GI bleeds: what’s GI bleeds: what’s old, what’s new?old, what’s new?Grand Rounds, Department of Grand Rounds, Department of

Emergency MedicineEmergency MedicineApril 15, 2004April 15, 2004

Christine Hall MSc MD FRCPCChristine Hall MSc MD FRCPC

OutlineOutline Upper GI bleeds overall summaryUpper GI bleeds overall summary

– PUD PUD – Drinkers and non drinkersDrinkers and non drinkers– VarianceVariance– NSAIDsNSAIDs

Upper GI bleeds specific physiologyUpper GI bleeds specific physiology– NSAIDsNSAIDs

Upper GI bleed Rx issuesUpper GI bleed Rx issues– PPI’sPPI’s– EGDEGD– Discharge criteriaDischarge criteria

Variceal bleeds Variceal bleeds Lower GI bleedsLower GI bleeds Patient dispositionPatient disposition

IntroductionIntroduction GI bleeding:GI bleeding: 2% of all US hospital admissions2% of all US hospital admissions 5% of admissions originating in the 5% of admissions originating in the

EDED Majority of bleeds are UGIMajority of bleeds are UGI

UGI bleeding incidenceUGI bleeding incidence 103/100,00 adult per year in UK103/100,00 adult per year in UK

– incidence 23/100,00 in age under 30 to incidence 23/100,00 in age under 30 to 485/100,00 in over 75485/100,00 in over 75

men more than double women men more than double women except in elderly except in elderly

14% occurred in inpatients already in 14% occurred in inpatients already in hospital for some other reasonhospital for some other reason

27% of cases (37% female, 19% 27% of cases (37% female, 19% male) patients were aged over 80. male) patients were aged over 80.

Rockall TA, Logan RF, Devlin HB, Rockall TA, Logan RF, Devlin HB, Northfield TC.Northfield TC. Gastrointest Endosc. 2002 Jan;55(1):1-5.Gastrointest Endosc. 2002 Jan;55(1):1-5.

UGI Bleeding mortalityUGI Bleeding mortality Overall mortality 14% Overall mortality 14%

– 11% in emergency admissions11% in emergency admissions– 33% in inpatients33% in inpatients

In the emergency admissions:In the emergency admissions:– 65% of deaths in pts under 80 associated with 65% of deaths in pts under 80 associated with

malignancy or organ failure at presentationmalignancy or organ failure at presentation Mortality for patients under 60 in the Mortality for patients under 60 in the

absence of malignancy or organ failure at absence of malignancy or organ failure at presentation was 0.8%. presentation was 0.8%.

Rockall TA, Logan RF, Devlin HB, Northfield TC.Rockall TA, Logan RF, Devlin HB, Northfield TC. Gastrointest Endosc. 2002 Jan;55(1):1-5.Gastrointest Endosc. 2002 Jan;55(1):1-5.

UGI bleeds in drinkers UGI bleeds in drinkers From August 1, 1990 through September From August 1, 1990 through September

9, 1994. Prospective.9, 1994. Prospective. Pts referred to GI (selection bias)Pts referred to GI (selection bias) subnormal hematocrit on or within 12 h of subnormal hematocrit on or within 12 h of

admission or a fall of at least 5 points from admission or a fall of at least 5 points from previous previous

Upper GI endoscopy was performed in all Upper GI endoscopy was performed in all patients within 48 h of admissionpatients within 48 h of admission

Alcohol use was quantitated as chronic (80 Alcohol use was quantitated as chronic (80 g or more per day for at least 1 month), g or more per day for at least 1 month), binge, occasional, or none.binge, occasional, or none.

UGI bleeds in drinkersUGI bleeds in drinkers 727 pts: 212 (29%) chronic alcohol 727 pts: 212 (29%) chronic alcohol

usersusers Peptic ulcer disease was most common Peptic ulcer disease was most common

cause of bleeding (60%). cause of bleeding (60%). Gastropathy etiological in only 32 Gastropathy etiological in only 32

patients (4%)patients (4%)– portal hypertension in 22 patientsportal hypertension in 22 patients– NSAID induced gastropathy in 5NSAID induced gastropathy in 5

Alcohol induced gastropathy in 5 ptsAlcohol induced gastropathy in 5 pts– bleeding was mild and self-limited. bleeding was mild and self-limited.

