics clinical practiceattending physician
  admitted patients based on own clinical judgment
  despite low risk endoscopic results.

18
Conclusion..

• Endoscopic triage is effective in avoiding
  hospitalization and reducing costs of low-risk
  patients
• However, if findings of endoscopy do not affect
  clinical practice by nonendoscopists (ED docs),
  endoscopic triage is not an effective tool

19
Back to our patient.Post-ED Course

• Patient admitted on a Friday?had another episode
  of melena over the weekend? Slight drops in hct,
  managed with fluids?EGD on Tuesday showed
• 1) antral erosions
• 2) healing Mallory Weiss ulcer
• Pt d/cd with following recs per GI
• -check HP Ab and tx with triple tx if
• -continue PPI
• -outpatient colonoscopy

20
Summary

• Assess hemodynamic stability
• Resuscitate
• History/physical risk factors?
• Re-assess need for resuscitation often
• NG lavage
• Endoscopy?
• All bleeding stopseventually

21
References

• Bjorkman DJ. Endoscopic triage for nonvariceal
  upper gastrointestinal bleeding the optimal
  approach in 2001? ASGE wesbite, 2001.
• Bjorkman DJ et al., Urgent vs elective endoscopy
  for acute nonvariceal upper GI bleeding an
  effectiveness study. Gastrointest endosc 2004
  6094-95.
• Blatchford O et al., A risk score to predict need
  for treatment for upper-gastrointestinal
  hemorrhage. Lancet 2000 3561318-21.
• Eisen GM et al., Guidelines An annotated
  algorithmic approach to gastrointestinal
  bleeding. Gastro Endo 2001 53853.
• Jutabha R, Jensen D. Approach to the Adult
  patient with upper gastro-intestinal bleeding In
  UpToDate, Wellesley, MA, 2006.
• Laine L, Peterson WL. Bleeding peptic ulcer. NEJM
  1994 331717-27.
• Lee JG, et al., Endoscopy-based traige
  significantly reduces hospitalization rates and
  costs of upper GI bleeding a randomized
  controlled trial. Gastrointest Endosc
  199950755-61.
• Peter DJ and Daughtery JM, Evaluation of the
  patient with gastrointestinal bleeding An
  evidence-based approach. Emerg Med Clin NA
  17239, 1999.