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A Bloody Mess Upper GI Bleeding

A Bloody Mess Upper GI Bleeding. Tim Pfanner, MD, COL, USAR(ret) Asst Professor of Medicine Chief, Section of IBD & Nutrition. Case. 85 year old male Presents with Melena & Dizziness PMHx: CHF CADz Etoh PE: passes the eyeball test Vital signs all look good

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A Bloody Mess Upper GI Bleeding

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  1. A Bloody MessUpper GI Bleeding Tim Pfanner, MD, COL, USAR(ret) Asst Professor of Medicine Chief, Section of IBD & Nutrition

  2. Case • 85 year old male • Presents with Melena & Dizziness • PMHx: • CHF • CADz • Etoh • PE: passes the eyeball test • Vital signs all look good • Is NOT tilt positive, Hbg 8, INR 1, Plts 300k

  3. Case • Now that you have done an initial survey, what other questions might you want to ask? • Any history of prior gi bleeding? • Any history of liver disease? • What meds is the patient on?

  4. The following questions enter your mind(or should) • What should I do to manage the pt now? • Where should the pt go & how do I decide? • Home, ward, icu • Are there admission/home Criteria??? • What are the causes of his GI bleed?

  5. More Questions enter your inquisitive mind • How good is the therapy? • What medical Rx should I order? • How good is it? • When should it begin? • How good is endoscopy? • Risk stratification • Therapeutic mgmt • When should I get others involved? • Surgery &/or interventional radiology?

  6. So Here is what we are talking about Gastric Ulcer with bleeding Visible vessel Duodenal ulcer

  7. NOW HERE’S A HAPPY CROWD VISITING FRIENDS

  8. So Why Focus on Peptic Ulcer Bleeding? • Majority of all gi bleeds are from upper gi source • 90% of all ugi bleeds are non-variceal • 400,000 admissions yearly • In-hospital direct medical costs = 2.5 billion • Mortality is still high • 5-10% mortality from peptic ulcer bleeding • More common in Men by 3:2 ratio • Mortality in UK • 3% in pts <60 • 20% in pts >80

  9. So what are you thinking about the source of bleeding here? • Esophageal varicies • Maybe he is a drinker • gastric varicies

  10. So what are you thinking about the source of bleeding here? • Mallory-weiss tear • Horrible ulcer(guess) • Syphilitic Ulcer

  11. So what are you thinking about the source of bleeding here? • AVMs • Polyps

  12. So what are you thinking about the source of bleeding here? • Gastric Ulcer • Duodenal ulcer

  13. Clinical Presentation • Most commonly with: • Melena • Hematemesis • Think about serious signs of intravascular volume status: • Hypotension & resting tachycardia • <100mmHg systolic & >100bpm • Orthostatic changes(tilts)-20mmHg/20bpm

  14. Clinical Presentation • Initial Tx: What is it? • Restore hemodynamic stability • Place 2 large bore iv & fluids • Supplemental oxygen esp in elderly • Consider: blood/correcting coagulopathy • Place an NG tube-does this really help • 15% with negative ng aspirate have high risk leisons on endoscopy

  15. Clinical Presentation • Helping the patient & Gastroenterologist? • Orogastric tube placement • Do not guiac • Erythromycin 250mg iv • 30 to 60 min prior to egd • ?iv ppi • 80mg bolus followed by 8mg/hour • Has not definitely been shown to help prior to egd

  16. how might I determine where they go? Clinical Risk Stratification • Pre-endoscopic scoring systems • Blatchford Score -Neural network • Rockall Score • General components • Systolic BP -heart rate • Hemoglobin -melena • Co-morbid conditions • Age -?etoh

  17. Forrest Classification Endoscopic Stigmata of Bleeding Peptic Ulcer, Classified as High Risk or Low Risk Grade 1a Grade 1b 2b 2a 3 2c Gralnek I et al. N Engl J Med 2008;359:928-937

  18. Clinical Risk Stratification • Systems combining clinical and endoscopic parameters • Rockall • Baylor bleeding score • Cedar Sinai

  19. Clinical Risk StratificationSo How should I use all this stuff? • Look at the patient and use your common sense • How did the pt present • syncope, orthostatic • Are they elderly • Do they have other serious diseases • What meds are they on(coumadin, NSAIDs) • Is the hemoglobin <10 • Is the BUN >25 • If you use scoring, • Rockall>5 is high risk, <2 is low risk

  20. Clinical Risk StratificationSo How should I use all this stuff? • High Clinical Risk • To the MICU & resuscitate • Call GI to scope within 24 hours • Does early endoscopy(before admit) change what the managing provider does? • Does early endoscopy save money? • GI Endoscopy 2004;60:1-8 NO • Low Risk in the United Kingdom can go home with no endoscopy

  21. Low Risk patients Gralnek I et al. N Engl J Med 2008;359:928-937

  22. Clinical Risk StratificationSo How should I use all this stuff? • If endoscopy has been performed and low risk leisons seen may consider outpatient Rx • Intermediate risk & low risk can go to ward • Usually keep high & intermediate for 72 hours • This is when risk for rebleed is highest • Octreotide if with cirrhosis/etoh • ppi

  23. Clinical Risk StratificationSo, What do I do? • In general do endoscopy within 24 hours • If we see: • high risk Rx & 24 h MICU, then 48h hospitalization • Ulcer >2cm, vessel > 2mm are high risk • Low risk Rx & consider home/early discharge

  24. Oh!, those places you will go!

  25. Management • Medical • octreotide • Goal-pH >6.0 • H2RA- not effective • PPIs-very effective • Endoscopic • Surgical RX-much less common • Interventional Radiology