Wilcox CM, Alexander LN, Straub RF, Clark WS Am J Gastroenterol. 1996 Jul;91(7):1343-7

UGI bleeds in drinkersUGI bleeds in drinkers Causes of bleeding were compared Causes of bleeding were compared

between drinkers and nondrinkersbetween drinkers and nondrinkers– drinkers were more likely to bleed from varices drinkers were more likely to bleed from varices

(p = 0.024) (p = 0.024)– portal hypertension-related causes (p < 0.01), portal hypertension-related causes (p < 0.01),

Peptic ulcer was more common in Peptic ulcer was more common in nondrinkers compared with chronic ETOHnondrinkers compared with chronic ETOH– (67 vs 53%; p < 0.01)(67 vs 53%; p < 0.01)

Esophagitis (p = 0.95) and Mallory-Weiss Esophagitis (p = 0.95) and Mallory-Weiss tear (p = 0.15) were NS between the two tear (p = 0.15) were NS between the two groups. groups.

Wilcox CM, Alexander LN, Straub RF, Clark WS Am J Gastroenterol. 1996 Jul;91(7):1343-7

UGI bleed varianceUGI bleed variance Qiu, YJ. Qiu, YJ. Zhonghua Hu Li Za ZhiZhonghua Hu Li Za Zhi. .

1987 Jun;22(6):269-70. 1987 Jun;22(6):269-70. Relation between hemorrhage Relation between hemorrhage

and the waxing or waning of the and the waxing or waning of the moonmoon – Unfortunately in Chinese so not Unfortunately in Chinese so not

available for today…available for today…

Upper GI bleeds: Upper GI bleeds: pathophysiologypathophysiology

EsophagitisEsophagitis– CandidalCandidal– Non candidalNon candidal– bisphosphonatesbisphosphonates

Esophageal tearsEsophageal tears GastritisGastritis That’s all we’ll say about the benign That’s all we’ll say about the benign

causescauses

UGI bleed diagnosis: to OG or UGI bleed diagnosis: to OG or not to OG?not to OG?

Not great evidence for confirming Not great evidence for confirming UGI bleed by putting in NG or OGUGI bleed by putting in NG or OG

Practice discouraged by most GI’sPractice discouraged by most GI’s Can confound UGI bleed re: trauma Can confound UGI bleed re: trauma

of insertionof insertion Relative contraindication in variceal Relative contraindication in variceal

bleed although this is witchcraft…bleed although this is witchcraft…more about that later…more about that later…

PUD CausationPUD Causation

10%

30%60%

Other H. Pylori NSAID

H. PyloriH. Pylori Serology never becomes negative Serology never becomes negative

once positiveonce positive Even if H. Pylori is eradicatedEven if H. Pylori is eradicated Complicates repeat breath tests or Complicates repeat breath tests or

biopsiesbiopsies PPIs are antimicrobial for h.pylori PPIs are antimicrobial for h.pylori

despite poor initial performance in despite poor initial performance in development as an antibioticdevelopment as an antibiotic

Current Rx for H. Pylori Current Rx for H. Pylori EradicationEradication

NSAID induced ulcersNSAID induced ulcers

NSAIDS: what’s the NSAIDS: what’s the problem?problem?

Toxic effects of NSAIDs thought to be due to Toxic effects of NSAIDs thought to be due to Cox-1 inhibitionCox-1 inhibition

launch of the cyclooxygenase-2 (COX-2) launch of the cyclooxygenase-2 (COX-2) selective NSAIDs was based on 2 hypotheses:selective NSAIDs was based on 2 hypotheses:

– the major adverse effects limiting the usefulness the major adverse effects limiting the usefulness of nonselective NSAIDs are gastrointestinal in of nonselective NSAIDs are gastrointestinal in nature nature

– COX-2 selective NSAIDs are associated with fewer COX-2 selective NSAIDs are associated with fewer gastrointestinal adverse effects than nonselective gastrointestinal adverse effects than nonselective NSAIDs. NSAIDs.

