GI BleedsRebecca Burton-MacLeodFeb 15th, 2007Emerg Med Resident Rounds

Overview Anatomy Upper GI bleeds Lower GI bleeds

Anatomy UGI vs. LGI defined by Ligament of

Treitz…located in 4th section of duodenum

UGI vs. LGI ? Melena and hematemesis means

UGI bleed, right? Hematochezia—10-15% of pts will be

UGI presentation

Ddx in adults UGI:

PUD Gastric erosions Varices Mallory-Weiss tear Esophagitis Duodenitis

LGI: UGI bleed Diverticulosis Angiodysplasia Ca/polyps Rectal disease

(hemorrhoids, fistulas, fissures)

IBD Infectious

75%80%

Ddx in adults No identifiable source found for GIB

in 10% of patients

Elderly and LGIB Tips from EMR… Don’t rely on the color of stool to determine the bleeding site.

Colors change as transit times vary and blood products break down.• All that bleeds bright red is not a hemorrhoid. Unless it’s bleeding before your eyes, look for another diagnosis.• Elderly patients may not manifest orthostatic changes from blood loss as readily as their younger counterparts. • The initial hemoglobin may not be a reliable indicator of the volume of blood lost, as the volume may be contracted. • Look for other systemic causes if your investigation of the abdominal structures turns up negative and the patient still has abnormal vitals, especially if the rectal bleeding has ceased.• Order typed blood products.• Peritoneal signs may take up to 20 hours to manifest.• Perform a digital exam and anoscopy on a patient with anorectal bleeding.

Case 78M presents with hematemesis and

hematochezia x 2hrs. States he has had increasing episodes over last 30min. Feeling presyncopal.

PMHx: HTN, CAD, AAA repair 3mos ago O/e: HR 110, BP 100/70; pale, clammy Any thoughts?

Ddx in peds

UGI: Esophagitis Gastritis Ulcer Varices Mallory-Weiss tear

LGI: Anal fissure Infectious colitis IBD Polyps Intussusception

Case 47M brought in with hematemesis…

EMS reports just vomited 1-2L of BRB. He reports this is his third episode in last 1hr

Feeling weak, pale. Says he thinks he’s going to vomit again…

HR 132, BP 86/62 Plan?

Case cont’d Monitors, supplemental O2 2 x 18G IVs CBC, INR/PTT, T+S 2L bolus IV N/S with monitoring

vitals Consider PRBC if ongoing vomiting,

vitals fail to improve Consult GI ASAP

Diagnosis History:

Hematemesis, melena, hematochezia Duration/amount of bleeding, previous

episodes, recent meds/Etoh/surgeries s/s of blood loss

Physical: Vitals—sustained tachycardia is most

sensitive Don’t forget the DRE…and good ol’ FOB

testing!

Case 56F who presents c/o abdo pain and “black

stool”. Epigastric pain x1day. No emesis. 1x episode of black stool this a.m. No previous hx

PMHx: HTN Meds: HCTZ, pepto-bismol (used last nite for

epigastric pain) O/E: HR 82, BP 140/80. exam unremarkable

except black stool on DRE (FOB negative) Any thoughts?

Ddx bleeding

Melena: Requires >150ml

blood digested over prolonged period (~8h)

Pepto-bismol Iron Blueberries

Hematochezia: Only 5ml of blood

required to turn “toilet water bright red”

Beets

FOB testing False positives:

Red fruits/meats Methylene blue Chlorophyll Iodide Cupric sulfate Bromide

False negatives: Rare! Bile Ingestion of Mg-

containing antacids Ascorbic acid

HOB testing What about pt with “coffee ground

emesis” appearing vomitus…any role for HOB testing?

Case 2day-old post SVD, no

complications. Discharged home earlier today. At home, had a bloody BM (parents bring the diaper just to show you!)

Pt exams well. Normal vitals. Any investigations?

GIB investigations CBC, INR/PTT, T+S

Remember, Hct lags behind clinical picture, and is affected by hemodilution

Consider lytes, BUN, Cr EKG Upright CXR if suspect perf

Case 78M presents to ED with hx of melena

x3days…wife convinced him to come get it checked. Slightly dizzy.

PMHx: Afib, diverticulosis Meds: metoprolol, warfarin O/e: HR 72 BP 118/69, obvious melena

stool on DRE. Exam otherwise unremarkable.

Thoughts ? Investigations ?

Case cont’d Blwk:

Hgb 117, Plt 450 INR >9

Reverse INR? Vit K? FFP?

Role of CT ? Not indicated in UGIB cases Sensitivity for identifying

mesenteric ischemia is 64-82% Identification of other colonic

pathology is 75% sensitive specificity 96% NPV 96%

Case 58M with hx of CAD. Presents with

2x episodes of melena yest and 1x episode hematemesis after breakfast this a.m. C/o epigastric pain which radiates into his chest, SOB, dizziness. No previous episodes

O/E: HR 92 BP 120/80 You order CBC, INR/PTT, T+S, EKG

EKG

Case cont’d His labs are still pending What do you want to do? One of your colleagues walks by and

eyeballs the EKG and says “wow, that patient needs ASA, b-blocker, heparin, cardiology consult STAT”…what do you think?

UGIB and NG tubes Any role for NG tube insertion?

May aid in ruling out LGIB in pt with hematochezia

Otherwise, 10% of established UGIB will have negative NGT aspirates…so NOT useful!

