1.10 GI Bleed Flashcards
Where do Upper GI Bleeds come from?
What are UGI bleed etiologies?
One particular etiology is usually due to operative complication… what is this UGI etiology?
- Where
- Stomach, esophagus, duodenum
- Etiologies
- Duodenal ulcer
- 80% of UGI bleed
- Esophagitis
- 10% of cases
- GERD, EtOH
- 10-15% risk of Barret’s Esophagus
- Peptic Ulcer Dz
- NSAID use
- H Pylori
- Varices
- Tumors/malig
- Mallory-Weiss tear
- Aortoenteric Fistula
- Rare, late postop aortic surgery complication
- Can be fatal
- Herald bleed: hematemesis or hematochezia
- Several day ‘grace period’
- Subsequent massive bleeding and CV collapse
- Abd pain, back pain, fever, sepsis
- Duodenal ulcer
Describe the risks of upper GI bleeding across the following areas:
- Acute illnesses
- Chronic conditions
- Drugs
- Devices
- Acute illnesses
- Shock
- Resp failure
- Head trauma
- Thermal injury
- Chronic conditions
- Renal dysfunction
- Liver dz
- Coagulopathy
- H Pylori
- Drugs
- NSAIDs
- Anticoagulants
- Antiplatelets
- Devices
- Mechanical ventilation
- RRT
- ECMO
Your patient with hx of GERD presents with 1d of hematemesis. Your suspicion for UGI bleed would be heightened further with any of the following physical findings:
- Confusion, lethargy
- Decreased UO
- Resting sinus tachy
- Hotn
- Orthostatic at first when supine
- Abdominal exam
- Changes in bowel sounds
- Tenderness
- Peritoneal signs
- Cirrhosis signs
- Ascites
- Caput medusae
- Spider angiomata
- Rectal Exam
- Melena
- BRBPR
What labs and diagnostics will you order to work up your pt with bloody stool and orthostatic hyoptension?
- Labs
- CBC
- CMP
- LFTs
- Coags
- Thrombocytopenia and coagulopathy can be signs of cirrhosis
Describe your ‘bleeding time’ terminology for your patient with concern for UGI bleed.
Time Zero
Acute bleeding episode
Treatment failure
Early rebleeding
- Time zero
- Time of admission to medical facility
- Acute bleeding episode
- Bleeding events within 120h (5d) from time zero
- Treatment failure: any of following within 120h from time zero
- Fresh hematemesis or more than 100cc blood in NG aspirate for >2h after start of drug/endo therapy
- Dvlpmt of hypovolemic shock
- Drop in Hgb > 3g within 24h
- Early rebleeding
- Bleeding for more than 120h, but less than 6 wks, from time zero
- Provided initial hemostasis was achieved and maintained for at least 24h
How would you stratify your patient in whom you are concerned for non-variceal UGI bleed?
- Hemodynamic status, hematemesis
- Comorbidities
- Lab results
- Hx of GIB in past d/t portal HTN, EtOH cirrhosis, or variceal bleed
How do you classify a severe UGI bleed?
- Over 2g/dL decrease in Hgb from baseline
OR
- Hgb under 8g/dL
AND OFTEN…
- Requirement of pRBC txfn
Describe the Glasgow-Blatchford Score
- Predicts outcomes of UGI bleed patients at presentation
- Blood urea
- Hgb
- SBP
- Pulse
- Hx/comorbidities
- Ranges 0-23
- 0: outpatient mgmt
- 2: endoscopy likely not indicated
- Higher score, more likely endo intervention needed
Your patient comes in with clear signs of GI bleed, and you want to order a GI consult and determine dispo. Describe your thought process about how to move forward
- High risk patients: hemodynamically unstable, require aggressive resuscitation, ICU admission
- Is the patient stable?
- NO: hotn, tachy, AMS
- Begin resuscitation
- ABCs
- Two large bore IVs
- Continuous monitoring
- Initiate IVF
- Labs
- Prepare for txfn
- Begin resuscitation
- Yes, stable
- H&P
- UGI vs LGI
- Active vs inactive
- Low Hgb/Hct
- H&P
- NO: hotn, tachy, AMS
Your GI bleed pt may need transfusion, how will you decide?
- No CV disease
- Only txf if active bleeding and/or Hgb < 7
- CV disease
- Only txf if active bleeding and/or Hgb < 8
- Restrictive txfn practices have significant mortality improvement at 6wks vs. liberal txf cutoff of Hgb < 9
Describe medical treatment for non-variceal UGI bleed.
Describe general endoscopic approch to UGI bleed.
- Med mgmt
- With active hematemesis
- PPI (pantoprazole) 80mg IV
- Followed by 8mg/h continuous infusion for 72h
- With active hematemesis
- Endo
- Early upper endoscopy preferred within 24h
- Results direct further mgmt
- Bipolar electrocoagulation, clipping, heater probe, banding
- Results direct further mgmt
- No need to re-scope unless recurrent bleed
- Recurrent bleed is treated with 2nd EGD
- If persists/recurs, surgery or IR is completed
- Early upper endoscopy preferred within 24h
Your UGI bleeding patient turns out to have a perforated ulcer. What specific considerations must you keep in mind when treating this patient?
- Duodenal ulcers tend to perforate
- Areas of perforation/fistula include: pancreas!
- May see perf of lesser omentum, biliary tract, liver, greater omentum, mesocolon, colon, vascular structures
- Emergent surgical consultation
- Maintain hemodynamic stability: #1 priority
- Cover enteric pathogens with ABX
What location of varices are most concerning for bleeding?
What are signs/symptoms of esophageal varices, and esophageal variceal bleed?
How will you treat (generally) and what pharm interventions?
- High risk location
- Esophageal
- GE junction
- Signs/symptoms
- Esoph varices usually painless
- Vomiting large amts of blood
- Black, tarry, bloody stools
- Lightheadedness
- Loss of consciousness
- Shock
- Treatment
- NGT not used
- IV fluid resuscitation w isotonic crystalloid
- Txfn as indicated
- Correct coagulopathy
- Pharmacologic interventions
- Start at time of presentation and don’t hold
- Octreotide (Sandostatin): somatostatin analogue
- 50mcg IV then 50mcg/h IV infusion for 2-5d
- Repeat bolus in 1st dose if bleeding continues
- Lower dose if on HD or severe liver dz
Describe octreotide pharmacology
- MOA: inhibits pituary and GI hormones, lessens bleeding
- Caution with:
- Cadriac patients (brady, arrythmias, QT prolong)
- DM (alters balance of insulin, glucagon, growth hormone)
- Thyroid dz (lowers TSH)
- GI malabsorption (decreases fat absorption)
- Contraindications
- Biliary dz (decreases bile secretion and gallbladder motility)
Endoscopic intervention has failed for your UGI bleed patient. What procedure might be attempted next?
- TIPS
- Transjugular intrahepatic portosystemic shunt
- Shunt btwn portal vein and hepatic vein
- Decreases pressure in portal system
- Decreases risk of bleeding varices
- Monitor for shunt blockage
- New ascites, rebleeding
- Encephalopathy
- F/u ultrasound
- Surgical Shunts
- Splenorenal
- Mesocaval shunt