The CLASS TrialThe CLASS Trial To determine whether celecoxib, a COX-2-specific To determine whether celecoxib, a COX-2-specific

inhibitor, is associated with a lower incidence of inhibitor, is associated with a lower incidence of significant upper GI toxic effects and other significant upper GI toxic effects and other adverse effects compared with conventional adverse effects compared with conventional NSAIDs. NSAIDs.

double-blind, randomized controlled trial double-blind, randomized controlled trial conducted from September 1998 to March 2000conducted from September 1998 to March 2000

Three hundred eighty-six clinical sites in the Three hundred eighty-six clinical sites in the United States and CanadaUnited States and Canada

The CLASS trialThe CLASS trial 8059 patients : >/=18 years old, OA or RA, 8059 patients : >/=18 years old, OA or RA,

7968 received at least 1 dose of study drug.7968 received at least 1 dose of study drug. 4573 patients (57%) received treatment for 4573 patients (57%) received treatment for

6 months6 months Random assign:Random assign:

– celecoxib, 400 mg twice per day (2 and 4 times celecoxib, 400 mg twice per day (2 and 4 times the maximum RA and OA dosages, respectivelythe maximum RA and OA dosages, respectively

– n = 3987n = 3987– ibuprofen, 800 mg 3 times per day (n = 1985)ibuprofen, 800 mg 3 times per day (n = 1985)– diclofenac, 75 mg twice per day (n = 1996). diclofenac, 75 mg twice per day (n = 1996).

ASA for CV prophylaxis (</=325 mg/d) was ASA for CV prophylaxis (</=325 mg/d) was permitted.permitted.

CLASS TrialCLASS Trial Incidence of prospectively defined symptomatic upper GI Incidence of prospectively defined symptomatic upper GI

ulcers and ulcer complications (bleeding, perforation, and ulcers and ulcer complications (bleeding, perforation, and obstruction) and other adverse effects during the 6-month obstruction) and other adverse effects during the 6-month treatment period.treatment period.

Overall annual incidence rates of UGI ulcer complications Overall annual incidence rates of UGI ulcer complications alone: 0.76% vs 1.45% with NSAIDs (p=0.09)alone: 0.76% vs 1.45% with NSAIDs (p=0.09)

Overall annual incidence rate of UGI ulcer complications plus Overall annual incidence rate of UGI ulcer complications plus symptomatic ulcers 2.08% vs 3.54% , p=0.02symptomatic ulcers 2.08% vs 3.54% , p=0.02

Pts not on ASA:Pts not on ASA:– UGI complication alone 0.44% vs 1.27%, p=0.04UGI complication alone 0.44% vs 1.27%, p=0.04– UGI complication plus symptoms: 1.40% vs 2.91%, p =.02UGI complication plus symptoms: 1.40% vs 2.91%, p =.02

For patients onASA:For patients onASA:– UGI complications alone 2.01% vs 2.12%,l p=0.92UGI complications alone 2.01% vs 2.12%,l p=0.92– UGI complications plus symptomatic ulcers 4.70% vs 6.00% (P UGI complications plus symptomatic ulcers 4.70% vs 6.00% (P

=.49).=.49).

CLASS conclusionsCLASS conclusions Fewer celecoxib-treated patients than NSAID-Fewer celecoxib-treated patients than NSAID-

treated patients experienced chronic GI blood loss, treated patients experienced chronic GI blood loss, GI intolerance, hepatotoxicity, or renal toxicity.GI intolerance, hepatotoxicity, or renal toxicity.

No difference was noted in the incidence of No difference was noted in the incidence of cardiovascular events between celecoxib and cardiovascular events between celecoxib and NSAIDs, irrespective of aspirin use.NSAIDs, irrespective of aspirin use.

CONCLUSIONS: Celecoxib, at big doses, was CONCLUSIONS: Celecoxib, at big doses, was associated with a lower incidence of symptomatic associated with a lower incidence of symptomatic ulcers and ulcer complications combined, as well as ulcers and ulcer complications combined, as well as “other clinically important toxic effects”, compared “other clinically important toxic effects”, compared with NSAIDs at standard dosages (800 mg tid). with NSAIDs at standard dosages (800 mg tid).

