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Acute Gastrointestinal Bleeding
Rajeev Jain, M.D.
GI Bleeding
• Clinical Presentation
• Acute Upper GI Bleed
• Acute Lower GI Bleed
Case Presentation
• CC: Melena• HPI: 54 yo man taking ibuprofen 200 mg
po tid for the past 2 wks b/o acute LBP after lifting presents with 2 day h/o melena
• PMHx: neg All: NKDA SHx/FHx: neg• Vitals: BP 105/75 P 90• PE: normal
Clinical Presentation
Hematemesis: bloody vomitus (bright red or coffee-grounds)
Melena: black, tarry, foul-smelling stool
Hematochezia: bright red or maroon blood per rectum
Occult: positive guaiac test
Symptoms of anemia: angina, dyspnea, or lightheadedness
Patient Assessment• Hemodynamic status• Localization of bleeding source• CBC, PT, and T & C• Risk factors
– Prior h/o PUD or bleeding– Cirrhosis– Coagulopathy– ASA or NSAID’s
Resuscitation
• 2 large bore peripheral IV’s
• Normal saline or LR
• Packed RBCs
• Correct coagulopathy
Location of Bleeding
• Upper– Proximal to Ligament of Treitz– Melena (100-200 cc of blood)– Azotemia– Nasogatric aspirate
• Lower– Distal to Ligament of Treitz– Hematochezia
Acute UGIBDemographics
• 10,000 - 20,000 deaths annually
• Mortality stable at 10%
• 80% self-limited
• Continued or recurrent bleeding - mortality 30-40%
• Cause of bleeding
• Severity of initial bleed
• Age of the patient
• Comorbid conditions
• Onset of bleeding during hospitalization
Acute UGIBPrognostic Indicators
NASOGASTRIC ASPIRATE
STOOL COLOR
MORTALITY RATE (%)
Clear Red, brown, or black 10
Coffee Grounds Brown or black 10
Red 20
Red Blood Black 10
Brown 20
Red 30
Acute UGIBPrognostic Indicators
Tedesco et al. ASGE Bleeding Survey. Gastro Endo. 1981.
Acute UGIBDifferential Diagnosis
• Peptic ulcer disease– Gastric ulcer– Duodenal ulcer
• Mallory-Weiss tear• Portal hypertension
– Esophagogastric varices
– Gastropathy
• Esophagitis
• Dieulafoy’s lesion• Vascular anomalies• Hemobilia• Hemorrhagic
gastropathy• Aortoenteric fistula• Neoplasms
– Gastric cancer– Kaposi’s sarcoma
Acute UGIBDifferential Diagnosis
DIAGNOSES % OF TOTAL
Duodenal ulcer 24Gastric erosions 23Gastric ulcer 21Varices 10Mallory-Weiss tear 7Esophagitis 6
Acute UGIBFinal Diagnoses of the Cause in 2225 Patients
Tedesco et al. ASGE Bleeding Survey. Gastro Endo. 1981.
DIAGNOSES % OF TOTAL
Peptic ulcer 55 Varices 14 Angioma 6 Mallory-Weiss tear 5 Erosions 4 Tumor 4
Acute UGIBCauses in CURE Hemostasis Studies (n=948)
Savides et al. Endoscopy 1996;28:244-8.
Acute UGIB
CORI Database
University, VA, & privatepractices
20 months (12/99-7/01)
7822 EGDs for UGIB
BoonpongmaneeS. et al. Gastrointest Endosc 2004;59:788-94.
Endoscopic Appearanceof Ulcers
Prognostic Features at Endoscopy in Acute Ulcer Bleeding
Laine and Peterson New Eng J Med 1994;331:717-27.
• Thermal– Bipolar probe– Monopolar probe– Argon plasma
coagulator– Heater probe
• Mechanical– Hemoclips– Band ligation
• Injection– Epinephrine– Alcohol– Ethanolamine– Polidocal
Endoscopic Therapy of PUD
Endoscopic Therapy of PUD
Laine and Peterson New Eng J Med 1994;331:717-27.
Adjuvant Medical Therapy of PUD
• Acid suppression (intragastric pH > 4)– Histamine 2 Receptor Antagonists (H2RAs)
• Ranitidine (Zantac)• Famotidine (Pepcid)
– Proton Pump Inhibitors (PPIs)• Pantoprazole (Protonix)• Lansoprazole (Prevacid)• Esomeprazole (Nexium)
Bleeding PUD: IV H2RAsMeta-Analysis
• Duodenal ulcer: no benefit
• Gastric ulcer: mild benefit– Mortality
• ARR 3%; NNT 33
– Surgery• ARR 7%; NNT 14
– Rebleeding• ARR 7%; NNT 14
• Caveats– Tolerance develops
within 24 hrs– More potent acid
suppression available
Levine JE et al. Aliment Pharmacol Ther 2002;16:1137-42.
