10/6- GI Hemorrhage Flashcards
What is “upper” GI bleeding?
- What percentage of GI bleeding cases does it account for?
Bleeding proximal to the ligament of Treitz
- 50% of admissions for GI bleeding
Etiology of upper GI bleeding?
- Peptic ulcer – 38%
- Varices – 16%
- Esophagitis – 13%
- Malignancy – 7%
- AVM – 6%
- Mallory-Weiss Tear – 4%
- Erosions – 4%
- Dieulafoy’s – 2%
- Unknown – 8%
What is this?
Esophageal cancer
What is this?
Mallory-Weiss tear (GE junction)
What is this?
NG tube trauma
What causes the majority of peptic ulcer disease?
- H. pylori infection
- NSAID use
What is the pathophysiology behind bleeding in cirrhosis?
Portal hypertension develops from:
- increased resistance to flow due to the architectural distortion of the liver along with
- intrahepatic vasoconstriction from decreased nitric oxide
Results in porto-systemic collaterals
- Hepatic venous pressure gradient (HVPG)
- Normal 3-5mmHg
- Esophageal varices develop above 10-12mmHG
- Varices present in 50% of cirrhotics, presence correlates with severity of liver disease
- Varices appear at 8% per year, small become large at 8% per year
- Variceal hemorrhage 5-15% per year, risk associated with large varices, decompensated cirrhosis, and red wale signs
- Variceal bleeding = 20% mortality at 6 weeks
- Gastric varices in 5-33% of patients with portal hypertension, 25% bleeding risk in 2 years
What is portal hypertensive gastropathy?
Chronic slow blood loss/anemia
What is gastric antral vascular ectasia?
Anemia; does not respond to TIPS/b-blockers
What is this?
Snake skin appearance of portal hypertensive gastropathy
What is this?
“Watermelon stomach” of gastric antral vascular ectasia
What should be covered in the history for evaluating upper GI bleeding?
- Prior bleeding episodes, from what source?
- Alcohol use
- History of liver disease
- GERD
- Weight loss, N/V, family history malignancy
What medications may contribute to upper GI bleeding?
- Ulcers can develop within a week of starting aspirin/NSAIDs
Combination antiplatelets/anticoagulants
- Aspirin and clopidogrel
- Aspirin and warfarin
- Aspirin, clopidogrel, and warfarin
- Dabigatran, rivaroxaban
What should the physical exam cover in the evaluation of upper GI bleeding?
- Vital signs
- Tachycardia
- Orthostasis – at least 15% blood loss
- Supine hypotension – 40% blood loss
- Signs of chronic liver disease
- NG tube: possibly wash and see if blood comes back
- Stool examination
What are the benefits of Fecal Occult Blood testing?
- What is it not diagnostic for?
- Has been shown to reduce mortality from colorectal cancer
- Cancer detection test – recommended as an alternative to patients who decline a cancer prevention test (colonoscopy)
- No role in evaluation of a patient presenting with GI bleeding
What are the important lab results in evaluating upper GI bleeding?
- H/H - BUN (prerenal rise in BUN)
- PT/INR
- Evidence of chronic liver disease and/or portal hypertension (bilirubin, albumin, INR, platelets)
What four questions should you ask yourself in the clinical assessment of someone with upper GI bleeding?
Is this a GI bleed?
- Combo of history, lab values, and vital signs which come together to make a believable story
Is this an active bleed?
- Ongoing hematemesis or melena, continued hemodynamic instability, failure to respond to transfusion (taking into account resuscitation)
Where is the source?
Is the patient stable?
What signs point to the location of GI bleeding?
- Hematemesis/coffee ground emesis: upper GI source
- Melena: upper GI through proximal colon
- Hematochezia: brisk upper GI through rectal bleeding
- Negative NG lavage does NOT exclude an upper GI source
What are prognostic scores of upper GI bleeding: Rockall?
0-3
- Based on age, shock, comorbidity, diagnosis, major SRH…
What are prognostic scores of upper GI bleeding: Blatchford?
Based on:
- Blood urea
- Hemoglobin
- Systolic BP
- Other markers
What are prognostic scores of upper GI bleeding: AIMS 65 Score?
1 point (5 max) for:
- Albumin under 3.0 mg/dL
- INR > 1.5
- Altered mental status
- SBP under 90 mmHg
- Age > 65 yo
What is treatment for upper GI bleeding?
Hospitalization
- Admission
- ICU vs. floor
- Suspected variceal bleeding Intubation
- Encephalopathic cirrhotic
- Prophylactic for EGD?
Resuscitation!
Transfusion
Medical therapy
Endoscopy
Adequate vs. inadequate resuscitation?
Left: inadequate
Right: adequate
Transfusion strategies for upper GI bleed?