The decrease in upper GI toxicity was strongest The decrease in upper GI toxicity was strongest among patients not taking aspirin concomitantly.among patients not taking aspirin concomitantly.

JAMA. 2000 Sep 13;284(10):1247-55.

The VIGOR trialThe VIGOR trial clinical upper gastrointestinal events occur in 2 to 4 clinical upper gastrointestinal events occur in 2 to 4

percent of patients who are taking nonselective percent of patients who are taking nonselective NSAIDs NSAIDs

Is rofecoxib associated with a lower incidence of Is rofecoxib associated with a lower incidence of clinically important upper gastrointestinal events than clinically important upper gastrointestinal events than Naproxen among patients with rheumatoid arthritisNaproxen among patients with rheumatoid arthritis

randomly assigned 8076 RA patients who were at randomly assigned 8076 RA patients who were at least 50 years of age (or at least 40 years of age and least 50 years of age (or at least 40 years of age and receiving long-term glucocorticoid therapy) receiving long-term glucocorticoid therapy)

received either 50 mg of rofecoxib daily or 500 mg of received either 50 mg of rofecoxib daily or 500 mg of naproxen twice dailynaproxen twice daily

primary end point was confirmed clinical upper primary end point was confirmed clinical upper gastrointestinal events (gastroduodenal perforation or gastrointestinal events (gastroduodenal perforation or obstruction, upper gastrointestinal bleeding, and obstruction, upper gastrointestinal bleeding, and symptomatic gastroduodenal ulcers)symptomatic gastroduodenal ulcers)

VIGOR TrialVIGOR Trial Rofecoxib and naproxen had similar efficacy Rofecoxib and naproxen had similar efficacy

against rheumatoid arthritis. against rheumatoid arthritis. median follow-up of 9 monthsmedian follow-up of 9 months

– 2.1 per 100 pt years confirmed gastrointestinal events 2.1 per 100 pt years confirmed gastrointestinal events with refecoxibwith refecoxib

– 4.5 per 100 pt-years with naproxen 4.5 per 100 pt-years with naproxen – relative risk, 0.5; CI 0.3 to 0.6; P<0.001 relative risk, 0.5; CI 0.3 to 0.6; P<0.001

The respective rates of The respective rates of complicatedcomplicated confirmed confirmed events (perforation, obstruction, and severe upper events (perforation, obstruction, and severe upper gastrointestinal bleeding)gastrointestinal bleeding)– 0.6 per 100 patient-years refecoxib0.6 per 100 patient-years refecoxib– 1.4 per 100 patient-years naproxen1.4 per 100 patient-years naproxen– relative risk, 0.4; CI 0.2 to 0.8; P=0.005 relative risk, 0.4; CI 0.2 to 0.8; P=0.005

VIGOR trialVIGOR trial The incidence of myocardial infarctionThe incidence of myocardial infarction

– lower among patients in the naproxen lower among patients in the naproxen group than among those in the rofecoxib group than among those in the rofecoxib groupgroup

– 0.1 percent vs. 0.4 percent0.1 percent vs. 0.4 percent– relative risk, 0.2; CI 0.1 to 0.7relative risk, 0.2; CI 0.1 to 0.7– the overall mortality rate and the rate of the overall mortality rate and the rate of

death from cardiovascular causes were death from cardiovascular causes were similar in the two groups. similar in the two groups. Bombardier C, Laine L, Reicin A, Shapiro D, Burgos-Vargas R,

Davis B, Day R, Ferraz MB, Hawkey CJ, Hochberg MC, Kvien TK, Schnitzer TJ N Engl J Med. 2000 Nov 23;343(21):1520-8

