Dyph Gi Bleed
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Gastrointestinal Bleeding
Janak N. Shah, MD
Assistant Clinical Professor of Medicine
University of California, San Francisco
Director of Endoscopy
San Francisco VA Hospital
October 2007
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GI Bleeding : Definitions
IDA : iron deficiency anemia
FOBT: fecal occult blood test
From Zuckerman, Lewis, et al. (AGA Clin Practice Committee). Gastroenterol 2000; 118: 201
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Acute GI Bleeding : epidemiology
UGI ~ 100 hospitalizations /
100,000 persons per year
M > F Increases with age
Rockall, BMJ 1995, 311: 222
Mortality 7-14%Rockall, BMJ 1995; 311: 222
Longstreth, AJG 1995; 90: 206
Yavorski, AJG 1995; 90: 568.
LGI ~ 21 hospitalizations /
100,000 persons per year
M > F Increases with age
Mortality 4%
Longstreth, AJG 1997; 92: 419
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Manifestations of Overt GI BleedingHemetemesis
Red blood or coffee-ground emesis
Melena
Black, tarry, foul-smelling Blood in GI tract > 14 hours
Hematochezia Bright red / maroon stool, bloody diarrhea, clots
Usually LGI source : UGI source in 10%
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How much blood does it take to
produce
Melena?
Hematochezia from UGI source?
FOBT + ?
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How much blood does it take toproduce
Melena? 50-100cc
Hematochezia from UGI source? 500-1000cc
FOBT + ?
From UGI source: 10-20 cc
From LGI source: 0.5 cc
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Acute UGI Bleeding : Etiology
What are common causes of UGIhemorrhage?
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Acute UGI Bleeding : Etiology
Etiology N = 4137
Peptic ulcer disease 1448 (35%)
Erosive mucosal disease 873 (21%)
Mallory-Weiss syndrome 214 (5%)
Varices 180 (4%)
Malignancy 155 (4%)
Other diagnoses 253 (6%)
No diagnosis made 1014 (25%)
Rockall, BMJ 1995, 311: 222
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Acute UGI Bleeding : Less Common Etiologies
Hemobilia
Hemosuccus pancreaticus
Aorto-enteric fistulas
GAVE (watermelonstomach)
AV malformation /
vascular ectasias
Dieulafoys lesion
Portal HTN gastropathy
Hereditary hemorrhagic
telangiectasia (Osler-
Weber-Rendu)
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Acute LGI Bleeding : Etiology
What are common causes of LGIhemorrhage?
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Acute LGI Bleeding : Etiology
From Elta, GIE 2004; 59: 402
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Case 1:
65-year old male presents to the ED with a 1-dayhistory of melena and coffee-ground emesis. Pt
reports feeling weak and light-headed. You are
called by the ED to evaluate this patient
What are important history, physical, and laboratory featuresto assess in this patient ?
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Overt GI Bleeding : Clinical Assessment
History and Physical
ASA / NSAIDs / anti-coags
Alcohol intake
Vitals/postural changes (vol
depletion of 15%)
Hx/ Signs of liver disease
Rectal exam- stool color N/G lavage (dx / pre-egd) : 16%
of UGI bleeds: negative N/G
Lab studies
CBC / coagulation studies
type and crossmatch
Liver tests
Chem 7
Clinical prognostic factors
Hemodynamic instability
on presentation Red blood emesis +
hematochezia
Failure of N/G clearing Advanced age (>60)
Medical co-morbidities
Laine and Peterson, Bleeding pepticulcer, NEJM 1995; 331: 717
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Case 1: Clinical assessment performed
History + NSAIDs QD x 1 month for back pain
EtOH: 1-2 glasses wine, 2-3 x week
Physical exam VS: supine 120/70, 105-sitting 105/65, 120
No PE signs of liver disease Abd: soft, NT, rectal- black, tarry stool
N/G lavage: large vol clots, does not clear
after 2L lavage
Labs CBC: wbc 9, hct 44, plts 180
Coags: nl
Liver tests: nl
What should be done now?
A) Emergent EGD in ERB) Admit to ward, EGD
tomorrow
C) Start PPI (IV), no needfor EGD
D) Fluid resuscitation,
admit to ICU, urgent
EGD after stabilization
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Case 1:
There is a shortage of ICU beds. The ED team asks
if a general ward admission would be appropriate.
They argue that the HCT is normal, and thus this
patient is not having substantial hemorrhage.
What is your response ?
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Hematocrit to Assess Blood Loss
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Issues to consider prior to EGD for
UGI bleeding Adequate hemodynamic resuscitation
Good IV access Hemoglobin >8 g/dl (higher with cardiopulmonary dz)
Carson, Lancet 1988; 1:727 , Carson, Lancet 1996; 348:1055
Need for intubation Consider intubation for persistent hemetemesis or
bloody N/G output
Conscious sedation vs. deep sedation (anesthesia)
Clotting parameters Platelets > 50,000
INR 1.5-2.5 Choudari, Gut 1994; 35: 464.
