Post on 17-Dec-2015
Upper GI BleedLeigh Vaughan, MD
Division of Hospital MedicineGeneral Internal Medicine and Geriatrics, MUSC
Identify common causes for acute gastrointestinal bleeding in the hospitalized patient
Describe clinical presentation and appropriate evaluation of patients with an acute upper GI bleed
Outline appropriate resuscitative measures for the patient with consideration given to co-morbid illnesses
Delineate high risk patients who may need more aggressive intervention or level of care
Objectives
The history and physical are essential to identifying the cause of an acute GI bleed
Physical exam and laboratory data can assess the severity of illness and the likelihood of clinical decompensation
Initial and rapid stabilization with IV fluids and blood products followed by intensive monitoring are the mainstays of resuscitation efforts
Key Messages
‣ Peptic ulcer disease ‣ Gastritis‣ Esophagogastric varices‣ Arteriovenous malformation ‣ Tumor‣ Mallory-Weiss (esophageal) tears
Causes Upper GI Bleed
History Physical examination Laboratory tests Assess the severity of the bleed Identify potential sources of the bleed
Initial evaluation
HPI◦ Inquire about hematemesis ◦ Coffee ground emesis suggests limited bleed ◦ BRBPR suggests faster bleed◦ Melena- tarry black stools*◦ Clots in stool less likely upper GI bleed
PMHx◦ Prior GI bleed- 60 % patients with a history of prior GI bleed,
rebleed from same cause◦ H. pylori status◦ Relevant comorbidities
Prior surgeries that may have affected anatomy Social history
◦ Prior smoking◦ Alcohol use
History – Pertinent points
Family history◦ Coagulopathy◦ Congenital disorders with AV malformation
Medications◦ ASA, NSAID◦ Pill esophagitis- bisphosphonates, doxycycline,
KCl, quinidine, iron◦ Anticoagulants◦ Bismuth, iron- darken stool
History -continued
Assessing clinical stability◦ Resting tachycardia suggests mild to moderate volume
loss◦ Orthostatic hypotension suggests blood volume loss of
at least 15%◦ Supine hypotension indicates blood volume loss of at
least 40%◦ Involuntary guarding consider perforation
Stigmata of liver disease Skin manifestations of systemic disorders (such
as petechiae or telangiectasia) that may predispose to gastrointestinal bleeding
Rectal exam
Physical Exam – Pertinent findings
RUQ pain, epigastric discomfortPUD Dysphagia, odynophagia, GERD
esophageal ulcer Retching, cough that precedes emesis
Mallory Weiss tear Weight loss, early satiety, cachexia
cancer
Finding that may correlate with etiology
Nasogastric lavage- not uniformly recommended◦ Assess ongoing bleeding◦ Confirm upper GI bleed as source◦ Identify those who might benefit from an early endoscopy
Type and cross CBC, serum chemistries, liver tests, and
coagulation studies◦ Elevated BUN: linear correlation with likelihood of source
of bleed being upper GI◦ Other labs depending on clinical scenario (LFT, alb)
Serial EKG’s and cardiac enzymes Once stable, all patients should undergo H. Pylori
testing
Workup & laboratory,
Initial Hgb in acute bleed- likely reflects baseline (no time to drop)
Check Hgb q 2-8 depending on clinical scenario
Over resuscitation can falsely dilute Hgb Normocytic anemia most expected type in
acute GI bleed; microcytic anemia suggests chronic bleed
Interpretation of data
Multiple validated models -Blatchford and Rockall Many include endoscopic data (which not available at
presentation) Poor prognostic indicators: age, shock, comorbidities,
Hgb, need for blood, sepsis, BUN, Cr., AST, high APACHE score
AIM 65 - each risk factor gets a point, endpoints mortality & hospital stay◦ Album <3.0, INR >1.5, altered mental status, SBP <
90mmHg, age > 65◦ Zero risk factors conveys 0.3% chance of death during
hospitalization. 5 risk factors 31.8 % chance of death during hospitalization
Saltzman JR, Tabak YP,. Gastrointest Endosc. 2011;74(6):1215.