So….So…. increased incidence of total and increased incidence of total and

nongastrointestinal serious adverse events with nongastrointestinal serious adverse events with the COX-2 selective NSAIDs remains a major the COX-2 selective NSAIDs remains a major concernconcern

increased morbidity may be a manifestation of increased morbidity may be a manifestation of the COX-2 selectivity or the supramaximal doses the COX-2 selectivity or the supramaximal doses of these drugs used in the trialsof these drugs used in the trials

proof that the increased harm was not caused by proof that the increased harm was not caused by the COX-2 selectivity of the drugs depends on a the COX-2 selectivity of the drugs depends on a randomized controlled trial of COX-2 selective randomized controlled trial of COX-2 selective NSAIDs at usual doses vs. nonselective NSAIDsNSAIDs at usual doses vs. nonselective NSAIDs

Thus far, no such trialThus far, no such trial What about Cox-2’s plus PPII’s?...no trialWhat about Cox-2’s plus PPII’s?...no trial

Rx of UGI bleedRx of UGI bleed Shots in the dark?Shots in the dark?

Upper GI bleedsUpper GI bleeds Coagulation and fibrinolysis are Coagulation and fibrinolysis are

dependent on intragastric pHdependent on intragastric pH When pH is below 6, platelet When pH is below 6, platelet

aggregation is abolished aggregation is abolished When pH is below 4, fibrin clots are When pH is below 4, fibrin clots are

digested by gastric pepsindigested by gastric pepsin In UGI bleed, need to raise gastric pH In UGI bleed, need to raise gastric pH

and keep it there for 72 hoursand keep it there for 72 hours

PUD H2 blockersPUD H2 blockers H2 receptor antagonists inhibit H2 receptor antagonists inhibit

gastric acid productiongastric acid production Little if any evidence of improved Little if any evidence of improved

outcome in active GI bleedoutcome in active GI bleed Insufficient acid suppressionInsufficient acid suppression Rapid drug toleranceRapid drug tolerance

Proton Pump InhibitorsProton Pump Inhibitors More profound and sustained acid suppressionMore profound and sustained acid suppression Binds irreversibly to H+K+ATPase (proton Binds irreversibly to H+K+ATPase (proton

pump) inhibiting actively secreting parietal pump) inhibiting actively secreting parietal cellscells

Predictable: t1/2 1 hr but effect 24 hrsPredictable: t1/2 1 hr but effect 24 hrs No tolerance developedNo tolerance developed Excellent safety profile, no dose reduction in Excellent safety profile, no dose reduction in

renal failure/cirrhosisrenal failure/cirrhosis IV Omeprazole released in 1991IV Omeprazole released in 1991

PPI’s in PUDPPI’s in PUD IV Proton pump inhibitorsIV Proton pump inhibitors

– Lau et al NEJM 2000 Aug 3: 343 (5) 310-16Lau et al NEJM 2000 Aug 3: 343 (5) 310-16– After endoscopic Rx, bleed recurs in 15-20%After endoscopic Rx, bleed recurs in 15-20%– Assess whether use of high dose PPI Assess whether use of high dose PPI

decreased recurrence within 30 daysdecreased recurrence within 30 days– Dbl blind rand to Omeprazole bolus and Dbl blind rand to Omeprazole bolus and

infusion vs placeboinfusion vs placebo– All got Omeprazole orally x 2 weeks post All got Omeprazole orally x 2 weeks post

infusioninfusion

PPI’s in PUD (Lau, ct’d)PPI’s in PUD (Lau, ct’d)– 240 patients, recur in 6.7% of 240 patients, recur in 6.7% of

omeprazole vs 22.5% of placeboomeprazole vs 22.5% of placebo– Most recurrent bleed occurs in first three Most recurrent bleed occurs in first three

daysdays– ““Only evidence for IV infusion is in acute Only evidence for IV infusion is in acute

bleed with ulcer with high risk stigmata bleed with ulcer with high risk stigmata (i,.e visible vessel)”(i,.e visible vessel)”

– But, EGD was done within 1 hour 24/7But, EGD was done within 1 hour 24/7

Waiting for EGDWaiting for EGD

PPI’s while waiting for EGDPPI’s while waiting for EGD R. Enns & C. Andrews, UBC, Can J Gastro 2003 & R. Enns & C. Andrews, UBC, Can J Gastro 2003 &

