Acute gi b leed (revised) (p) copy

Acute Upper Gastrointestinal Acute Upper Gastrointestinal BleedingBleeding

Entesar El SharqawyEntesar El Sharqawy

MDMD

Hepatology, Hepatology, Gastroenterology and Gastroenterology and Infectious Diseases.Infectious Diseases.

Benha UniversityBenha University

26/09/1226/09/12

ObjectivesObjectives

Discuss and provide background information of Discuss and provide background information of upper GIT bleeding.upper GIT bleeding.

Identify goals of history, physical finding and care Identify goals of history, physical finding and care in UGIB.in UGIB.

Discuss utility of NGT in the evaluation of UGIB.Discuss utility of NGT in the evaluation of UGIB. Identify key points to resussitation and work up Identify key points to resussitation and work up

of UGIB.of UGIB. Discuss therapy of upper GIB.Discuss therapy of upper GIB. Outline key informations to have when calling GI Outline key informations to have when calling GI

consultants.consultants.

Gastrointestinal BleedingGastrointestinal Bleeding Introduction:Introduction:

GI bleeding is a common disorder that GI bleeding is a common disorder that troubles all medical/surgical specialtiestroubles all medical/surgical specialties

UGI bleeding>LGI bleedingUGI bleeding>LGI bleedingPrevalence: 170 cases/100.000 Prevalence: 170 cases/100.000

adults/yradults/yrCost estimate: $2.5B/yr (USA)Cost estimate: $2.5B/yr (USA)Mortality 5-12% Mortality 5-12%

40% for recurrent bleeders40% for recurrent bleedersSeverity: Severity:

acute/chronic/intermittent/occultacute/chronic/intermittent/occult

Epidemiology:Epidemiology:Upper: Lower GI bleeding = 5:1Upper: Lower GI bleeding = 5:130% pts are older than 65 years. 30% pts are older than 65 years. Incidence:Incidence: 1-2% of all hospital admissions1-2% of all hospital admissions

Most common diagnosis of new ICU admitsMost common diagnosis of new ICU admits85% stop sponateously85% stop sponateously

Those with massive bleeding need urgent Those with massive bleeding need urgent interventionintervention

Only 5-10% need operative intervention Only 5-10% need operative intervention after endoscopic interventionsafter endoscopic interventions

Early therapeutic maneuvers decrease mortality Early therapeutic maneuvers decrease mortality ratesrates

Gastrointestinal BleedingGastrointestinal Bleeding

Presentation of bleeding:Presentation of bleeding:

Hematemesis-UGI sourceHematemesis-UGI sourceMelena-UGI source usually but 5% can be Melena-UGI source usually but 5% can be

from LGI sourcefrom LGI sourceHematochezia (BRBPR)-LGI source usually Hematochezia (BRBPR)-LGI source usually

but 15% from UGI sourcebut 15% from UGI sourceOccult-UGIBOccult-UGIB

Chain of eventsChain of events

1.1. Recognize severityRecognize severity

2.2. Establish access for resusitationEstablish access for resusitation

3.3. ResusitateResusitate

4.4. Identify sourceIdentify source

5.5. InterventionIntervention


UGI vs LGI location determined by UGI vs LGI location determined by the Ligament of Treitz:the Ligament of Treitz:

UGI – proximal to LTUGI – proximal to LT*Esophagus, *stomach, *duodenal bulb, *Esophagus, *stomach, *duodenal bulb,

22ndnd/3/3rdrd portion of duodenum, Hepatic and portion of duodenum, Hepatic and PancreaticPancreatic

LGI – distal to LTLGI – distal to LTSmall bowel, *colonSmall bowel, *colon

Etiology of Significant UGI Etiology of Significant UGI Bleeding in AdultsBleeding in Adults

Varices Varices Peptic ulcer disease Peptic ulcer disease

Gastric erosions Gastric erosions Mallory-Weiss tear Mallory-Weiss tear Esophagitis Esophagitis DuodenitisDuodenitis

Etiology of Significant UGI Etiology of Significant UGI Bleeding in ChildrenBleeding in Children

Esophagitis Esophagitis Gastritis Gastritis Ulcer Ulcer Esophageal VsEsophageal Vs Mallory-Weiss Mallory-Weiss

Initial AssessmentInitial Assessment History and PEHistory and PE Vitals, ABC’s, and IVFsVitals, ABC’s, and IVFs

HR, BP, OrthostaticsHR, BP, Orthostatics Signs of gross blood loss?Signs of gross blood loss?