472 patients required no endoscopic treatment
27 patients not included: comorbid or no consent
120 patients received IV omeprazole 80 mg bolusthen 8 mg/hr for 72 hours
120 patients received placebo
267 received endoscopic treatment
739 patients admitted with GI bleeding
Lau et al. New Eng J Med 2000;343:310-316.
Adjuvant Medical Therapy of PUD
Adjuvant Medical Therapy of PUD
Lau et al. New Eng J Med 2000;343:310-316.
Bleeding PUD: PO/IV PPIsMeta-Analysis
• Reduction in:– RebleedingNNT* 4-17– Surgery NNT* 6-25
• No change in mortality• PPIs add to endoscopic
therapy but do not supplant endoscopic therapy
* Estimates from pooled ORsLeontiadis, GI et al. BMJ 2005;330:568-75.
Mallory-Weiss Tear
Esophageal Varices
Variceal Band Ligation
Variceal Band Ligation
• Vasopressin/Glypressin• Nonselective vasoconstrictor• 50% efficacy in controlling bleeding• 25% vasospastic side effects
• Octreotide• Cyclic octapeptide analog of
somatostatin• Longer acting than somatostatin• Equivalent to sclerotherapy and
improves endoscopic results
MEDICAL THERAPYAcute Variceal Bleeding
TIPS
IVC
Portal Vein
Splenic Vein
Coronary Vein
Aortoduodenal Fistula
Aorta
Duodenum
Graft
Fistula
Acute BleedingChanges Before and After 2 Liter Bleed
0
1
2
3
4
5
6
Before During 24-72 Hrs
VO
LU
ME
( L
)
Plasma RBC
27%45%45%
Acute UGIB Surgery
• Recurrent bleeding despite endoscopic therapy
• > 6-8 units pRBCs
Case Presentation
• CC: Hematochezia• HPI: 74 yo woman presents with 6 hour
history of painless maroon blood per rectum • PMHx: CAD, Chol, AFib, CABG, L-CEA• Meds: ASA, coumadin, digoxin, lovastatin• Vitals: BP 105/75 P 90• PE: irreg rhythm, maroon blood on DRE
Acute LGIBDifferential Diagnosis
• Diverticulosis• Colitis
– IBD (UC>>CD)– Ischemia– Infection
• Vascular anomalies• Neoplasia• Anorectal
– Hemorrhoids– Fissure
• Dieulafoy’s lesion• Varices
– Small bowel– Rectal
• Aortoenteric fistula• Kaposi’s sarcoma
• UPPER GI BLEED
Acute LGIBDifferential Diagnosis
DIAGNOSES % OF TOTAL
Diverticulosis 40Vascular anomalies 30Colitis 21Neoplasia 14Anorectal 10Upper GI sites 10
Acute LGIBDiagnoses in pts with hemodynamic compromise.
Zuccaro. ASGE Clinical Update. 1999.
Diverticulosis
Diverticular Bleeding
Urgent Colonoscopy for the Diagnosis and Treatment of Severe Diverticular
Hemorrhage
• 121 pts with severe bleeding (>4 hrs after hospitalization)
• 1st 73 pts: no colonoscopic tx
• Last 48 pts eligible for colonoscopic tx
• Colonoscopy w/in 6-12 hrs
Urgent Colonoscopy for the Diagnosis and Treatment of Severe Diverticular
Hemorrhage
Jensen DM, et al. New Eng J Med 2000:342:78-82.
Hemorrhoids
Bleeding AVM
Radiation Proctitis
• Incidence 0.3 - 3.0 %• Etiology Incomplete obliteration of
the vitelline duct.• Pathology50% ileal, 50% gastric,
pancreatic, colonic mucosa• Complications
– Painless bleeding (children, currant jelly)– Intussusception
Acute LGIBMeckel’s Diverticulum
Study Yield
% Comments
Colonoscopy 69-80 Therapeutic
Arteriography 40-78 1 ml/min,
risks
Tagged RBC Scan 20-72 Localization
Acute LGIBEvaluation
Zuccaro. ASGE Clinical Update. 1999.
• Resuscitation• UGI source• Most bleeding ceases• Colonscopy - early• No role for barium studies• 5% Mortality
Acute LGIBKey Points