High Value Care of GI Bleeding Bennie R. Upchurch MD, FACP, FASGE, AGAF, FACG Medical Director, GI Bleeding Program, Division of Gastroenterology, Nutrition, and Hepatology Ohio State University Wexner Medical Center
Objectives Accurately assess, triage and resuscitate the GI bleeding patient. Recognize common causes of GI bleeding and the approach in management. Understand and facilitate a multidisciplinary approach to management of the GI bleeding patient.
Acute Gastrointestinal Bleeding Annually ~ 300,000 hospitalizations and ~ 20,000 deaths in US Common cause for ICU admission and potentially lethal medical emergency Overall incidence: 50-100/100,000 pts/yr Incidence of UGI : LGI bleeding ~ 5:1 More common in elderly esp. men > 70 yrs, who comprise ~ 30 % of all pts with UGI bleeding Mortality rates over past 40-50 yrs have been stable at ~ 7-10%
Initial Assessment of Severe UGIB 1. Resuscitation and stabilization 2. Assessment of severity and location of bleeding 3. Preparation for emergent upper endoscopy 4. Role of endoscopist - Localization and identification of the bleeding site - Control of active bleeding or high risk lesions - Stratification of the risk for rebleeding - Minimization of treatment-related complications - Treatment of persistent or recurrent bleeding
Initial Evaluation - History - Age: Elderly ( ischemia, cancer, diverticula) Young ( ulcers, esophagitis, varices) - Prior GI Bleeding - Previous gastrointestinal disease - Previous GI surgery - Underlying Medical Disorders ( esp - liver disease, CKD) - Meds : NSAIDS - ASA/Anticoagulant use - Symptoms: Abdominal pain, fever, wt loss, anorexia, epistaxis, hematuria etc - Allergies
Physical examination - Hemodynamics with a thorough cardiopulmonary exam - Skin ( spider angiomata, purpura, cutaneous telangiectasias /pigmentation) - Abdomen ( ascites, tenderness, masses ) - Digital Rectal exam
Initial Patient Care/Management - Appropriate IV access: 2 large bore I.V catheters - IV fluids (NS/LR) and/or blood product resuscitation. ( Target HCT 30% in elderly/ 25-30% in young adults and pts with in Portal HTN ) - Continuous cardio-pulm monitoring for those with coronary risk factors with supplemental O2. - Frequent vital signs / urine output monitoring. - Consider intubation in those with altered mental status or brisk bleeding.
Labs and Studies Complete blood count ( check MCV) and electrolytes ( BUN >> Cr ), Iron studies. Coagulation Panel: PT/INR Type + screen or type + cross-match blood EKG for patients > 50 yrs or risk factors for heart disease. Abdominal radiographs usually not indicated
Naso Gastric Lavage - 79% sensitivity and 55% specificity for active bleeding - Positive NGL does not provide etiology - A non bloody aspirate in ~ 25% of UGIB - A bile aspirate does not R/O UGIB - NO evidence based data that NGL affects outcome
Increasing age - Age > 70 yrs Predictors of Mortality Concurrent active major organ disease Preexisting hospitalization ( mortality rate ~ 34% ) Passing frequent frank blood. Esp if - Shock or Orthostatic hypotension Variceal vs. Non variceal ( eg. Variceal bleed has mortality rate of 30% during initial hosp, with 1 yr mortality rate of ~ 60% ) Requiring emergency surgery for GIB Active bleeding / Transfusion requirement 4 or more red cell units in the first 24 hours 2 or more units for rebleeding event 6-8 units total
Forrest Classification System with Respective Prognosis Forrest Classification Type I: Active Bleed Ia: Spurting Bleed Ib: Oozing Bleed Rebleeding Incidence Surgical Requirement 55-100% 35% 11% Incidence of Death Type II: Recent Bleed Ila: Non-Bleeding Visible Vessel (NBVV) Ilb: Adherent Clot 40-50% 34% 11% 20-30% 10% 7% Type III: Lesion without Bleeding Flat Spot Clean Base 10% 6% 3% 5% 0.5% 2%
The Forrest Classification of Peptic Ulcers (Stigmata of recent hemorrhage)
Prognostic Features of GD Ulcers Ulcer size > 1 cm is associated with increased rebleeding and mortality Endoscopic hemostasis is less successful in ulcers > 2 cm in size Greatest re-bleeding risk from ulcers is within first 72 hours
H. pylori (H.P) and PUD Some studies suggest rebleeding less with H. pylori Rx than PPI TX. NSAID users infected with H.P has ~ two-fold risk of ulcer bleeding. ASGE guidelines suggest that all pts with PUD should be checked and treated for H.pylori. ( Class A rec ) Note rapid urease tests have reduced sensitivity in acute GIB. Use tests of active infection.to r/o infection.