Hematemesis, melena, hematocheziaHematemesis, melena, hematocheziaNG TubeNG Tube

LabsLabsCBC, Kidney Profile, LFT, Electrolytes, Coags, Acid-Base CBC, Kidney Profile, LFT, Electrolytes, Coags, Acid-Base

balance, type and crossbalance, type and crossHct unreliable Hct unreliable ECGECG Imaging: chest & abd. radiography, US, CTImaging: chest & abd. radiography, US, CT

Gastrointestinal BleedingGastrointestinal BleedingDetermine the urgency of the clinical Determine the urgency of the clinical

situation:situation:Is the patient in shock? Is the patient in shock?

40% loss of circulating blood volume40% loss of circulating blood volumeAgitation, pallor, tachycardia, hypotensionAgitation, pallor, tachycardia, hypotension

Is the patient orthostatic? Is the patient orthostatic? 20% loss of circulating blood volume20% loss of circulating blood volumePostural hypotensionPostural hypotension

Never rely on initial H/H values to asses amount Never rely on initial H/H values to asses amount of blood loss (hemoconcentration)of blood loss (hemoconcentration)

ATLS Classification of ShockATLS Classification of ShockAssess Blood LossAssess Blood Loss

CategorCategoryy

% loss% loss HRHR BPBP Pulse Pulse PressurPressur

ee

Cap refillCap refill NeuroNeuro

Stage 1Stage 1 <15 %<15 % < < 100100

NormalNormal NormalNormal WNLWNL WNLWNL

Stage 2Stage 2 15-30%15-30% > > 100100

NormalNormal DecreaseDecreasedd

> 3 sec> 3 sec AlertAlert

Stage 3Stage 3 30-40%30-40% > > 120120

DecreasedDecreased DecreaseDecreasedd

> 3 sec> 3 sec LethargicLethargic

Stage 4Stage 4 > 40%> 40% > > 140140

DecreasedDecreased DecreaseDecreasedd

> 3 sec> 3 sec ObtundedObtunded

If they are hypotensive,

you are in trouble!

HR not useful if patients are

on AV node blockers

From Advanced Trauma Life Support Guidelines

Tachycardic means they have lost about 1 liter

of blood!

General ApproachGeneral Approach

Upper GI BleedUpper GI Bleed

vsvs

Lower GI BleedLower GI Bleed

Upper GI hemorrhageUpper GI hemorrhageHow do you know its upper?How do you know its upper?

85% of all GI hemorrhage is upper85% of all GI hemorrhage is upperHematemesis diagnosticHematemesis diagnostic

Don’t forget about nasal bleeding as possible Don’t forget about nasal bleeding as possible sourcesource

MelenaMelenaDegradation of hemoglobin to hematin by acidDegradation of hemoglobin to hematin by acidBowel bacteria and digestive enzymes also Bowel bacteria and digestive enzymes also

contributecontributeHematocheziaHematochezia

10-15% of patients with very rapid UGI source10-15% of patients with very rapid UGI source


Nasogastric aspirate:Nasogastric aspirate:Determines the status of UGI Determines the status of UGI

bleeding and gives indirect bleeding and gives indirect information in LGI bleedinginformation in LGI bleedingBright red/clots – active UGI bleedBright red/clots – active UGI bleedCoffee-grounds – slow bleeding, Coffee-grounds – slow bleeding,

oozing, stoppedoozing, stoppedClear – indeterminate (16% still Clear – indeterminate (16% still

bleeding)bleeding)Bilious – UGI bleeding has stoppedBilious – UGI bleeding has stopped

DiagnosisDiagnosis Questions to ask in historyQuestions to ask in history Any hematemesis, coffee-ground emesis, melena, or Any hematemesis, coffee-ground emesis, melena, or

hematochezia.hematochezia. Any vomiting and retching.Any vomiting and retching. Any history of viral infection.Any history of viral infection. Any history of ASA, NSAID’s, steroids.Any history of ASA, NSAID’s, steroids. Any ETOH abuse.Any ETOH abuse. Any history of iron or bismuth which can simulate Any history of iron or bismuth which can simulate

melena and beets which can simulate hematochezia. melena and beets which can simulate hematochezia. Any weight loss or changes in bowel habits.Any weight loss or changes in bowel habits. Any history aortic graft.Any history aortic graft.

DiagnosisDiagnosis

Physical examPhysical exam Vital signs may show hypotension and Vital signs may show hypotension and

tachycardia.tachycardia. Cool, clammy skin then in shock.Cool, clammy skin then in shock. Spider angiomata, palmer erythema, Spider angiomata, palmer erythema,

jaundice, and gynecomastia seen in liver jaundice, and gynecomastia seen in liver disease.disease.

Petechiae and purpura seen in Petechiae and purpura seen in coagulopathy.coagulopathy.