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Case 1: Upper Endoscopy Performed
Visible vessel in duodenal bulbar ulcer (3cm). Active bleeding
started during EGD prior to endoscopic therapy.
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Endoscopic Prognostic Factors in
Ulcer Hemorrhage
What are the endoscopic factors associatedwith a worse prognosis (rebleeding, death)
in this patient?
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Endoscopic Prognostic Factors
What are the endoscopic factors associatedwith a worse prognosis (rebleeding, death)
in this patient?
Actively bleeding ulcerLaine, NEJM 1995; 331: 717.
Large ulcer size (>1cm)
24% vs 12% rebleed, 13% vs 1.6% mortalityBranicki, World J Surg 1990; 14: 262.
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Prevalence and Outcome of Bleeding Ulcer by
Endoscopic Appearance
From Laine, NEJM 1995; 331: 717.
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Endoscopic Stigmata in PUD
Flat spot Clot
Clean base
From Laine, NEJM 1995; 331: 717.
Visible vessel Active bleeding
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Endoscopic Treatments for PUD with High-risk
Stigmata (active bleeding / visible vessels)
Epinephrine injection (1:10000)
Contact thermocoagulation(BPEC, heater probes)
Non-contact thermal (laser,
APC)
Endoclips
Sclerosant injection
(polidocanol, absolute alcohol)
Fibrin glue, thrombin injection Saline injection (tamponade)
Combo tx superior to mono tx (epi alone) for high risk lesions
10% vs 18% rebleeding (Meta-analysis) Calvet, Gastroenterol 2004; 126: 441.
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Endoscopic Techniques : Coaptive Thermocoagulation
Large caliber probe (10F)
Firm tamponade
Bipolar (multipolar electrocautery) : 15-25 Watt setting
Heater probe : 30 joule setting
hemostasis: > 90% Complications: induce bleeding 0.3%; perforation 0.5%
From Laine, NEJM 1995; 331: 717.
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Endoscopic Techniques : Endoclips
hemostasis: > 90%
From Raju, GIE 2004; 59: 267.
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Case 1 : Endoscopic Therapy
successful hemostasis with contact thermocoagulation and hemoclips
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Case 1: Post-treatment recommendations:
Endoscopic treatment is successful in achieving
hemostasis. The ICU nurse manager asks you
Can the patient be transferred to the medical ward?
Should any other medications be started?
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Algorithm for the Management of
Bleeding Ulcers
ICU for 1 day;
Ward for 2 days
Endoscopic Therapy
Active Bleeding
or
Visible Vessel
Ward for 3 days
No Endoscopic Therapy
Clot or
Flat Spot
Discharge within 1 day
No Endoscopic Therapy
Clean Base
ULCER
Adapted from Laine, NEJM 1995; 331: 717.
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PPI for Bleeding Ulcers
Low intragastric pH (
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Case 1: continued
The patient is hemodynamically stable over the next
22 hours. Just prior to transfer to the medical
floor, the patient develops hemetemesis, withhypotension and tachycardia.
What is the recommended management :
A) Repeat endoscopyB) Endoscopic therapy has failed call IR for angio
C) Continue PPI (IV), no need for EGD
D) Endoscopic therapy has failed call surgery
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Recurrent Bleeding after Endoscopic Therapy
~ 20% rebleed after endoscopic txLower with PPI therapy Lau, NEJM 2000; 343: 310
Permanent hemostasis with repeat endo tx in 50%
of re-bleeders
~ 10% with high-risk stigmata require surgery
Laine, NEJM 1994; 331: 717
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Non-endoscopic Therapy for Bleeding Ulcers
Surgery:
Endoscopic failures
Angiographic treatment:
Intra-arterial vasopressin : 50% success
Embolization: 75% success, but rebleed in 50%;complications- ischemia, perforation
High surgical risk, endoscopic failure
Laine, NEJM 1994; 331: 717
C 2
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Case 2:
A 45 old female with known cirrhosis secondary to alcoholabuse presents with a 2-day history of melena.
PE:
vitals: 85/65, 115vitals: 85/65, 115 AbdAbd: soft,: soft, nontendernontender,, splenomegalysplenomegalyRectal: black, tarry stool
N/G lavage: 200cc maroon blood / clots, clear after 1L lavage
Labs: hct 27, plts 130, INR 1.7
She is presumptively dxd in the ED with acute varicealhemorrhage, and is awaiting a bed in the ICU. Blood, Plts,
FFP transfusions have been started.
The ED resident pages the on-call medical intern and asks,
Should any medications be started while awaiting endoscopy?
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Case 2 : Endoscopy performed
Active variceal bleeding
noted
What types ofendoscopic treatments
are available ?