Lots of false negatives (ex: bleeding in duodenum or bleeding already stopped)

Bottomline…not very useful…

UGIB management GI—endoscopy Gen Surg—operative Intervent Radiol—angio

Melena, Cuba

UGIB and endoscopy Most accurate diagnostic tool Identifies source in 78-95% of pts,

when performed within 12-24hrs post-UGIB

Allows for risk stratification (rebleeding and mortality) as well as treatment (banding or sclerosing of varices)

When to scope ? Most authors suggest within 12-24hrs Lin et al (1996): Large RCT (n=124pts) showed that

endoscopy within 12h is safe and effective Leads to dec transfusion requirements Dec length of hospital stay Dec costs

UGIB and angiography Detects location of UGIB in 2/3 of pts Usually performed during active

bleeding Unstable vitals Ongoing transfusion requirements

UGIB and surgery Mortality for pts undergoing surgery for

UGIB is 23% Hemodynamically unstable pts, not

responsive to medical/transfusion mgmt, endoscopy unavailable

Consider if >5U PRBC given over first 6h or when 2U PRBC required q4h after replacing initial losses—and still unstable!

UGIB medications PPI—pantoloc

Bolus 80mg then run @ 8mg/h x 72hrs Role in pts with PUD as cause Is an adjunct, not therapy for UGIB…still need

endoscopy Somatostatin analogues—octreotide

Bolus 40ug then continuous infusion Role in esophageal varices Peptide analogue which causes splanchnic

vasoconstriction by direct effect on vascular smooth muscle

Pantoloc ?

Octreotide ? Multicenter RCT of octreotide vs. injection

sclerotherapy for acute variceal hemorrhage

N=150 No significant differences in control of

bleeding, re-bleeding, and mortality Octreotide felt to be as effective as

injection sclerotherapy Jenkins SA, et al. A multicentre randomised trial comparing octreotide and

injection sclerotherapy in the mgmt and outcome of acute variceal hemorrhage. GUT. 1997.

Vasopressin ? Has been used in pts with

esophageal variceal hemorrhages No effect on overall mortality High rate of complications (9%

major, 3% fatal) Only role would be in exsanguinating

pt, with endoscopy or other measures unavailable

Sengstaken-Blakemore tubes Useful if esophageal

variceal bleeding source

Linton tube if gastric varices

High risk of complications (14% major, 3% fatal)

One of those last-ditch efforts!

Insertion techniques…

SB tubes… Equipment:

Sterile Sengstaken-Blakemore tube

Pair of scissors 50ml syringe 2 x rubber tipped artery

forceps Water soluble lubricant 3 metres of white linen

tape Pressure gauge Weight for traction Pulley PPE

Precautions: Balloon pressure should

always be <45mmHg Pt should be intubated

prior to procedure Keep scissors near bed at

all times (to cut tube prn if migrates and causes resp distress)

Check tube placement by:• Aspirate and check pH• Inject air and auscultate

over stomach• XR

Insertion… Any takers ?

SB tube

Sengstaken vs. Linton tubes ? RCT of SB vs. LN tubes in pts with known

esophageal/gastric varices N=79 Primary hemostasis in 86% of pts If esophageal varices as cause, SB more

effective at permanent hemostasis (52 vs. 30%)

If gastric varices as cause, LN tube much more effective (50 vs. 0%)

Teres J et al. Esophageal tamponade for bleeding varices. Controlled trial between the Sengstaken-Blakemore tube and the Linton-Nachlas tube. Gastro 1978.

LGIB and scopes Must r/o UGIB source first usually If mild LGIB with no evidence of

hemorrhoids, then anoscopy / proctosigmoidoscopy recommended

Absence of blood above rectum indicates rectal source; however, blood above rectum does not r/o rectal source

LGIB and angiography Does not usually diagnose cause of

bleeding, but identifies source in 40% of pts

Arterial embolization may be useful if ongoing bleeding

Disposition Very-low risk Low risk Medium risk High risk

D/c home if: No comorbid disease Normal vitals Normal or trace FOB positive +/- neg gastric aspirate Normal (or near) Hgb/Hct Good social situation F/u within 24hrs Understanding as to when to return…

Initial ED stratification Low Risk Moderate Risk High Risk

Age <60 Age >60  

Initial SBP ≥100 mm Hg Initial SBP <100 mm Hg Persistent SBP <100 mm Hg

Normal vitals for 1 hr Mild ongoing tachycardia for 1 hr

Persistent moderate/severe tachycardia

No transfusion requirement Transfusions required ≤4 U Transfusion required >4 U

No active major comorbid diseases

Stable major comorbid diseases

Unstable major comorbid diseases

No liver disease Mild liver disease—PT normal or near-normal

Decompensated liver disease—i.e., coagulopathy, ascites, encephalopathy

No moderate-risk or high-risk clinical features

No high-risk clinical features

 

Stratification with initial and endoscopy findings

  Clinical Risk Stratification

Endoscopy Low Risk Moderate Risk High Risk

Low risk hospitalization

Immediate discharge[*] 24-hr inpatient stay (floor)[†] Close monitoring for 24 hr[‡]; ≥48-hr

Moderate risk 24-hr patient stay[†]

24–48 hr inpatient stay (floor)[†]

Close monitoring for 24 hr; ≥48-hr hospitalization

High risk Close monitoring for 24 hr; 48–72 hr hospitalization

Close monitoring for 24 hr; 48–72 hr hospitalization

Close monitoring ≥72-hr hospitalization

So what does this mean at FMC for UGIB pts… Low-risk pts:

Hold o/n in ED until scoped

Consider admission to Hospitalist until scoped (depending on GI suggestions)

Med risk pts: Admit to

Hospitalist/Medicine until scoped

Scope immediately High risk pts:

Scope immediately Admit to

Medicine/ICU

Disposition LGIB pts If not clearly due to hemorrhoids,

fissures, proctitis then should admit Low risk: admit to Hospitalist with

scoping Med/High risk: admit to

Medicine/ICU with scoping +/- angio