GI Bleeding Jeopardy!
UGIB therapy
LGIB
Clinical stuff
General mgmt
Potpourri
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These are your first 3 initial
management priorities given a 51y M
currently vomiting blood, has vomited
~1L blood with EMS
VS: 125, 88/57
A: maintaining
B: adequate
C: vomiting blood, VS as above
Brisk UGIB Management
1) Protection! – gown, gloves, face shield
2) Monitors, O2, IV x 2 (at least 18G)
3) Initial fluids?
• NS vs blood
• pRBC if ongoing vomiting or VS don’t improve
These are the top 3 medications you
might order for a patient with an UGIB
UGIB Pharmacotherapy
• Gastric acid suppression
• Pantoloc 80mg IV then 8mg/h infusion
• Somatostatin analogue
• Octreotide 50ug IV then 50ug/hr infusion
• Abx
• Ceftriaxone 1g IV
•What’s the point?
UGIB Pharmacotherapy
• PPI’s
• Improve clot formaion and breakdown
• Leontiadis GI et al. Cochrane rev Nov 2006
• re-bleeding risk (OR 0.49 (0.37-0.65))
• need for surgery (OR 0.61 (0.48-0.78))
• mortality in bleeding pts (OR 0.53 (0.31-0.91))
• No effect on overall mortality
• H2-blockers not shown to have same benefit
UGIB Pharmacotherapy
• Octreotide
• Causes splanchnic vasoconstriction
portal venous pressures
rebleeding
• Imperiale et al. Ann Intern Med 1997;127:1062-71
• Similar control of bleeding varices as EGD
• risk of continued bleeding in PUD (RR 0.53;)
UGIB Pharmacotherapy
• Antibiotics
In cirrhosis (Soares-Weiser et al. Cochrane rev, 2002):
• infectious complications (RR 0.40 (0.31-0.51))
• mortality (RR 0.66 (0.49-0.88))
• rebleeding
• No evidence that abx need to be started in the ED
This is the indication for using vasopressin
in UGIB, and its mechanism of action
UGIB Pharmacotherapy
• Vasopressin
• 20U IV over 20min then 0.2-0.4U/min
• Constricts mesenteric arterioles
• No mortality benefit (?mortality)
• Complication rate
• 9% major (myocardial, cerebral, bowel, limb ischemia)
• 3% fatal
• Indication
• Can try in exsanguinating patient with ?variceal
bleeding if EGD not available
This is what the acronym
“TIPS” stands for
Transjugular Intrahepatic Portosystemic Shunt
• Interventional radiology
• Connection between
• Hepatic vein
• Intrahepatic portion of portal vein
• Indication?
• Continued bleeding despite Rx/EGD
The rate of major complications from this
procedure is 15%, and the rate of fatal
complications is 3%
Linton tube
• Major complications
• Mucosal ulceration, tracheal compression, aspiration
pneumonia, esophageal/gastric rupture, asphyxiation
• Consider if exsanguinating patient with ?variceal
bleeding and EGD not immediately available
• Temporizing measure until EGD/surgery/TIPS
• Anything you need to do before putting it in?
• Need to secure A/W
The type of stool usually seen in LGIB
Stool – LGIB vs UGIB
• Hematochezia
• Usually LGIB (10% UGIB)
• Melena
• Need 200mL blood x 8hrs (70% UGIB)
These are 3 causes of false +ve
Hemoccult tests
FOB Testing
• False +ve
• Red fruits, meats, methylene blue, chlorophyll,
iodide, cupric sulfate, bromide
• What about iron? Pepto-Bismol?
• Not causes of false +ve
• False –ve?
• Bile, Mg-containing antacids, ascorbic acid
FOB Testing
• What about testing coffee ground emesis?
• Hemoccult are pH dependent
• Antacids/vitamin C cause false –ve
• False +ve with copper/iron salts
• +ve result can usually be trusted
This is the type of physician you will consult
and the urgency in the following patient with
hematemesis & hematochezia:
61y F
PMH: A.fib, NIDDM, HTN, AAA (repair 2y ago)
Rx: warfarin, metformin, glyburide
Hematochezia/hematemesis After AAA Repair
• ?Aortoenteric fistula
• STAT consult to vascular surgery!
• Incidence of up to 4% post-repair
• Usually presents as UGIB
• Aortoduodenal fistula
They are 3 investigation modalities that can
be used to help localize LGIB
LGIB Localization
• Scope
• Anoscopy
• Sigmoidoscopy/colonoscopy
• Angiography
• Requires 0.5cc/h bleeding
• ID’s site in 40%
• Radionuclide scan
• Technetium labeled RBC’s
• Need 0.1cc/h bleeding
These are the 3 main causes of painful
LGIB
Painful Rectal Bleeding
• Ischemic colitis
• Infectious colitis
• Inflammatory colitis
• 5 bacteria causing bloody colitis?