Careful ENT exam to rule out causes Careful ENT exam to rule out causes that can mimic upper GI bleeds.that can mimic upper GI bleeds.

Proper abdominal exam and rectal exam.Proper abdominal exam and rectal exam.

Upper GI hemorrhageUpper GI hemorrhage

Upper endoscopy indicationsUpper endoscopy indicationsHematemesisHematemesisMelena or hematochezia with Melena or hematochezia with hypotensionhypotension

NGT with guiac positive fluidNGT with guiac positive fluidShould be completed in 24hrs for Should be completed in 24hrs for stable patientsstable patients


Role of endoscopy in triage of UGI Role of endoscopy in triage of UGI bleeders:bleeders:

Accurate identification of the urgency of the Accurate identification of the urgency of the clinical situation: hemodynamic clinical situation: hemodynamic compromise/signs of on-going compromise/signs of on-going bleeding/coagulopathy.bleeding/coagulopathy.

Who should be hospitalized?Who should be hospitalized?Where to admit?Where to admit?Diagnosing the causeDiagnosing the causeRisk stratificationRisk stratification


Risk stratification in UGI bleeding:Risk stratification in UGI bleeding:Very low risk endoscopic findings:Very low risk endoscopic findings:

Clean-bsed ulcerClean-bsed ulcerClean based Mallory-Weiss tearClean based Mallory-Weiss tearGastritis/duodenitis/esophagitisGastritis/duodenitis/esophagitisPortal hypertensive gastropathy Portal hypertensive gastropathy

Disposition: Discharge if stableDisposition: Discharge if stable


Risk stratification in UGI bleedingRisk stratification in UGI bleedingMedium risk endoscopic findings:Medium risk endoscopic findings:

AVM’sAVM’sUlcer with stigmata of recent hemorrhageUlcer with stigmata of recent hemorrhageMallory-Weiss with stigmata of recent hemorrhageMallory-Weiss with stigmata of recent hemorrhageVarices with recent bleedingVarices with recent bleedingCancerCancer

Hemostasis and medical ward/intermediate care Hemostasis and medical ward/intermediate care unitunit


Risk stratification in UGI bleeding:Risk stratification in UGI bleeding:High risk endoscopic findings:High risk endoscopic findings:

Active variceal bleeding Active variceal bleeding Active ulcer bleedingActive ulcer bleedingActive bleeding Dieulafoy’s lesionActive bleeding Dieulafoy’s lesion

Hemostasis and ICU admissionHemostasis and ICU admission

ResuscitationResuscitationPlace in ICU and Surgery consultation Place in ICU and Surgery consultation Airway protectionAirway protectionMaintain intravascular volume, O2Maintain intravascular volume, O2Give NS until PRBC and FFP availableGive NS until PRBC and FFP availableFollow vitals, orthostatics, and urine Follow vitals, orthostatics, and urine

outputoutput

Acute U.G.I. Acute U.G.I. BleedingBleeding **Shock management: (**Shock management: ( ABC ) ABC )

Airway: Airway: endotracheal tube, oropharyngeal airway. *Give endotracheal tube, oropharyngeal airway. *Give oxygenoxygen

Breathing: support respiratory functionBreathing: support respiratory function* * Monitor: resp. rate, bld gases, chest Monitor: resp. rate, bld gases, chest

radiographradiograph Circulation: expand circulating volume: Circulation: expand circulating volume: blood, blood,

colloids, crystalloids support CVS function: colloids, crystalloids support CVS function: 1- 1 unit PRBC increases Hgb by 1 gm/dl and increase Hct 1- 1 unit PRBC increases Hgb by 1 gm/dl and increase Hct

by 3%by 3% 2- FFP for INR greater than 1.52- FFP for INR greater than 1.5 3-Platelets for platelet count less than 50.0003-Platelets for platelet count less than 50.000

* Monitor: skin color, peripheral temp., urine * Monitor: skin color, peripheral temp., urine flow, BP, ECGflow, BP, ECG

Rockall risk stratification Rockall risk stratification scorescore

VariableVariable 00 11 22

Age (yrs)Age (yrs) < 60< 60 60-8060-80 >80>80

ShockShock SBP>100mmHgSBP>100mmHg

HR<100 bpmHR<100 bpmSPB>100mmHgSPB>100mmHg

HR>100bpmHR>100bpmSPB<100mmHgSPB<100mmHg

Co-morbidityCo-morbidity No major co-No major co-morbiditymorbidity

Heart failure, IHD.Heart failure, IHD.

Renal Failure. Liver Renal Failure. Liver disease. disease. Disseminated Disseminated malignancy.malignancy.