Aliment Pharmacol Ther 2003.Aliment Pharmacol Ther 2003. To evaluate cost effectiveness of IV PPI while To evaluate cost effectiveness of IV PPI while

awaiting EGD compared with EGD aloneawaiting EGD compared with EGD alone Probabilities of rebleeding and surgery taken into Probabilities of rebleeding and surgery taken into

account account In a hypothetical cohort of 1000 patients, IV PPI In a hypothetical cohort of 1000 patients, IV PPI

utilization while awaiting EGD = mean savings of utilization while awaiting EGD = mean savings of $20,700 Canadian$20,700 Canadian

Using PPI pre EGD averted 37 rebleedsUsing PPI pre EGD averted 37 rebleeds Use of PPI while awaiting EGD is cost effectiveUse of PPI while awaiting EGD is cost effective Finidngs do not apply to low risk stigmata, Finidngs do not apply to low risk stigmata,

variceal bleeds, lower GI bleedsvariceal bleeds, lower GI bleeds

PUD: RUGBEPUD: RUGBE Canadian Registry of patients with Upper GI Canadian Registry of patients with Upper GI

Bleeding Undergoing EndoscopyBleeding Undergoing Endoscopy Pt char and Rx from 1999 onPt char and Rx from 1999 on J. Romagnolo is local PIJ. Romagnolo is local PI Protective effect of PPI use and EGD in Protective effect of PPI use and EGD in

specific patient subgroupsspecific patient subgroups Meta-analysis supports high dose IV PPIs Meta-analysis supports high dose IV PPIs

leads to improvement when coupled with leads to improvement when coupled with EGDEGD

Optimum dose, timing, and subgroup analysis Optimum dose, timing, and subgroup analysis needs further workneeds further work

PPI’s the local challengePPI’s the local challenge CHR: Pharmanews CHR: Pharmanews Vol 28 Issue 3 Revised November Vol 28 Issue 3 Revised November

20032003 Kaplan Gf, Bates D, McDonald D, Kaplan Gf, Bates D, McDonald D,

Romagnulo J.Romagnulo J. ““Inappropriate Prescribing Leading to Inappropriate Prescribing Leading to

Rapidly Escalating Costs of IV PPI in Rapidly Escalating Costs of IV PPI in the Calgary Health Region”the Calgary Health Region”

PPI’s the local costPPI’s the local cost

YearYear FMCFMC PLCPLC RGHRGH TotalTotal

19991999 $56K$56K $35K$35K $9K$9K $100K$100K20002000 $149K$149K $86K$86K $73K$73K $308K$308K20012001 $207K$207K $96K$96K $121K$121K $425K$425K20022002 $168K$168K $94K$94K $123K$123K $386K$386K

PPI’s Local guidelinesPPI’s Local guidelines Ideally withold PPI’s until EGD but case by Ideally withold PPI’s until EGD but case by

case adaptation…i.e. nightcase adaptation…i.e. night IV Omeprasole 80 mg bolus and 8mg/hr IV Omeprasole 80 mg bolus and 8mg/hr

infusion for max of 72 hoursinfusion for max of 72 hours Pts with HRS on EGD (arterial or venous active Pts with HRS on EGD (arterial or venous active

bleed, visible vessel, adherent clot) should bleed, visible vessel, adherent clot) should have endo Rx and then 72 hr infusionhave endo Rx and then 72 hr infusion

No HRS = stop infusionNo HRS = stop infusion Inpts who are NPO get bid dosing not infusionInpts who are NPO get bid dosing not infusion

PPI’s Local guidelines ct’dPPI’s Local guidelines ct’d Clinical equivalence between IV PPI Clinical equivalence between IV PPI

and oral PPI in GERDand oral PPI in GERD Clinical equivalence between IV PPI Clinical equivalence between IV PPI

and NG PPIand NG PPI 40 mg PPI IV = $13.7040 mg PPI IV = $13.70 40 mg PPI po = $0.4540 mg PPI po = $0.45

Can UGI bleeds go home?Can UGI bleeds go home? Selection of patients for early discharge or Selection of patients for early discharge or

outpatient care after acute UGI outpatient care after acute UGI haemorrhage. National Audit of Acute haemorrhage. National Audit of Acute Upper GI HaemorrhageUpper GI Haemorrhage

Attempted to identify patients who had Attempted to identify patients who had negligible risk of further bleeding or death negligible risk of further bleeding or death and for whom early discharge or even and for whom early discharge or even outpatient management would be possible outpatient management would be possible with no adverse effect on standards of with no adverse effect on standards of care. care.

