Outline. GI-Bleeding. Initial intervention

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1 Internal Medicine Board Review 2016: GI-Bleeding Stephan Goebel, M.D. Assistant Professor Division of Digestive Diseases Management UGI-Bleeding (80%) Ulcers Varices others LGI-Bleeding (20%) Outline Initial intervention Fluid resuscitation (BP>100, HR<120) Blood/Blood products (Hct 20%, 30%) Correction of coagulopathy (plt>50.000, INR<3) Gastric lavage (?blood, bile, nothing) Other supportive measures Intubation Vasopressors Erythromycin (250mg iv) or Reglan (10mg iv) GI-Bleeding Upper GI bleed (variceal vs. non variceal) Hematemesis, melena, coffee-ground Lower GI bleed Hematochezia, maroon stool Obscure GI bleed recurrent visible blood loss without identified source on EGD/colonoscopy Occult GI bleed No visible blood loss, i.e FOBT+ UGI Bleeds: Causes Ulcers (45%) Esophageal, Gastric, Duodenal (1:2) Erosions (20%) Varices (10%) Esophageal, Gastric Mallory Weiss Tear (5%) -itis (5%) AVM s (5%) Cancer (5%) Esophageal, Gastric, Intestinal Dieulafoy (5%) Question 1 A 45 year old woman presents with hematemesis. She also has postprandial epigastric pain for the last month. Supine BP 90/60 mmhg and HR 110/min. Following administration of crystalloid solution, the patient is transferred to the ICU. Hct 22%, normal INR. Upper endoscopy reveals a 2cm ulcer in the duodenal bulb. The ulcer contains a non-bleeding protuberant lesion. No blood is seen in the stomach or duodenum. Which of the following is the most appropriate next step? A. injection therapy and electrocautery B. Oral PPI and repeat EGD in 3months C. Antibiotics for 10days for presumed H. pylori infection D. Discharge from hospital 1

2 Incidence of GI-Bleeding Peptic Ulcer Disease In the US, more than 4 million people develop new or recurrent ulcers. The majority of ulcers (>90%) are due to H.pylori and NSAIDS. Smoking, alcohol, steroids, and stress are NOT independent factors for ulcer formation. Most patients present with gnawing epigastric abdominal pain, occurs during fasting, and wakes them up at night. Pain from duodenal ulcers improves with eating. Pain from gastric ulcers worsens with eating. Pearl: Presence of pain overall has poor predictive value for PUD Treatment of PUD 1. Decrease acid secretion For bleeding: PPI iv x72h, consider Octreotide PPI BID x at least 6 weeks Alternatives: Misoprostol: diarrhea, spontaneous abortion Carafate: not as effective as PPI/misoprostol, QID dosing H 2 blockers: not as effective, tachyphylaxis 2. Eradicate H.pylori if present 3. Stop exacerbating process NSAIDS Alcohol/Tobacco 4. Document healing of GASTRIC ulcer Repeat EGD in 8 weeks NSAID Prophylaxis: Risk Factors High Risk for NSAID complications 1. Previous complicated ulcer 2. Multiple risk factors (>2) Moderate Risk (1-2 risk factors) 1. Age >65 2. High dose NSAID 3. Previous history of uncomplicated ulcer 4. Use of ASA (including LOW dose) 5. Use of NSAIDS + steroids 6. Anticoagulants 7. Chronic debilitating conditions Low risk 1. No risk factors Consider CV risk and H. pylori status! Avoid NSAIDS or Cox 2 inhibitor + misoprostol or PPI Cox 2 inhibitor alone or NSAID + misoprostol / PPI No prophylaxis necessary 2