Restrictive strategy (7 g/dL to goal 7-9) was better than liberal (9 g/dL to goal 9-11) strategies
Hazard ratios with restrictive strategy:
- Death within 45 days 0.55 (95% CI 0.33 – 0.92)
- Further bleeding 0.62 (0.43 – 0.91)
- Adverse events 0.73 (0.56 – 0.95)
What is medical therapy prior to endoscopy in a non-cirrhotic patient with an upper GI bleed?
Proton pump inhibitor drip (omeprazole, esomeprazole, pantoprazole)
Reduce acid
- Allow normal platelet aggregation for hemostasis
- Allow ulcer/esophagitis to heal
What is medical therapy prior to endoscopy in a cirrhotic patient with an upper GI bleed?
Octreotide (somatostatin analog)
- Reduce portal pressures
Antibiotics (ceftriaxone or ciprofloxacin)
- Prophylaxis against spontaneous bacterial peritonitis (SBP) and bacteremia PPI – cirrhotics can also have ulcers
What is the goal of antisecretory therapy?
How is it accomplished?
Goal is pH > 6 to allow normal platelet aggregation
- IV PPI bolus/infusion is the most effective
What is the most important medical treatment in upper GI bleeds?
Antibiotics in the cirrhotic patient
- This actually improves mortality
What is the significance of timing with an endoscopy?
- Generally low quality evidence
- Earlier endoscopy = more likely to find high risk stigmata -> more likely to receive endoscopic therapy
- Patients with UGIB should undergo endoscopy within 24 hours
- Patients with high risk features may have improved clinical outcomes with endoscopy within 12 hours
What is the purpose of performing an endoscopy?
- Diagnosis
- Risk stratification
- Endoscopic therapy
What are conditions requiring post-endoscopy meds?
- Peptic ulcer diseas
- Varices
What is seen here?
Clean base
What is seen here?
Flat red spots; low risk
What is seen here?
Adherent plaque; need to remove and find ulcer
What is seen here?
Visceral area; protuberant instead of flat
- Much higher risk
What is seen here?
Left: adherent clot
Right: treated?
What is seen here?
Actively bleeding/oozing ulcer
What is seen here?
Active arterial spurting; very high risk
T/F: IV PPI after endoscopic treatment of bleeding ulcers improves need for surgery and 30 day mortality
False; does neither
What are some other considerations after treatment of bleeding ulcers?
Ensure follow-up of H. pylori testing (serology or biopsy) with treatment and confirmation of eradication
- Amox/clari/metro/PPI
- Bismuth/tetracycline/metro/PPI
Restart aspirin prior to discharge in patients who have a good indication
What is seen here?
Whale sign; visible vessel
What is seen here?
We treat peptic ulcers with banding (?)
What is after treatment for varices?
- Continue prophylactic antibiotics to complete a maximum of 7 days
- Continue octreotide to complete 3-5 days
- PPI for prophylaxis against banding ulcer bleeding
- Repeat endoscopy for ablation of varices
What should be done when endoscopy fails?
Refractory ulcer bleeding
- High risk ulcers
Refractory variceal bleeding
- Gastric varices when cyanoacrylate not available
- Esophageal varices that fail endoscopic therapy Interventional radiology and surgery
What are the main causes of lower GI bleeding?
- Diverticulosis (30%)
- Hemorrhoids (14%)
- Ischemic (12%)
- IBD (9%)
- Post-polypectomy (8%)
- Colon cancer/polyps (6%)
- Rectal ulcer (6%)
- Vascular ectasia (3%)
- Radiation colitis/proctitis (3%)
- Other (6%)
What should be considered in the history when evaluating a lower GI bleed?
- Abdominal pain, diarrhea, weight loss
- History of IBD (Crohn’s, ulcerative colitis)
- History of GI malignancy
- Recent colonoscopy (with polypectomy)
- Radiation to prostate
- Abdominal aortic aneurysm
Consider upper GI source
- 15% of cases of hematochezia from upper GI source
- Significant hematochezia with orthostasis or hypotension requires EGD
- Consider NG lavage
Can have melena from small bowel or right colon (may also need colonoscopy, especially if EGD negative)
What is management for lower GI bleeding?
Resuscitation, transfusion
Colonoscopy
- Therapeutic
- Can find non-bleeding stigmata
- Visualization may be limited by blood
Tagged RBC scan (0.04 mL/min)
- Safe, only diagnostic
- Requires active bleeding
Angiography (0.5 mL/min)
- Therapeutic
- Requires active bleeding
- Risks of contrast dye
Surgery
- Need to localize and identify source prior to surgery
- Malignancy
- Recurrent diverticular bleeding
Endoscopy treatment for varices and ulcers?
Varices: banding Ulcers:
- Metal clip
- Epenephrine
