GI #22; Friday, 27th, 2004
10am
Dr. Hoang
Scott Emerson
page1
Lower GI Bleed
I. Case Presentation:
62 yo males presents to ER with bright red blood/rectum of one day
duration. No abd pain, no nausea nor emesis.
~Initial steps?
~Additional info needed?
~DDX?
~Management of this patient?
PMH: Coronary artery dz (ischemic bowel dz), HTN, DM, Prostate CA (radiation
tx; radiation proctitis is a common cause of bleeding in this age group)
PSH: TURP, Cholecystectomy
FmHxt: Father died of colon CA @70yo (has this guy been screened)
SoHxt: 20 pack year tobacco, quit 10 yrs ago
Meds: ASA 81mg qd, insulin, lisinopril (ask if taking advil, etc. pain meds)
Allergy: NKDA
ROS: Weakness, dizziness, chest pain (R/O MI)
VS: 98.4F, BP 90/50, HR 115, RR 20, O2 sat: 98% on room air
HEENT: no epistaxis (nose bleeds can contribute)
Hrt: tachy but regular
Lungs: clear
Abd: +bowel sounds, soft non-tender, non-distended, no peritoneal sign
Extremities: cool feet, no cyanosis
Neuro: AO3, CN 2-12 intact
Rectal: hemorrhoids, +hematochezia (bleeding from lower), 500cc of blood
pooled on bed sheets
Labs:
1. CBC:
~WBC: 10.2
~Hb: 9.8 (normaocytic) (actute GI bleed can look normal; takes a
day to see changes in Hb; still consider transfusion when
<10)
~Hct: 30.1
~Plt: 255
2. CMP:
~BUN: 22 (pre-renal 20:1 ratio; signs of upper GI bleed, but also
from diuretic use or dehydration)
~Cr: 1.1
~HCO2: 22
3. Coagulation profile:
~PT: 12.3
~INR:1.2
~PTT: 32
GI #22; Friday, 27th, 2004
10am
Dr. Hoang
Scott Emerson
page1
*always get coag studies to R/O coagulopathy
4. CK:270
5. Troponin: 0.3
6. EKG> no acute ST-T wave changes
Acute abd series: negative
Colonoscopy findings:
1. pan-diverticular dz
2. old and small amnt of fresh blood throughout colon, but no obvious
sourse of bleeding (tough to see bleed unless streaming out of one
area)
3. hemorrhoids
12 hours later, pt. rebleeds with bright red blood. Hemodynamically stable.
Repeat Hb: 10.2 (due to receiving 2 units of pRBC/s earlier). Run a nuclear scan
or angiography next. His scan was negative (therefore watch/supportive tx; 90%
of lower GI bleeds will stop); no recurrent bleeding; Hb stable; diet advanced.
Finally discharged home. Had his scan been positive, would have gone to surgery
and removed the whole colon (sub-total colectomy) since he had pandiverticular dz. (remove right/left colon depending on if that is where the
particular dz is located). Remove colon if continous bleeding and presentations to
ER.
A. Initial Steps:
1. Triage
~check how sick the pt. is by looking at vital signs
~see if actively bleeding
~tachycardic, hypotensive, alert/awake/obtunded/coma
2. Resuscitate/Stabilize
~if tachycardic and hypotensive: in shock so give them volume,
blood
~make sure don't have EKG changes
~give oxygen if not breathing (intubate if needed)
~stabilize first if acute bleeding
~don't do extensive Hxt and PE (only after triaged and stabilized)
3. Determine site of bleeding
~is it upper/lower?
~if someone comes in with bright red blood/rectume and blood all
over the sheets (ie. diffuse) and they are tachy and
hypotensive; make sure not an upper GI by NG tube and
lavage the stomach: if negative then SB source or lower GI
bleed.
~Lower GI bleed defined as bleeding below the ligament of Treitz;
NG tube and no blood could be a lower GI from right colon
GI #22; Friday, 27th, 2004
10am
Dr. Hoang
Scott Emerson
page1
~Melena usually upper GI but still could be loser
B. Additional Info
1. Detailed Hxt and PE
2. Lab data
3. X-ray studies
C. Management
1. Dx? Lower GI (could be upper b/c of hemodynamic changes; put in
NG tube and if clear (negative) than more than likely a lower
(doesn't R/O upper or small bowel b/c could have a pyloric
stricture [lesion is post-pyloric but above ligament of Treitz])
2. Txt options? not answered
D. DDX
1. Chart (slide 9) listing the "Common Causes of Lower GI Bleeding"
~Elderly pt most likely is a left diverticular dz
~Most common reason of bleeding is right sided colon dz (thinner
mucosa)
~Watershed areas for ischemic colitis are the splenic flexure and
recto-sigmoid junction
~Hemorrhoids rare cuase of hemodynamtic changes
~Colon ulcers from CMV, NSAIDs
~Find out if had recent biopsy; invasive proceedure could cause
E. Colonoscopy pictures
1. Our guy has diverticular dz with painless lower GI bleeding
2. Thin mucosa with vessel protruding into lumen and spontaneously
bleeds
F. Slide 14 omited
G. Diagnostic Imaging
"Procedures Used for Localization of Diverticular Bleeding"
1. After colonoscopy (don't repeat) but do a nuclear scan
~take sample of pt's blood and lable it →put back in →wait →look
for accumulation of blood** in an area (if bleeding than see
accumulation nuclear activity in that particualr area)
2. Angiography
~in through IMA to look at lower Gi blood distibution to see bleed
~usually don't do unless have a poitive tagRBC scan (b/c detects
bleeding at a rate of 0.5cc/min; radionuclide detects at 0.1cc/min
GI #22; Friday, 27th, 2004
10am
Dr. Hoang
Scott Emerson
page1
3. Colonoscopy is low yield
H. Technetium labled red blood cell scan
~tagged RBC scan to see accumulation of radioactive blood in a particular
area; see active GI bleed here
~splenic flexure to localize
II. Images
A. Angiodysplasia
1. arterio-venous malformation
2. pretty yet dangerous........