Risk stratification tools
All patients with hemodynamic instability (shock, orthostatic hypotension)
All patients with active bleeding (hematemesis, BRB per nasogastric tube, or hematochezia)
Resuscitation and close observation◦ Monitoring blood pressure, pulse oximetry, urine
output◦ Electrocardiogram monitoring
Who needs ICU? & Why?
• Fluid resuscitation with 2 large bore IVs• Bolus (not only hourly drip) of isotonic crystalloid• Consideration for invasive hemodynamic monitoring• Packed RBCs – revised transfusion criteria:
◦ Hemodynamic instability, despite fluid resuscitation◦ Hgb < 8 high risk patient, intolerant to anemia
(CAD, Pulmonary HTN, Pulmonary disease)
◦ Hgb < 7 in low risk patient◦ Overall data supportive of restrictive transfusion if
early endoscopy available◦ Every 4 u PRBC’s necessitates unit of FFP
Management – volume resuscitation
Barkun AN, Bardou M, Kuipers EJ, et al., Ann Intern Med. 2010; 152(2):101Carson JL, et al., Ann Intern Med 2012;157:49-58
NPO O2 supplement Correction of coagulopathy
◦ INR > 1.5 FFP (not vit K acutely)◦ Platelets < 50,000 transfusion◦ Recent use of ASA/ antiplatelet agent- indication for
platelet transfusion in massive bleed 2/2 induced platelet dysfunction
Empiric IV PPI (Omeprazole IV 80 bolus, plus hourly infusion)- until etiology established
Provide appropriate nutritional support Assess aspiration risk, need for intubation Early GI/ IR/ surgery involvement
Management
Beware of over zealous fluid resuscitation in CHF, renal disease
Avoid over transfusion in variceal bleed- do not exceed Hgb >10g/dL
Esophageal varices, cirrhosis◦ IV somatostatin bolus, followed by hourly infusion◦ Broad spectrum antibiotics* - 20% patients have
concurrent infection, 50% develop infection during hospital course
Confounding variables
Do NOT delay endoscopy-moderately anticoagulated (INRs of 1.3 -2.7) success rates are comparable to those not anticoagulated ◦ INR > 3.0 urgent reversal prior to endoscopy◦ Attempt to lower below 2.5 -3.0 when possible
No reversal agent for direct thrombin inhibitors or Factor Xa inhibitors
Anticoagulation & active bleed
Endoscopy- #1 tool, used early (24 hr)◦ Can locate bleed◦ Can achieve hemostasis◦ Can prevent rebleed◦ Requires hemodynamic stability◦ Patients likely get erythromycin (as prokinetic)
prior to procedure in severe bleed Tagged red cell Angiography NO GI barium- contraindicated
Invasive tests, studies
Reliable patient with good follow-upFavorable factors
Few comorbiditiesNegative NG aspirateHemodynamic stablilityNormal labs (Hgb, BUN, Cr.)Likely source of bleed identified (from endoscopy
or other modality)Absence of factors associated with rebleed
(variceal bleeding, active bleeding, bleeding from a Dieulafoy's lesion, or ulcer bleeding with high-risk stigmata)
Who can be discharged quickly & safely?
All decisions predicated on favorable risk benefit analysis
Resumption of warfarin after bleed◦ Many risk stratification tools (HAS-BLED, ATRIA)◦ If risk/benefit ratio favors resuming, wait 4 days after bleed
‣ Patients who require NSAIDS - PPI with a cyclooxygenase-2 inhibitor can reduce, not prevent, rebleed
‣ Discharge in cardiac patients requiring ASA- ASA +PPI may be resumed in 7 days
‣ Most patients should receive a single Rx for daily dosing of PPI; duration should be determined by cause of bleed
Discharge medications
Barkun AN, Bardou M, Kuipers EJ. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010;152(2):101.
The role of endoscopy in the management of acute non-variceal upper GI bleeding. Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy. Gastrointest Endosc. 2012;75(6):1132.
Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012 Mar;107(3):345-60; quiz 361. Epub 2012 Feb 07.
Carson JL, Grossman BJ, Kleinman S, et al. Red blood cell transfusion: a clinical practice guideline from the AABB. Ann Intern Med 2012;157:49-58
References