PUD and NSAIDS / ASA Mechanism : Reduced production of cycloxygenase generated cytoprotective PG, platelet dysfunction Risk of Bleeding : gastric ulcers > duodenal ulcers RR of NSAIDS is 4-7 compared to ASA (2.5) and COX 2 inhibitors (1.5). Relative risk varies with individual NSAIDS ex : piroxicam > ibuprofen etc Risk of bleeding is dose dependant Multiple cofactors contribute to risk ( eg. age > 75 yrs, h/o CAD, prior GIB, H. pylori, steroids, bisphosphonates & ETOH etc )
Resumption of Low Dose ASA ( 81 mg ) After Bleeding Ulcer Sung et al. Gastro 2006;130 (suppl 2): A 44 8 week DB RCT after Endoscopic Therapy. i.v PPI X 3 days followed by oral PPI Rx. Rebleeding at 1 month; 11% of pts on placebo (N=55) rebled c/to 18% of pts on ASA (N=58). - P = 0.25 Mortality at 2 months: There was a 14% mortality in placebo group (n=55) c/to 2% in pts on ASA (N=58). - P = 0.012.
Guidelines for Medical Tx for Non Variceal UGIB Somatostatin /Octreotide reduce portal venous blood flow and gastroduodenal arterial flow, while preserving renal blood flow. These are not routinely recommended for patients with acute ulcer bleeding. ( Class A rec), Dose - 50-100 mcg bolus f/by 25 mcg/hr x 3 days. In Meta-analyses of 14 studies, 1829 pts with Non variceal UGIB PPI reduced risk of continued bleeding and need for surgery. ( Khuroo et al -NEJM 1997;336:1054-8 ) PPIs were better for bleeding from PUD than non PUD bleeding; eg.- hemorrhagic gastritis. I.V Erythromycin 250 mg i.v bolus or 3 mg/kg over 30 min, administered 30-60 minutes before EGD significantly increases quality of mucosal visibility. ( Class A rec) PPI ( Pantoprazole ) 80 mg i.v bolus followed by an infusion of 8 mg/hr x 72 hrs. ( Class A rec)
Rebleeding after Endoscopic Therapy ~ 20% of pts with active UGIB rebled. A second-look endoscopy demonstrated benefit in only those cases with active re-bleeding. 3386 patients with bleeding peptic ulcers Initial therapy 98.6% successful Rebleeding 8.2% Predictors of rebleeding: OR Hypotension 2.2 Anemia <10 gm/dl 1.9 Active bleeding / fresh blood 1.7 / 2.2 2 cm ulcer 1.8 Wong et al Gut 2002
Early (2-24 hrs) vs. Delayed Endoscopy for UGIB Lower costs: - Early discharge of low risk patients. - Location of admission (ICU vs. ward) Significant benefit of endoscopic therapy in high risk pts suggests early endoscopy is beneficial, but has not been documented in RCTs. Major clinical outcome parameters such as rebleeding rate, mortality and the need for an emergency operation have no bearing with timing of endoscopy. There is insufficient evidence to support endoscopy within 12 hours of presentation leading to better clinical outcome. J Sung, AGA Perspectives Vol 5, Dec 2009
Indications for Angiography in UGIB Consensus statement from American College of Radiology: - Endoscopy is the best dx and therapeutic procedure. - Surgery and transcatheter arteriography /intervention (TAI) are equally effective following failed EGD. TAI is considered in cases with high operative risk. - TAI is less successful in pts with impaired coagulation - TAI is best technique for UGIB into the biliary tree or pancreatic duct.
Angiographic Therapy Bleeding should be > 0.5 ml/hr. Selective Intra-arterial vasopression not used now. Risks: Brady-arrhythmias, ischemia etc Selective occlusion of bleeding arteries with gelfoam, beads, tissues adhesives and coils etc are used. Rebleeding is common, and complications such as ischemia, infarction, perforation and abscess etc are prominent. CTA, MRA, CTe
Technetium Tagged RBC Scan
Surgical Therapy for UGIB- When? Role is controversial. Is usually considered in high risk cases when ; 1) HD instability even after > 3 units PRBC transfusions 2) TWO unsuccessful EGDs/attempts at hemostasis 3) Shock with recurrent hemorrhage 4) Continuous bleeding with transfusion requirements of > 3 units PRBC / day.