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Endoscopic techniques for variceal hemorrhage
Band ligation vs sclerotherapy
Similar / better initial hemostasis
> 90%
Decreased complications
Esophageal strictures / ulcers
infectionsLo, Hepatol 1997; 25:1101
Laine, Ann Int Med 1993; 119:1
Stiegmann, NEJM 1992; 326: 1527
Decreased mortality ?19% vs. 35% Lo, Hepatol 1997; 25:1101
28% vs. 45% Stiegmann, NEJM 1992;326:1527From Rockey, NEJM 2001; 345:669
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Endoscopic Variceal Band Ligation
From Helmy, APT 2001; 15: 575
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Case 2 : Endoscopic therapy performed
Deployment of bands was suboptimal due to
ongoing hemorrhage and difficult
visualization, and was unsuccessful.
Sclerotherapy was also attempted, butfailed.
What other treatment options are available ?
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Balloon Tamponade
Minnesota Tube High rates of initial bleed
control (>70%)Fort, Hepatol 1990; 11:678
Paquet, Hepatol 1985; 5:580
High rebleed rates (40%)Paquet, Hepatol 1985; 5:580
Complications:
esophageal perforation
< 8%Chojkier, Dig Dis Sci 1980; 25:267
TIPS f A t R f t
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TIPS for Acute Refractory
Variceal Hemorrhage
~ 10% fail endo tx
Rockey, NEJM 2001; 345:669
TIPS effective > 95%Sanyal, Gastroenterol 1996; 111:138
Boyer, Gastroenterol 2003; 124:1700
Rebleed 18%
Mortality (in acute
setting) 38%From Boyer, Gastroenterol 2003; 124:1700
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TIPS Complications
From Boyer, Gastroenterol 2003; 124:1700
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TIPS vs Endoscopic Therapy
From Boyer, Gastroenterol 2003; 124:1700
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Surgical Shunts for Variceal Hemorrhage
for variceal bleeding unresponsive to
endo/pharmacologic tx; and TIPS unavailable
High rates of bleeding control
High 30-day mortality rates (~ 80%)Jalan, AJG 1995; 90: 1932
Case 3:
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Case 3:
A 75-year old male with hx of HTN and osteoarthritis presents with 1-dayhistory of hematochezia (large volume, maroon color). Denies nausea,
vomiting, or abdominal pain.
PMH: otherwise unremarkable meds: ACE inhib, NSAIDs
PE: Patient is comfortable, no acute distress
vitals- 130/90, 95 supine : 110/85, 98 sitting
abd- soft, nontender rectal- maroon stool, clotsN/G lavage- bilious aspirate
labs- plts 190, INR 1.1, init hct 32, 4hr f/u hct 30
IVF fluids were started and the patient is placed in a monitored bed.
The ED resident calls the on-call medical team.
What are the possible management options ?
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LGI Bleeding : Diagnostic / Tx Options
Bleeding scan- nuclear scintigraphy
Urgent colonoscopy
IR-angiogram
Surgery
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Nuclear Scintigraphy Bleeding rate: 0.2-0.5 cc/min
Positive yield in acute LGIB: 40%
Accurate positive yield: 48%
Contradictory bleeding site: 10%
Increased yield with increased transfusion requirement
Olds, J Clin Gastroenterol 2005; 39.
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LGI Bleeding : Urgent Colonoscopy
12-48 hrs of admission
Dx made in 74-90%
Oral purge technique
Polyethylene glycol
1 L every 30-45 min (consider N/G)
Median 5.5 L , 3-4 hrs
Elta, GIE 2004; 59: 402
l f d
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Case 3: urgent colonoscopy performed
What is the diagnosis ? Can this patient be endoscopically treated ?
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Diverticular Hemorrhage : Endoscopic Treatment
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Diverticular Hemorrhage : Endoscopic Treatment
From Elta, GIE 2004; 59: 402
UCSF experience 2003-2004: 11 with active or visible vessel treated with clips +/- epi
100% initial hemostasis
18% rebleed during mean 13.5 month follow-up
Management of Massive LGI Bleeding
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Management of Massive LGI Bleeding
Angiography / IR
+/- nuclear bleeding scan for localization
Requires 0.5-1.0 cc/min bleeding rate
Techniques: intra-arterial vasopressin (>90% success, 50% rebleed)
Selective embolization (>90% success, 76% ITT basis)
Complications: ischemia 7%, rebleed 20%, surgery 20%Gordon, Am J Surg 1997; 174.
Surgery
Hemicolectomy with accurate localization (endo / IR) Subtotal colectomy
Consider for large transfusion requirements: > 6U/24hrs
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From GIE 2001; 53:859
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Endoscopic Bleeding Lesions
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Endoscopic retroflexed view, GE junction
Diagnosis ?
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Mallory-Weiss tear treated with endoclip
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Endoscopic view, fundus of stomach
Diagnosis ?
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Dieulafoys lesion treated with contact
thermocoagulation and endoclip
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Endoscopic view, distal esophagus
Diagnosis ?
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Mallory-Weiss tear closed with endoclip
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Endoscopic image through a side-viewing scope,
2nd portion of duodenum
Diagnosis?
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Endoscopic view, distal esophagus
Diagnosis ?
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Esophageal ulcer with actively bleeding visible vessel
treated with epinephrine injection and endoclip
Varices with stigmata of bleeding:
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Varices with stigmata of bleeding:
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