3. abnormal collection of blood vessel
B. Ischemic Colitis
1. Left pic's pt. needs surgery
2. Right pic's pt needs supportive care
3. Remember "thumb-printing": mucosal edema of bowel wall
C. IBD
1. Difficult to differentiate between IBD and Ischemic Colitis (IC)
~need biopsy
~watershed and other parts of colon fine then IC
~Ulcerative colitis affects rectum
~Crohn's has skip leasions
D. Colon CA
1. circumferential and polyploid masses
Upper GI Bleed
Obscure/Occult GI Bleed
Dr. Hoang flew through this last lecture in the last 15 minutes of class…which will
explain why some of the blanks aren’t filled in…
I. Classification UGI Bleed
A. Non-Variceal Bleed (Most Common)
1. Helicobacter pylori
2. NSAIDS
B. Variceal Bleed
1. Esophageal
2. Gastric
GI #22; Friday, 27th, 2004
10am
Dr. Hoang
Scott Emerson
page1
II. Differential Diagnosis (see slide 3)
No need to memorize.
III. Most common UGI bleeds are peptic ulcers followed by esophageal/gastric varices
IV. Acute Management of Sever Upper GI Bleeding (Same main points as lower GI)
A. Resuscitation and stabilization
B. Assesment of onset and severity of bleeding
C. Diagnostic Endoscopy
1. Preparation of emergent upper panendoscopy
2. Localization and identification of bleeding site
3. Stratification of the risk for rebleeding
D. Theraputic Endoscopy
1.Control of active bleeding or high risk lesions
2. Minimization of treatment-related complication
3. Treatment of persistent or recurrent bleeding
V. Case 1: 62 BM presents to ER with complaints of diarrhea , black stools of 2 days
duration. Vague epigastric pain last 1-2 weeks. No N/V (nausea/vomiting).
Initial Impression? Upper GI must still rule out lower GI
Next steps? NG tube
Triage-Stable?
IV acess- 2 sites 18 gauge
Labs
X ray? Depends on Sx (acute abd n/v, risk of aspiration pneumonia)
Focused H&P
NGT lavage?
VS: BP 130.65 HR 75 RR 16 T 98.7 97% RA
Tilt negative
A/O x 3 NAD
PE: Pale conjunctiva
No signs of an acute abdomen
Rectal Exam reveals melena (real melena- thick, tar, greasy)
 With Fe supplements can be slate appearance, dull black
 Pepto use – can be black, also look at tongue
EKG negative
NGT Lavage- coffee grounds clear with 700cc H2O (can use normal room
temperature tap water, expensive if you use normal saline- all going to stomach
anyway, no need to be sterile.)
Labs: Hb 7.3, Hct 26.2
Coags normal
BUN 54, CR 1.2
X ray- none
What next? Stabelize, IV Pepcid (H2 antagonist) [IV PPI not indicated because it
will not stop the bleeding, will only help heal ulcer later]
GI #22; Friday, 27th, 2004
10am
Dr. Hoang
Scott Emerson
page1
EGD (slide 10) – reveals a duodenal ulcer (5-6 o’clock position) with a clean base, no
visible clot →good prognosis
EGD with Bx (Bx look for benign
Duodenal ulcer- clean base (Most common site for duodenal ulcer with H. pylori,
NSAID ulcer most
common presentation in the stomach)
CLO + (H. pylori related test -Camplobacter Like Organism)
GMF vs Tele vs ICU (depends on situation. Active GI bleed →transfer to
telemetry.)
Risk of re-bleeding ? 3-5%
Treatment?