UGI bleed and dischargeUGI bleed and discharge Used a validated risk scoring system Used a validated risk scoring system

based on:based on:– age (score 0-2)age (score 0-2)– presence of shock (0-2)presence of shock (0-2)– comorbidity (0-3)comorbidity (0-3)– diagnosis (0-2)diagnosis (0-2)– endoscopic stigmata of recent haemorrhage endoscopic stigmata of recent haemorrhage

(0-2)(0-2)– maximum possible score was 11. maximum possible score was 11.

Rockall’s Scoring SystemRockall’s Scoring SystemVARIABLEVARIABLE 0 0 1 1 22 33AgeAge <60<60 60-7960-79 > 80> 80 --------ShockShock HR<100HR<100 HR>100, HR>100,

SBP >100SBP >100HR>100, HR>100, SBP<100SBP<100

--------

ComorbidityComorbidity NoneNone -------- CHF, IHD, CHF, IHD, any major any major dxdx

Renal Renal failurefailureLiver Liver failurefailureMetsMets

Dx post OGDDx post OGD MW tearMW tear All other All other dxdx

UGI malig, UGI malig, Blood in Blood in UGIUGI

--------

Major SRHMajor SRH None or None or dark dark spotspot

-------- Adherent Adherent clot, vis clot, vis vesselvessel

--------

UGI bleed and dischargeUGI bleed and discharge 2531 patients who underwent endoscopy after an 2531 patients who underwent endoscopy after an

acute admissionacute admission 744 (29.4%) of the 2531 patients scored 2 or less 744 (29.4%) of the 2531 patients scored 2 or less

on the risk scoreon the risk score Of these:Of these:

– 32 or 4.3% rebled [95% Cl 3.0-6.0] 32 or 4.3% rebled [95% Cl 3.0-6.0] – 1 or 0.1% died [95% CI 0.006-0.75] 1 or 0.1% died [95% CI 0.006-0.75]

Conclusions: the risk score identifies patients at Conclusions: the risk score identifies patients at low risk of rebleeding or deathlow risk of rebleeding or death

Median hospital stay increased with risk scoreMedian hospital stay increased with risk score Within low risk score categories of 5 or less:Within low risk score categories of 5 or less:

– trend of increasing hospital stay as the time between trend of increasing hospital stay as the time between admission and endoscopy increasedadmission and endoscopy increased

Lancet. 1996 Apr 27;347(9009):1138-40Lancet. 1996 Apr 27;347(9009):1138-40Rockall TA, Logan RF, Devlin HB, Northfield TC.Rockall TA, Logan RF, Devlin HB, Northfield TC.

UGI bleed and dischargeUGI bleed and discharge Three year prospective validation of a PRE-Three year prospective validation of a PRE-

EGD risk stratification in patients with EGD risk stratification in patients with acute UGI hemorrhageacute UGI hemorrhage

To assess the accuracy of a risk To assess the accuracy of a risk stratification used at initial assessment stratification used at initial assessment (does not rely on EGD)(does not rely on EGD)

To identify groups with increased risk of To identify groups with increased risk of mortality and requirement for urgent mortality and requirement for urgent treatment interventiontreatment intervention

Prospective assessment of risk Prospective assessment of risk stratification in consecutive patients with stratification in consecutive patients with acute upper-gastrointestinal haemorrhage. acute upper-gastrointestinal haemorrhage.

UGI risk stratificationUGI risk stratification 3-year period, 1349 consecutive 3-year period, 1349 consecutive

patients, risk stratified and followed patients, risk stratified and followed up for 2 weeksup for 2 weeks

Two-week, all-cause mortality, re-Two-week, all-cause mortality, re-bleeding, and need for urgent bleeding, and need for urgent treatment intervention.treatment intervention.