3 Question 2 A 68 yo female was recently hospitalized from a bleeding duodenal ulcer. She underwent an EGD with cauterization of a visible vessel. Biopsies of the antral mucosa showed H.pylori. She was given appropriate antibiotic treatment x 2 weeks. Which of the following is the ideal test to document eradication of H.pylori? A. No documentation of eradication is necessary B. H.pylori serum IgG C. EGD with antral biospies D. C 14 urea breath test Diseases Associated with H.pylori Duodenal ulcer > gastric ulcer Gastric adenocarcinoma Gastritis MALT lymphoma Intestinal metaplasia in antrum Non-ulcer dyspepsia Question 3 A 55 year old woman presents to the ED with hematemesis. She has no history of previous bleeding. She was disoriented during the event but is now alert and oriented. Her PMH is remarkable for diabetes, HTN and obesity. PE shows normal vital signs, anicteric sclera, mild tenderness in RUQ and peripheral edema. She is admitted to the ICU and an EGD is performed. Which of the following regimens would be recommended for treatment? A. No treatment is necessary B. Nitrate drip C. Octreotide drip and repeat banding in 3 weeks D. TIPS Varices: Treatments Non specific: Hb not above 9/g/dl Pharmacological intervention Octreotide Vasopressin/Terlipressin Antibiotics/PPI Specific Band ligation Sclerotherapy For failure: Balloon tamponade Portal-systemic shunt (TIPS) Surgical shunt (DSR-shunt) Prophylaxis of variceal bleeding Primary (no prior bleeding) depending on size of varices and MELD score non selective b-blocker or banding Secondary (post bleeding episode) band ligation until varices obliterated b-blocker (Propanolol, Nadolol, Carvedilol) consider TIPS Gastric varices Glue injection TIPS Question 4 A 70 year old woman presents with left-sided crampy abdominal pain for the last 6 hours. She passed several loose, watery stools and then 3 small maroon stools. PE: BP 130/70 mmhg, HR 92/min, no orthostasis and bowel sounds present. Abdomen is soft with moderate L-sided tenderness and some localized rebound. Reddish secretions on DRE. Labs show Hb 12.8g/dl and WBC 13.4x10 9 /l. The most likely diagnosis is: A. Diverticular bleeding B. E. coli O157:H7 colitis C. Colonic vascular ectasia (AVM) D. Ischemic colitis E. Duodenal ulcer 3

4 Studies for rectal bleeding Colonoscopy (needs prep, may be therapeutic) Nuclear scan ( ml/min, no prep, low specificity) Angiography (1-1.5ml/min, no prep, lower sensitivity, may be therapeutic) Surgery (only after localization) Causes of copious bright red rectal bleeding Diverticula (33%), self limited 75%, rebleed 25% Colitis (18%) Cancer/polyps (19%) AVM s (8%), rebleed 80% Post-polypectomy (8%) Hemorrhoids (4%), under 50y: most frequent UGI-bleeding (rare, Meckel s) Unknown (16%)! Zuckerman, G Gastrointest Endosc 1999 Question 5 A 74 year old man reports a 2 month history of recurrent melena. He has had 2-3 day episodes of black, tarry stool followed by normal stool for the next week. His most recent black stool was yesterday. During this time he has developed anemia and required a total of 8 PRBC s. He denies any other symptoms. PMH includes HTN and mild COPD. PE is unremarkable except for black stool, hemoccult positive. Hb 8.6gm/dl and MCV 80fl. Two EGD s and a colonoscopy fail to identify a bleeding source. Which of the following is the most appropriate next step in the evaluation of this patient? A. CT angiography B. Double balloon enteroscopy C. Intraoperative endoscopy D. Small bowel barium examination E. Wireless capsule endoscopy Obscure GI-Bleeding DDx based on age <20: Peutz-Jeghers, Meckel s, hemangioma, Dieulafoy 20-60: Crohn s, Cameron lesions, Meckel s, NSAID >60: amyloid, AVM s, malignancy, Cameron Dx Repeat EGD/colonoscopy Capsule endoscopy test of choice following neg. scopes Balloon enteroscopy if VCE neg. or to treat lesion Push enteroscopy (proximal small bowel) Angiography Tagged RBC scan Answer Key Q1: A Q2: D Q3: C Q4: D Q5: E 4

5 Complications of PUD Bleeding Occurs in up to 15% of patients with PUD Rarely presents with iron deficiency anemia, usually manifests as melena, hematemesis, or hematochezia. Endoscopic therapy based on risk of rebleeding. Visible Vessel risk of rebleeding is up to 50% IF NO endoscopic treatment performed Complications of PUD (2) Perforation 6-7% of patients with PUD present with this complication Presents acutely and with peritoneal signs Surgical treatment Duodenal ulcers can penetrate posteriorly and result in pancreatitis Pancreas Free air Gastric ulcers can penetrate anteriorly into left lobe of liver abscess Complications of PUD (3) Gastric outlet obstruction 1-2% Management: Medical: NG tube, PPI drip, endoscopic dilation Surgical: if medical treatment fails Narrowed pylorus - ulcer Dilated stomach Pearl: Patients can present with complication related to PUD without having prior warning signs. 5

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