1. GI BLEEDING Brad Martin, MD c/o Jason De Roulet, MD July 18, 2012

2. OBJECTIVES • Define some common terms associated with GI bleeds • Review the ways patients commonly present with GI bleeds • Review how to assess patients presenting with GI bleed • Identify the most common causes of both upper and lower GI bleeds • Identify key information to have available when calling a GI consult • Review the medical and endoscopic treatments for both upper and lower GI bleeds

3. DEFINITIONS • Acute GI bleed • < 3 days duration • hemodynamic instability • requires blood transfusion • Overt vs. occult • overt = visible blood (melena, bright red blood, coffee grounds) • occult = only detected by lab tests

4. DEFINITIONS • Upper vs. Lower GI bleed • UGIB = proximal to ligament of Treitz • LGIB = distal to ligament of Treitz Ligament of Treitz

5. GOALS OF CARE • Stabilize patient’s hemodynamics • Assess patient, determine source of bleed • Stop any active bleeding • Treat underlying cause • Prevent recurrence

6. PRESENTATION • “The patient has been vomiting blood” • Usually indicates upper GI source • Can include: • bright red blood • coffee ground emesis • clots

7. PRESENTATION • “The patient has had bloody stools” • need to determine stool characteristics, especially color, consistency, and frequency • melena = black, tarry stool (melena ≠ dark, formed stool!) • usually indicates upper GI bleed, although ~5% can be from small bowel or proximal colon • only need around 50cc of blood to get melena • adjective is melenic, not melanotic • hematochezia = BRBPR or clots • usually indicates lower GI bleed, although can be brisk upper bleed • brown stool, formed stool usually not aggressive bleed

9. INITIAL ASSESSMENT • Is the patient hemodynamically stable? • Replace intravascular volume • History, physical exam • Nasogastric intubation • Lab evaluation • Floor vs. ICU

10. INITIAL ASSESSMENT – STABLE? • Is the patient orthostatic? • requires loss of 20% of blood volume • “dizzy when I get up” • Is the patient in shock? • requires loss of 40% of blood volume • hypotensive, tachycardic, pallor

11. INITIAL ASSESSMENT – RESUSCITATION • Establish good access • 2 large bore (ideally 18-gauge peripheral IVs) • in MICU, may place triple-lumen or Cordis • Replace intravascular volume • if hypotensive and/or orthostatic, give NS boluses • if anemic, give PRBCs • may need FFP and/or platelets if massive GI bleed

12. INITIAL ASSESSMENT – HISTORY • Age • risk, mortality increase with age • Previous bleeding • Comorbidities • CAD • heart failure • AAA repair • liver disease • Previous endoscopies (look at reports!) • Associated symptoms • pain • retching • anorexia, weight loss • nausea/vomiting • early satiety • dysphagia • epistaxis, hemoptysis • Medication history – NSAIDs, warfarin, ASA, Plavix

13. INITIAL ASSESSMENT – PHYSICAL • Vital signs: tachycardia? hypotension? hypoxia? • Gen: distress? alert + oriented? • HEENT: pallor, blood in nares or mouth • Abd: distension, tenderness • Rectal – visualize the stool! • BRB, melena, maroon, brown, no stool in vault • “The ER said it was heme positive”

14. INITIAL ASSESSMENT – NG TUBE • Nasogastric intubation, NG lavage • confirm NGT is in stomach (KUB) • inject 250cc NS, then draw 250cc back or place to wall suction • can be repeated for up to total of 2L • stop when fluid is clear (or when reach 2L) • Contraindications • facial trauma, nasal bone fracture • known esophageal abnormalities (strictures, diverticuli) • ingestion of caustic substances, esophageal burns • generally, esophageal varices are NOT a contraindication to NG tube placement

15. INITIAL ASSESSMENT – NG TUBE • Interpretation of aspirate: • bright red, clots = active UGIB • coffee grounds = slow bleeding, may have stopped, localizes to upper GI source • clear = indeterminate (NOT a guarantee that the bleeding has stopped) • bilious = bleeding has stopped

16. INITIAL EVALUATION – LABS • CBC • H+H, including BASELINE • how often to check? • goal H+H? • may take up to 72 hrs to equilibrate • Platelets • goal platelet count? • Renal function panel • BUN/Cr ratio • see increased BUN in UGIB due to absorbed blood proteins • ratio usually > 20:1 • Coags • goal INR < 1.5 • reverse with FFP, vitamin K unless contraindicated • LFTs • Iron studies