  26. Management • Medical • PPIs Decrease: • rebleed risk(odds ratio =.40) • surgery risk(odds ratio = .50) • Death (odds ratio=.53) • PPI Dosing • Iv- 80mg bolus and 8mg/hour for 72 hours(most effective dosing method) • High dose oral effective in Asian populations

  27. Effect of Proton-Pump Inhibition in Peptic-Ulcer Bleeding From Leontiadis GI, etal. Cochrane Database Syst Rev 2006;1 Gralnek I et al. N Engl J Med 2008;359:928-937

  28. Management Helicobacter Pylori Yep, you wanna test For me.

  29. Managementtesting for H. Pylori

  30. Management of H. pylori + • Initial Rx: • Clarithromycin 500mg bid • Amoxicillin 1000mg bid • PPI bid • All for 10-14 days, then PPI qd x4-8 wks’ • Healing of DU takes 3-4 wks & GU 6-8 wks • Salvage Rx: • Bismuth 120mg qid • Metronidazole 500mg tid • Tetracycline 500mg qid • PPI bid • All for 14 days

  31. So does RX of H. Pylori work? • Eradication of H. Pylori reduces the 1 year recurrence of ulcers from 75% to 15-20%. • H. pylori has been strongly associated with gastric cancer • Japanese eradication trials = no gastric cancer • Eradication in MALT lymphoma • Regression in 70-80% • Eradication prior to NSAIDs can reduce ulcer risk

  32. NSAID’s & PUD Perforating gastric ulcer • 33 million commonly use NSAIDs • Ulcers found in 5-20% of chronic users • Only a third of chronic NSAID users have normal EGD’s • Gastric ulcers more common than duodenal • NSAID’s increase risks of ulcer complication – bleeding, obstruction and perforation • .5%-4% per year risk • >50% May present as a “silent” hemorrhage Bleeding gastric ulcer with visible vessel

  33. AFTER ALL, don’t we all want to be LONGHORNS?

  34. Most studies use emergent endoscopy with 12-24 hours of admission Identifies bleeding site & stigmata of recent hemorrhage Able to predict likelihood of continued or recurrent bleeding Early treatment reduces hospital costs and length of stay Endoscopic Management

  35. We can burn it!

  36. We can inject it!

  37. We can clip it!

  38. Endoscopic Tx for PUD bleedingSo, How good are we? LesionRebleed RiskRisk after Tx clean base 3% pigmented spot 7% Oozing 10-27% Adherent clot 12-33% 5% visible vessel 50% 15-30% actively bleeding 90% 15-30% Repeat endoscopic therapy is effective in approximately 70% of recurrent bleeders

  39. ManagementBut, what does the literature say? • Endoscopic • Overall Effectiveness • Active bleeding-NNT=2 • Visible vessel-NNT=5 • Injection of epi should not be done alone • NNT=9 • Burn the vessel • NNT=5 • Clip the vessel • NNT = 4-5 • Combination appears most effective • NNT = 4-5 • What about when rebleeding occurs? • NNT 4-5 Laine, et al; Endoscopic Therapy for Bleeding Ulcers: An Evidence-Based Approach Based onn Meta-Analyses of Randomized Controlled Trials, Clinical Gastro & Hep 2009;7:33-47

  40. Management • Does endoscopic Rx lower rates of Surgery? • Surgical rates before and after Endoscopic Rx Before After Active Bleeding 35% 7% Visible Vessel 34% 6% Adherent Clot 10% 2% Flat Spot 6% <1% Laine L. Et al: Bleeding Peptic Ulcer NEJM;331:717, 1994

  41. Honduras, 2007

  42. Management • Surgery • Surgical rates • Prior to the 1980’s • operative rate 20-27% • Mortality 5%, 20% in recurrent bleeds • Now the rate is 6.5-7.5% • What happened in the 1980’s?

  43. Management • Surgery • Indications: • Bleeding continues after 2nd Endoscopy • Pt cannot be stabilized • Pts who cannot tolerate recurrent or worsening bleeding • After the first endoscopic RX • Pts with ulcers >2cm or large vessels(>2mm) • WHY? This is associated with endoscopic Tx failure

  44. Management • Surgery- Operations commonly used • Vagotomy with pyloroplasty & oversew • Vagotomy with Antrectomy & oversew • Recent cohort studies indicate equivalency De la Fuente SG, et al: Comparative analysis of vagotomy and drainnage versus vagotomy and resection procedures for bleedinng peptic ulcer disease: results of 907 patients from the Dept of VA National Surgical QI Program Database. J Am Coll Surg 2006;202:78-86 • Surgical success: • 23% recurrent bleeding • 31% additional surgery • 20% mortality is possible

  45. Honduran Jurassic Park

  46. Management • Interventional Radiology • Angiography with transcatheter embolization This uses: • gelfoam, coils, super glue, polyvinyl alcohol • Usually reserved for high risk who • Failed endoscopic Tx • Too high risk for surgery • In other words: The sickest of the sick who failed all other attempts at treatment

  47. Here is what the little springs look like

  48. Management • How good is Interventional Radiology • Technical success is 52-94% • Uncontrolled trials-reduces bleeding & death • Recurrent bleeding rate=29% • Mortality=26% • Additional surgery=16.1% • Problems: • ischemic bowel • secondary duodenal stenosis • Infarct of liver, spleen or stomach

  49. Since payments are decreasing, this is the future of GI

  50. Summary • PUDz accounts for most Acute significant UGI bleeds • It is a very common and expensive problem • Identify high risk clinical criteria: • Old age -hemoglobin <10 -etoh • Syncope -elevated BUN • Tilt positive -comorbities

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