Surgical Therapy Typically pts are severely ill and mortality is ~ 25 % c/to ~ 10% in un-operated pts. Primary objective is not to cure ulcer disease but stop hemorrhage. Acid-reducing procedures may be added. A large RCT trial of 92 pts demonstrated that after initial failure of Endo Tx an endoscopic re-treatment reduced the need for surgery without increasing death and had fewer complications than surgery. At this time, no data from current endoscopic era supports early surgery except - A-E fistula, bleeding benign tumors and severe GAVE
Acute Lower GI Bleeding
LGIB Epidemiology Bleeding distal to ligament of Treitz Self-limited in over 80% More commonly from colon than SB (<15%) Annual incidence 20/100000 (1/5 of UGI bleeding) Mean age over 65 years Incidence increases with age Mortality 1-5% (23% if bleeding after hospitalization)
Outcomes Acute rebleeding 7-32 Delayed rebleeding 12-38 Surgery 4-24 Mortality 1-5 PRBC (mean #units) 1.8-4 Length of stay 4-11 *(%) Strate LL. Gastro Clin N Am 2005;34:643-664
Predictors of Mortality Age > 60 Concurrent active major organ disease Renal, cardiopulmonary, hepatic, neurological Preexisting hospitalization Passing frequent frank blood Orthostatic hypotension Transfusion requirement 4 or more red cell units in the first 24 hours 2 or more units for rebleeding event 6-8 units total
LGIB Etiology Colonic sources (243/300) 81% Diverticulosis 29.6 Internal Hemorrhoids 14.0 Ischemic colitis 12.3 Rectal ulcers 9.1 UC, Crohn s, other colitis 8.2 Post-polypectomy ulcer 7.4 Colon polyp or cancer 6.2 Colon angiomas or radiation proctitis 5.7 Other LGI diagnoses 7.5 UGI source 15.3% SB source 1.3% No identified source 2.4% CURE hemostasis research group
Evaluation of LGIB Medical history Nature and duration of bleeding episode Symptoms: pain, fever, dyspepsia Relevant history: bleeding, trauma, GI surgery, comorbidity, risk factors for liver disease Medications: NSAIDs, ASA, anti-coagulants Physical examination Vital signs, orthostatics Cardiopulmonary exam Abdominal and rectal exam (repeat even if reported by ED)
Evaluation Laboratory Complete blood count and electrolytes PT/PTT Type blood / screen/cross-match EKG for patients > 50 yrs or risk factors for heart disease Abdominal radiographs not indicated Barium studies contraindicated Appropriate IV access Fluid and/or blood product resuscitation PRBC to HCT >30 FFP to INR <1.2 Platelets to > 50k Continuous cardiac monitoring for those with coronary risk factors Monitored bed/ frequent VS
Management Pass NGT to exclude UGIB 10-20% with hematochezia have UGI source of bleeding Consider EGD if NGT inconclusive (particularly w/ hemodynamic compromise, risk factors for UGI source) Helps to prep colon (Golytely) Early colonoscopy (within 12-24hr) After Golytely prep Identifies lesion in over 75% cases Therapy possible Associated with reduced length of stay Low complications 0.5-1% 10-20% undergoing urgent colonoscopy receive endoscopic therapy
ASGE 2001
Vascular Ectasia Multiple, mainly right colon Associated with advanced age, CRF, Valvular heart disease Intermittent hematochezia, massive bleeding rare Argon Plasma Coagulation effective, widely used All lesions should be treated
Cecal AVM
Radiation Proctopathy Intermittent hematochezia with tenesmus 9m to 4 yrs after XRT for prostate or gyn cancers Multiple telangiectasias on endoscopy APC most effective All visible lesions treated and repeated Q 4 weeks, full bowel prep advised, mean 2.9 sessions (1-8) Post procedure rectal pain and cramps possible Post procedure rectal ulcers Rx with 5 ASA suppositories
Radiation Proctitis
Internal Hemorrhoids Most common cause of LGI bleeding in ambulatory adults Second most common cause of severe LGIB High fiber diet, avoiding straining and sitz baths usually effective Emergency hemostasis and refractory cases treated with rubber band ligation and rarely surgery
Internal Hemorrhoids
External Hemorrhoids
Ischemic Colitis Results from sudden and often temporary reduction in mesenteric blood flow Sudden lower abdominal pain followed w/in 24 hrs by bloody diarrhea Segmental involvement of water shed areassplenic flexure and descending colon Endoscopy mainly diagnostic - mucosal erythema, friability, necrotic ulcerations Supportive management
Ischemic Colitis
Small Bowel Bleeding
Small Bowel Bleeding 5-7 % of obscure GI bleeding Proximal jejunum angioectasia Similar to right colon AVMs Capsule endoscopy Balloon assisted enteroscopy Double balloon endoscopy Single balloon enteroscopy Intraoperative enteroscopy
Capsule Endoscopy Bleeding consensus 2005 Should be part of initial evaluation of obscure bleeding Earlier use may be positive for QOL and alter management Lead to treatment success 86.9% when actively bleeding State of the art in small bowel imaging
Double Balloon Enteroscopy Indications OGIB after Neg capsule Surveillance of FAP or Peutz Jaegers PEJ Roux-en Y endoscopy(ercp) Advantages Steer/wash/therapeutic ½ to 2/3 of bowel seen avg. Target lesion on CE or CTe helps determine route Learning curve Time/flouro/depth 1 st 10 cases 109 mins to ~90 after Retrograde 31% failure Outcomes Yield as high as capsule Mehdizadeh et al, GIE 2006 Courtesy of Fujinon Corp.
Conclusions: Medical stabilization Signs and symptoms help to localize Direct the investigation Alter risk factors Value = Benefits/Costs
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