• E. coli
• Campylobacter
• Yersinia
• Salmonella
• Shigella
• C. difficile
These are 3 risk
factors for poor
outcome in UGIB
Risk factors for poor outcome (UGIB)
• Age > 60y
• Coagulopathy
• Liver failure
• Cardiac disease
• Severe bleeding
The 3 of these are responsible for 75%
of all UGIB
Differential diagnosis of UGIB
• Esophageal/gastric varices
• PUD
75%
• Gastritis/gastric erosions
• Esophagitis
• Mallory-Weiss tear
• Gastric CA
• Aortoenteric fistula
• Angiectasias
• Osler-Weber-Rendu syndrome
Differential diagnosis of UGIB
• 10% of GIB patients have no identifiable
source
The 2 of these are responsible for 80%
of all LGIB
Differential diagnosis of LGIB
• Diverticulosis
• Angiodysplasia
• Malignancy
• UGIB
• Polyps
• IBD
80%
• Infectious colitis
• Ischemic colitis
• Radiation colitis
• Anorectal varices
• Aortoenteric fistula
• Perianal disease
• Hemorrhoids
• Fissure
• Trauma
These are 4 things that could be the
cause of your patient’s dark stools
DDx Melena
• UGIB
• High LGIB
• Swallowed blood (epistaxis, etc)
• Iron
• Bismuth (Pepto-Bismol)
• Food products (eg. blueberries)
The utility of postural vital signs and
capillary refill in predicting
hypovolemia
Physical Exam Skills
• Postural vital signs
• HR by 20bpm sustained
• 98% specific for significant blood loss in GIB
• sBP by 20mmHg
• 97% specific for significant blood loss in GIB
• CR > 2-3sec
• 10% SN for significant hypovolemia
These are the investigations you order for
the patient with a brisk UGIB
UGIB investigations
• CBC, T&S, INR/PTT
• Lytes, BUN, Cr
• ±ALT, ALP, bili, GGT
• ECG?
• CAD hx, age > 50, CP, SOB, hypotension
• CXR?
• If ?aspiration or ?perforation
They are the 3 specialties that you might
have to consult with a GIB (other than ICU)
HELP!
• GI
• Scope
• Interventional radiology
• TIPS
• Angiography
• General surgery
• Anyone else?
• Vascular surgery
This is the likely source of bleeding
(UGIB vs LGIB) in the following patient:
72y M, PMH: HTN, OA, A.fib; Meds: ?
Hematochezia x 5 episodes over 90min
VS: 112, 81/40, 22, 370
Hematochezia + Shock
• Hematochezia + shock = UGIB
• Rapid transit
This is the utility of NG tube insertion in
the patient with blood per rectum
NG tube in patient with bloody stools?
• If +ve blood
• UGIB
• LGIB + oral/nasal mucosal bleed
• If –ve blood
• UGIB + bleeding stopped, duodenal blood
• 10% of UGIB have –ve NG aspirate
• LGIB
•Bottom line
• Not diagnostic…not helpful
This is the expected rise in Hb and Hct
for 2U pRBC
Transfusion Facts
• 1U pRBC (if no ongoing bleeding)
• Hb by 10mmol/L
• Hct by 3%
They are 3 risk factors for ischemic
colitis
Painful Rectal Bleeding
• Risk factors for ischemic colitis?
• Dysrhythmia
• CAD
• Heart failure
• Prolonged hypotension
• Marathon running
They are 2 potential future diagnostic
modalities for GIB
Future Diagnosis
• CT/MRI reconstruction “endoscopy”
• Wireless capsule endoscopy
These are the GIB patients you can send
home from the ED
Disposition
• Very low risk (d/c home)
• No comorbidities
• N VS
• N/trace + FOB
• NG aspirate –ve if done
• Home support in place
• Understand symptoms sig bleed
• Easy access to ED
• F/U within 24h
Risk Stratification
Risk Stratification
They are the 2 potential causes of an
increased BUN in the GIB patient
Increased BUN
• Prerenal azotemia
• Digested blood
It is much more likely to be your diagnosis
in a patient with hematochezia and a
history of cirrhosis
(and it’s not brisk UGIB)
Liver Disease and LGIB
• Anorectal variceal bleeding
• Superior hemorrhoidal veins and
middle/inferior hemorrhoidal veins
Rules:
• Teams decide how much to wager
• Each team pick one skilled participant
• Participants leave the room for setup of
Final Jeopardy!
Task:
• Race to fill the Linton tube
with 600cc air
• Opposing team counts cc’s