GI Bleeds: The Basics

EM Rounds 2009

Anatomy

UGI vs. LGI defined by Ligament of Treitz…located in 4th section of duodenum

Epidemiology

UGIB more common in men

LGIB more common in women

Ddx in adultsUGI:

PUD

Gastric erosions

Varices

Mallory-Weiss tear

Esophagitis

Duodenitis

LGI: UGI bleed Diverticulosis Angiodysplasia Ca/polyps Rectal disease

(hemorrhoids, fistulas, fissures)

IBD Infectious

75%80%

Ddx in peds

UGI:

Esophagitis

Gastritis

Ulcer

Varices

Mallory-Weiss tear

LGI: Anal fissure Infectious colitis IBD Polyps Intussusception

Diagnosis

History:

Hematemesis, melena, hematochezia

Duration/amount of bleeding, previous episodes, recent meds/Etoh/surgeries

s/s of blood loss

Physical:

Vitals—sustained tachycardia is most sensitive

FOB?........

Resuscitation

Two large bore IV’s....foot IV’s don’t count!

Oxygen

2 liters crystalloid if hypotensive

Ddx bleeding

Melena:

Requires >150ml blood digested over prolonged period (~8h)

Pepto-bismol (will not test FOB positive)

Iron

Blueberries

Hematochezia: Only 5ml of blood

required to turn “toilet water bright red”

Beets

FOB testing

False positives:

Red fruits/meats

Methylene blue

Chlorophyll

Iodide

Cupric sulfate

Bromide

False negatives: Rare! Bile Ingestion of Mg-

containing antacids Ascorbic acid

GIB investigations

CBC, INR/PTT, T+S, LFT’s

Remember, Hct lags behind clinical picture, and is affected by hemodilution

Consider lytes, BUN, Cr

EKG

Upright CXR if suspect perf

UGIB management GI—endoscopy

Gen Surg—operative (hemodynamically unstable patients unresponsive to conventional treatments)

or some suggest if > 5U blood in 1st 4 - 6 hrs...

Intervent Radiol—angio

UGIB and endoscopy Most accurate diagnostic tool

Identifies source in 78-95% of pts, when performed within 12-24hrs post-UGIB

Allows for risk stratification (rebleeding and mortality) as well as treatment (banding or sclerosing of varices)

UGIB and angiography

Detects location of UGIB in 2/3 of pts

Usually performed during active bleeding

Unstable vitals

Ongoing transfusion requirements

UGIB medications PPI—pantoloc

Bolus 80mg then run @ 8mg/h x 72hrs

Role in pts with PUD as cause

Is an adjunct, not therapy for UGIB…still need endoscopy

Somatostatin analogues—octreotide

Bolus 50ug then continuous infusion of 25 - 50ug/hr

Role in esophageal varices

Peptide analogue which causes splanchnic vasoconstriction by direct effect on vascular smooth muscle

Vasopressin ?Has been used in pts with esophageal variceal hemorrhages

No effect on overall mortality

High rate of complications (9% major, 3% fatal)

Only role would be in exsanguinating pt, with endoscopy or other measures unavailable

Sengstaken-Blakemore tubes

Useful if esophageal variceal bleeding source

Linton tube if gastric varices

High risk of complications (14% major, 3% fatal)

One of those last-ditch efforts!

Insertion techniques…

SB tubes… Equipment:

Sterile Sengstaken-Blakemore tube

Pair of scissors

50ml syringe

2 x rubber tipped artery forceps

Water soluble lubricant

3 metres of white linen tape

Pressure gauge

Weight for traction

Pulley

PPE

Precautions: Balloon pressure should

always be <45mmHg Pt should be intubated prior

to procedure Keep scissors near bed at all

times (to cut tube prn if migrates and causes resp distress)

Check tube placement by:• Aspirate and check pH• Inject air and auscultate over

stomach• XR

SB tube

LGIB and scopes

Must r/o UGIB source first usually

If mild LGIB with no evidence of hemorrhoids, then anoscopy / proctosigmoidoscopy recommended

Absence of blood above rectum indicates rectal source; however, blood above rectum does not r/o rectal source

LGIB and angiography

Does not usually diagnose cause of bleeding, but identifies source in 40% of pts

Arterial embolization may be useful if ongoing bleeding

Disposition

Very low risk (can be d/c’d home)

Low risk

Moderate risk

High risk

Very low risk

No comorbid disease

Normal vitals

Normal or trace FOB positive

+/- neg gastric aspirate

Normal (or near) Hgb/Hct

Good social situation

F/u within 24hrs

Understanding as to when to return…

Initial ED stratification Low Risk Moderate Risk High Risk

Age <60 Age >60  

Initial SBP ≥100 mm Hg Initial SBP <100 mm Hg Persistent SBP <100 mm Hg

Normal vitals for 1 hrMild ongoing tachycardia for 1 hr

Persistent moderate/severe tachycardia

No transfusion requirement Transfusions required ≤4 U Transfusion required >4 U

No active major comorbid diseases

Stable major comorbid diseasesUnstable major comorbid diseases

No liver disease Mild liver disease—PT normal or near-normal

Decompensated liver disease—i.e., coagulopathy, ascites, encephalopathy

No moderate-risk or high-risk clinical features

No high-risk clinical features  

Final Stratification for Pt’s with UGIB after endoscope combined with initial ED stratification

  Clinical Risk Stratification

Endoscopy Low Risk Moderate Risk High Risk

Low risk hospitalization Immediate discharge[] 24-hr inpatient stay (floor)[†]

Close monitoring for 24 hr[‡]; ≥48-hr

Moderate risk 24-hr patient stay[†] 24–48 hr inpatient stay (floor)[†]

Close monitoring for 24 hr; ≥48-hr hospitalization

High risk Close monitoring for 24 hr; 48–72 hr hospitalization

Close monitoring for 24 hr; 48–72 hr hospitalization

Close monitoring ≥72-hr hospitalization

So what does this mean at FMC for UGIB pts…

Low-risk pts:

Hold o/n in ED until scoped

Consider admission to Hospitalist until scoped (depending on GI suggestions)

Med risk pts: Admit to

Hospitalist/Medicine until scoped

Scope immediatelyHigh risk pts: Scope immediately Admit to Medicine/ICU

Disposition LGIB ptsIf not clearly due to hemorrhoids, fissures, proctitis then should admit

Low risk: admit to Hospitalist with scoping

Med/High risk: admit to Medicine/ICU with scoping +/- angio

Airway in GI BleedsLow threshold for capturing airway

Have suction (or two) ready

Extra hands

Follow the bubbles

Airway Rescue devices ready

Pearls

Elderly patients or those with underlying CAD can present with ischemic chest pain secondary to blood loss from GI bleed.

Don’t forget NSAID or EtOH hx

Correct coags ASAP

BUN is often elevated in UGI bleeds secondary to absorption of blood from GI tract and hypovolemia causing prerenal azotemia (BUN:CR ratio > 20)

Pearls

AAA repair and GI bleed need to r/o aorto-enteric fistula

Fever and GI bleed consider aorto-esophageal fistula

Resuscitate, resusciate, resuscitate