17. THE STOOL GUAIAC • Stool guaiac is a great tool for colon cancer screening • It is NOT a test for acute GI bleed • Causes of false-positives include: • Trauma • Extraintestinal blood loss • epistaxis • hemoptysis • Medications • ASA, NSAIDs (gastric irritation) • Exogenous peroxidase activity • red meat consumption • fruits (grapefruit, cantaloupe, figs) • uncooked vegetables (broccoli, cauliflower, radish, cucumber, carrot)

18. INITIAL EVALUATION - TRIAGE • What necessitates a MICU admission? • Hemodynamic instability despite adequate volume resuscitation • NG lavage does not clear with 2L • History of cirrhosis, concern for variceal bleed • Continued bleeding • Be concerned when: • Age > 60 • Multiple comorbidities • Coagulopathy (i.e. Plavix, warfarin, cirrhosis) • Known portal hypertension • Hematemesis is bright red blood • History of AAA repair in the past

20. DETERMINING THE SOURCE • History is crucial • NSAIDs, postprandial epigastric pain (ulcer?) • hypotension preceding BRBPR (mesenteric ischemia?) • retching or recurrent vomiting (Mallory-Weiss?) • history of cirrhosis (variceal bleed?) • Stool exam • NG lavage • 11% of patients initially suspected of LGIB actually have UGIB

21. UPPER GI BLEED (Other includes Dieulafoy’s lesion, GAVE, foreign body, etc.)

22. LOWER GI BLEED • Differential diagnosis: • Diverticulosis (up to 42%) • Ischemia (up to 18%) • Hemorrhoids, fissures (up to 16%) • UGI or small bowel bleed (up to 13%) • Neoplasia (up to 11%) • Other (IBD, infectious colitis, post-polypectomy) • Unknown cause in up to 23% of cases

23. CALLING A GI CONSULT • Presentation • PMHx, especially if h/o liver disease • NG lavage results • RECTAL EXAM!!-Stool characteristics • Vital signs, hemodynamics, orthostatics • Labs • Previous endoscopy reports • Have a differential

25. MEDICAL THERAPY FOR UGIB • PUD: • PPI bolus of 80mg, then drip at 8mg/hr • has been shown to accelerate resolution of bleeding and decrease need for therapy during EGD • Varices • Octreotide 50-100mcg bolus, then 50mcg/hr drip • If pt has ascites, will need antibiotics for 7 days for SBP prophylaxis • norfloxacin 400mg BID • Bactrim DS BID

26. ENDOSCOPIC THERAPY FOR UGIB • PUD • epinephrine injection • bipolar cautery • hemoclip • Varices • endoscopic band ligation • >90% success • 30% rebleeding rate • TIPS for hemorrhage refractory to banding • also used for gastric varices

27. UGIB ADMISSION • NPO after midnight • Call GI fellow first thing the next morning (8am) • If patient cannot consent, make sure medical decision maker is identified and have phone numbers available

28. TREATMENT OF LGIB • No medical treatments • Diverticular bleeds stop on their own 75% of the time • Bleeds due to angiodysplasia stop spontaneously around 85% of the time • If pt continues to bleed • CT angiography to localize bleed • can often be accompanied by embolization to stop the bleeding • requires > 0.5cc per minute of blood loss • Tagged RBC scan • can detect bleeding at > 0.1cc per minute • unreliable localization, high false positive rate

29. TREATMENT OF LGIB • Usually no need for emergent colonoscopy • If stable but continued bleeding can do “rapid purge” (GoLYTELY 4L given quickly) and colonoscopy can be done in 6-12 hours • Colonoscopy reveals cause in > 70% of cases • Tools used include • epinephrine injection • cautery • hemoclip • surgery

30. LGIB ADMISSION (ON THE FLOOR) • Clear liquid diet the day prior to endoscopy • 1 gallon GoLYTELY started the afternoon/evening before procedure • Goal is for stool to be CLEAR

31. SUMMARY • A detailed history is crucial in diagnosing GIB • It is also very important to characterize the emesis and/or stool to aid in diagnosis • Stool guaiac testing is not indicated in acute GIB • Most important step is assessing hemodynamic (in)stability and resuscitating with NS and/or blood if needed • In most cases, the patient will need endoscopy, but you can help to improve outcomes with specific medical treatments

32. Thank you! Enjoy your time in Cleveland!