EGD Predictors of recurrent Ulcer Hemorrhage
 Active arterial bleeding → risk of re-bleeding 90%
 Non-bleeding visible vessel → risk of re-bleed 50%
 Adherent Clot → Risk of re-bleed 25-30%
 Clean Ulcer bast → 3-5%
Transfusion prior to EGD
PPI initially (this “initial” is after scope- IV Pepcid is before EGD)
No ASA, NSAIDS
Treat for H. pylori
 Prevpac
 Helidac (w/ penicillin allergies)
PPI QD additional 4 wks after above regimen
Consider repeat EGD after treatment – gastric ulcer not heal increase risk for gastric
cancer
VI. Risk Factors that increase Mortality and morbidity (not emphasized)
A. Age older >60 years
B. Severe Comorbid medical or surgical illness
C. Inpatient Hemorrhage
D. Persistent hypotension and shock
E. Persistent Hematochezia; red blood emesis or NG aspirate
F. Transfusion of 6 or more units RBCs for a single bleed
G. rebleeding from the same lesion while hospitalized
H. Severe coagulopathy
VII. ICU Admit
A. No consensus or criteria
B. Clinical judgement
C. BLEED criteria
 B= active GI bleed
 L= Low BP
 E= elevated coag profile
GI #22; Friday, 27th, 2004
10am
Dr. Hoang
Scott Emerson
page1
 E= encephalopathy
 D= Comorbid diseases
VIII. AVM (anywhere in GI tract –slide 16)
IX. Mallory-Weiss Tear (Erosin below the gastroesophogeal junction, associated with
alcoholics or individuals with a large amount of retching)
X. Watermelon Stomach (GAVE – Gastric Antro Vasculas Ectasia) Unknown etiology
(slide 18)
XI. Dieulafoy’s Lesion (rare)- Visible BV without ulceration, BV sticks out and
bleeds→inject with epinephrine and cauterize. (slide 19)
XII. Case 2: 45 CM Hep C cirrhosis presents to ER with mental status change and
bright red emesis. Onset 4 hrs earlier. Unable to obtain hx from patient.
What is your impression? Variceal Bleed
Next Steps?
Triage
Hemodynamically stable?
Active Bleeding” NGT?
Labs/X rays?
Blood Products?
IV access
Airway secured? Elective intubation if in profile to prevent aspiration
Focused H&P
PMH: Hep C cirrhosis, PUD
PSH: EGD 5ya, Appendectomy
SoHx: 6 pack/wk, 2 pack year, prior IVDU
FmHx: neg
Meds: MVI, Folate, Aldactone, Lasix
VS: BP 78/35 HR 120 RR 18 94% RA
Obtunded
NGT Lavage + unable to clear
HEENT: Icteric
Abd: Distention, ascites
Ext: 2mm edema
Neuro: obtunded
Rectal: Hematochezia
Skin: Spider angiomas chest
Labs: WBC 4.0, Hb 8.0, Hct 30, Plt 100
BUN 22, CR 1.0, Na 130, AST 210, ALT 102, Tbil 2.0
PT 18, INR 2.0, NH4 95
What next?
Stabelize patient
Transfuse
pRBC’s
FFP
GI #22; Friday, 27th, 2004
10am
Dr. Hoang
Scott Emerson
page1
Octreotide (variceal bleed) Somatostatin analog 50 mcg IV bolus followed by 50 mcg/hr
drip
ICU admit
Vitamin K 10 mg SQ/IV
SBP prophylaxis
Emergent EGD
EGD – Esophageal Varices (dialated vein ruptures depending upon size) (slide 25-26)
EGD with sclerotherapy
Actively bleeding esophageal varix
Gastric varices- injection
Portal HTN gastropathy
What is his prognosis? Poor (↑ risk of death) (slide 28)
Further treatment needed?
Medical therapy
Non-selective β-blocker
Nitrates (not for mono therapy)
Avoid ASA, NSAIDS
PPI
Endoscopic Therapy
EVL- Endoscopic variceal ligation (banding)
Sclerotherapy
Other
TIPS (transjugular intrahepatic portosystemic shunt)
Stop ETOH!!!
XIII. Case 3: 67 CF with ESRD on HD presents to ER with c/o increasing weakness,
fatigue, SOB, intermittent black stool, but on FeSO4 supplements. This is her 4th
admission in last 6 mts. Multiple transfusions in past and now has developed a rare blood
antibody. It takes 24 hrs to obtain blood for her.
PMH: HTN, CAD DM, CRF on HD
PSH: Cholecystectomy, EGD x2 negaive, coonoscopy x2 tubular adenoma
SoHx: neg
FmHx: Non-contributory
Meds: ASA, Lisinopril, Glucotrol XL, Amphogel, Calcium, Fe SO4
Occult Bleeding (read through, did not go into any detail)
VS: BP 112/73, HR 94, RR 18, 97% RA
A/O x3 NAD
HEENT- pale conjuctiva
HRRR II/VI SEM LSB
LCTAB
Abd: beingn
Ext: 2mm edema LE
Rectal: dark brown stool, Heme +++
Labs:
GI #22; Friday, 27th, 2004
10am
Dr. Hoang
Scott Emerson
page1
CBC- Hb 7.2, Hct 28, MCV 68, MCH 25
Fe 10, TIBC 247, ferritin 439
CMP- BUN 36, Cr 8.0
Coags normal
NGT lavage negative
What is your impression? Occult bleeding
DDX? (slide 34) did not go over
What next? (slide 35) did not go over
XIV. Capsule Endoscopy- M2A (mouth to anus pill)
Takes picture of small bowel lesions
Capsule endoscopy revealed 2 jejunal ulcers.