Any co-morbidityAny co-morbidity

Endoscopic Endoscopic DiagnosisDiagnosis

Mallory-Weiss tear. Mallory-Weiss tear. No lesion No lesion identified. No SSHidentified. No SSH

Peptic ulcerPeptic ulcer

Erosive diseaseErosive disease

EsophagitisEsophagitis

Malignancy of Malignancy of upper GITupper GIT

Major SSHMajor SSH None/Clean base. None/Clean base. Dark spot sign on Dark spot sign on ulcer baseulcer base

Adherent clot. Adherent clot. Visible vessel (non Visible vessel (non bleeding). Oozing bleeding). Oozing bleeding, spurting bleeding, spurting arterial vesselarterial vessel

Blatchford risk stratification score Blatchford risk stratification score (23)(23)

VariableVariable 11 22 33 44 66

SBP (mmHg)SBP (mmHg) 100-109100-109 90-9990-99 > > 9090

Blood urea Blood urea (mg(mg//dl)dl)

18-2218-22 22-2822-28 28-6928-69 <<7070

Hamoglobin Hamoglobin (M)(M)

(g(g/ / dl)dl)

12-12.912-12.9 10-10-11.911.9

>>1010

Hamoglobin (F)Hamoglobin (F)

(g(g/ / dl)dl)10-11.910-11.9 > > 1010

Other Other variables variables

HR>100bpHR>100bpmm

MelenaMelena

Syncope Syncope

Heart failureHeart failure

Hepatic Hepatic DiseaseDisease

INDICATIONS FOR INDICATIONS FOR ADMISSION & REFERRALADMISSION & REFERRAL

Admit pts with h/o recent brisk bleeding & Admit pts with h/o recent brisk bleeding & orthostatic changesorthostatic changes

Admit pts with less severe blood loss who have Admit pts with less severe blood loss who have comorbid conditions aggravated by anemiacomorbid conditions aggravated by anemia

Profound anemia with no evidence of blood lossProfound anemia with no evidence of blood lossRefer pts who are candidate for endoscopy when Refer pts who are candidate for endoscopy when

source of bleeding is elusivesource of bleeding is elusive

Causes of Causes of Upper GI BleedUpper GI BleedErosive EsophagitisErosive Esophagitis

Grade 1 EE Grade 2 EENormal GEJ

Grade 3 EE Grade 4 EE

CausesCausesUpper GI BleedUpper GI Bleed

4. Esophageal or Gastric Varices4. Esophageal or Gastric VaricesEsophageal VaricesNormal Esophagus

Normal FundusGastric Varices

Gastric varicesBleeding ulcers

EsophagealVarices

Dieulafoy’s lesion

Causes of Upper GI BleedCauses of Upper GI BleedDieulafoy’s LesionDieulafoy’s Lesion

Dieulafoy’s Lesion Actively Bleeding

Causes - Causes - Peptic ulcer diseasePeptic ulcer disease

Gastric UlcerGastric Ulcer

Pyloric Channel Ulcer Duodenal

Ulcer

Gastritis

Mallory-weiss

Watermelon stomach

Causes - Upper GI BleedCauses - Upper GI BleedGastritisGastritis

Diffuse GastritisErosive Gastritis

Causes of Upper GI BleedCauses of Upper GI BleedEsophageal, Gastric, or Duodenal CAEsophageal, Gastric, or Duodenal CA

Gastric Cancer

Ulcer with red Ulcer with red spotspot Aortoduodenal Aortoduodenal

FistulaFistula

Aorta

Duodenum

Graft

Fistula

Gastrointestinal BleedingGastrointestinal BleedingPrognostic factors in UGI bleeding:Prognostic factors in UGI bleeding:

Severity of initial bleed. Severity of initial bleed. SHock/hemodynamic instabilitySHock/hemodynamic instabilityAge of patientAge of patient < < 6565Comorbid diseaseComorbid diseaseAnticoagulants/ coagulopathyAnticoagulants/ coagulopathyHb < 8g/dlHb < 8g/dlAPACHE IIAPACHE II < < 1111

Presence of high-risk lesion, as varices/giant ulcer Presence of high-risk lesion, as varices/giant ulcer Endoscopic stigmata of significant hemorrhage (SSH)Endoscopic stigmata of significant hemorrhage (SSH)Need for emergency surgeryNeed for emergency surgery

Modified Forrest Classification for Upper GI Modified Forrest Classification for Upper GI bleedingbleeding

Prognosis of endoscopic UGI bleeding finding:Prognosis of endoscopic UGI bleeding finding:

ClassClass Endoscopic findingsEndoscopic findings Re-Re-bleeding bleeding rate (%)rate (%)

Mortality Mortality

rate (%)rate (%)

1a1a Spurting arterial vesselSpurting arterial vessel << 90 90 1111

1b1b Oozing hemorrhageOozing hemorrhage 8080 1111

2a2a Non-bleeding visible Non-bleeding visible vesselvessel

440 - 600 - 60 1111

2b2b Adherent clotAdherent clot 20-3020-30 77

2c2c Ulcer base with black Ulcer base with black spot signspot sign

1010 33

33 Clean baseClean base 55 22

Gastrointestinal BleedingGastrointestinal BleedingSpecial considerations in TTT UGI bleedingSpecial considerations in TTT UGI bleeding::

Keep Nsaid’s in mind in all patients (the cause of Keep Nsaid’s in mind in all patients (the cause of non-healing until proven otherwise) non-healing until proven otherwise)

Evaluate and treat Evaluate and treat Helicobacter pylori Helicobacter pylori infections in infections in the peptic disorderthe peptic disorder

Stress related mucosal disease (SRMD) in Stress related mucosal disease (SRMD) in hospitalized patients with non-bleeding illnesseshospitalized patients with non-bleeding illnesses

Suppress gastric acid secretionSuppress gastric acid secretionCorrect coagulopathy in most casesCorrect coagulopathy in most casesMust get early consultation with gastroenterologist Must get early consultation with gastroenterologist

and general surgeon for significant GI bleeds. and general surgeon for significant GI bleeds.

TherapyTherapy Supportive careSupportive care: begin promptly: begin promptly

IV fluids, blood products, pressorsIV fluids, blood products, pressors Class I + II hemorrhage replace with crystalloid.Class I + II hemorrhage replace with crystalloid. Class III + IV hemorrhage replace with crystalloid and Class III + IV hemorrhage replace with crystalloid and

blood.blood. Specific careSpecific care

Barrier agents (sucralfate)Barrier agents (sucralfate) HH2 2 receptor antagonists (ranitidine)receptor antagonists (ranitidine) Proton pump inhibitors (omeprazole, lansoprazole)Proton pump inhibitors (omeprazole, lansoprazole) Vasoconstrictors (somatostatin analogue, terlipressin)Vasoconstrictors (somatostatin analogue, terlipressin)

Endoscopic therapyEndoscopic therapy: stabilize and prepare patient first: stabilize and prepare patient first Variceal injection or band ligation Variceal injection or band ligation Coagulation (injection, cautery, heater probe, laser)Coagulation (injection, cautery, heater probe, laser)

Gastrointestinal BleedingGastrointestinal BleedingUGI bleeding in portal hypertension: VaricesUGI bleeding in portal hypertension: Varices

High mortality on first bleed, 70% rebleed rate in High mortality on first bleed, 70% rebleed rate in next 12 monthsnext 12 months

Start IV octreotide in all suspected PHT bleedsStart IV octreotide in all suspected PHT bleedsAntibiotic prophylaxisAntibiotic prophylaxisEndoscopic ligation is procedure of choice Endoscopic ligation is procedure of choice

(prophylactic banding is standard of care, (prophylactic banding is standard of care, surveillance for variceal recanalization q 6mos-surveillance for variceal recanalization q 6mos-12mos)12mos)

TIPS for endoscopy failuresTIPS for endoscopy failuresMinnesota tube/Blakemoore tubeMinnesota tube/Blakemoore tubeSurgical (shunts, transection)Surgical (shunts, transection)

TreatmentTreatmentEndoscopic interventionEndoscopic intervention

BandingBandingSclerotherapySclerotherapyThermocoagulationThermocoagulationElectrocoagulationElectrocoagulationArgon Plasma Coagulation Argon Plasma Coagulation

TreatmentTreatmentTreatmentTreatment

Submucosal injection of EpinepherineSubmucosal injection of Epinepherine

Duodenal Ulcer Injection Therapy

TreatmentTreatment ThermocoagulationThermocoagulation

Duodenal Ulcer Heater Probe Therapy

TreatmentTreatment Argon Plasma Coagulation (APC)Argon Plasma Coagulation (APC)

TreatmentTreatmentBanding LigationBanding Ligation

Further treatmentFurther treatment

ICU careICU careTreatment of complicationsTreatment of complications

- sepsis- sepsis

- DIC- DIC

- MODS- MODS

TIPSTIPS

IVC

Portal Vein

Splenic Vein

Coronary Vein

General Approach to GI General Approach to GI BleedingBleeding

StablizeStablize

LocateLocate

TreatTreat

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Acute gi b leed (revised) (p) copy