UGI bleed and discharge UGI bleed and discharge without EGD?without EGD?

Stratification within the high-risk group predicted a Stratification within the high-risk group predicted a significant increased risk of 2-week, all-cause mortality (P < significant increased risk of 2-week, all-cause mortality (P < 0.001) 0.001) – Hi risk 11.8%Hi risk 11.8%– Intermediate risk 3%Intermediate risk 3%– Low risk 0%Low risk 0%

High risk strata significantly higher re-bleeding (P < 0.001)High risk strata significantly higher re-bleeding (P < 0.001)– Hi risk 44.1%Hi risk 44.1%– Intermediate 2.3%Intermediate 2.3%– Low risk 0% Low risk 0%

High risk strata significantly higher need for urgent High risk strata significantly higher need for urgent treatment intervention (P < 0.001) treatment intervention (P < 0.001) – Hi risk 71%Hi risk 71%– Intermediate risk 40.6%Intermediate risk 40.6%– Low risk 2.6% Low risk 2.6%

Cameron EA, Pratap JN, Sims TJ, Inman S, Boyd D, Ward M, Middleton SJ. Eur J Gastroenterol Hepatol. 2002 May;14(5):497-501.

So, who admits?So, who admits? Physician specialty and variations in the cost of treating Physician specialty and variations in the cost of treating

patients with acute upper gastrointestinal bleeding.patients with acute upper gastrointestinal bleeding. Pts stratified into three groups based on a validated risk Pts stratified into three groups based on a validated risk

scorescore Length of stay and hospital costs comparedLength of stay and hospital costs compared

– primarily cared for by internists, surgeons, and primarily cared for by internists, surgeons, and gastroenterologistsgastroenterologists

Median length of stay (2 days) if admitted to GIMedian length of stay (2 days) if admitted to GI– Significantly shorter than admitted under other physicians (P < Significantly shorter than admitted under other physicians (P <

0.05)0.05) Median hospitalization cost ($2856) if admitted to GIMedian hospitalization cost ($2856) if admitted to GI

– Significantly lower than other services (P < 0.01)Significantly lower than other services (P < 0.01) No differences in the time to endoscopy among services. No differences in the time to endoscopy among services.

Quirk DM, Barry MJ, Aserkoff B, Podolsky DKGastroenterology. 1997 Nov;113(5):1443-8Gastroenterology. 1997 Nov;113(5):1443-8

Now for some risky Now for some risky business…business…

Variceal bleedingVariceal bleeding Esophageal and/or gastric varices account for Esophageal and/or gastric varices account for

about 20% of all GI bleedsabout 20% of all GI bleeds Most dramatic and life threatening Most dramatic and life threatening

presentation of portal hypertensionpresentation of portal hypertension 25-50% of bleeds in cirrhotic pts is non 25-50% of bleeds in cirrhotic pts is non

varicealvariceal– Dave P et al, Clin Gastroenterol 5:113, 1983Dave P et al, Clin Gastroenterol 5:113, 1983

After 1 bleeding episode, risk of a second is After 1 bleeding episode, risk of a second is 70%70%

Accounts for 50% of all deaths from cirrhosisAccounts for 50% of all deaths from cirrhosis

Variceal bleedingVariceal bleeding Risk of mortality from each bleeding Risk of mortality from each bleeding

episode is 20-84%episode is 20-84% Risk depends on etiology of portal Risk depends on etiology of portal

hypertension, hepatic reserve of the hypertension, hepatic reserve of the pt., duration of hemorrhage prior to pt., duration of hemorrhage prior to presentationpresentation

IV OctreotideIV Octreotide Octreotide or Somatostatin is a Octreotide or Somatostatin is a

potent nonselective vasoconstrictorpotent nonselective vasoconstrictor Should be routine in known or Should be routine in known or

strongly suspected variceal bleedstrongly suspected variceal bleed Can be used alone or in conjunction Can be used alone or in conjunction

with sclerotherapy/bandingwith sclerotherapy/banding No role in non variceal UGI bleedsNo role in non variceal UGI bleeds

Balloon tamponadeBalloon tamponade Originated in the 1930s, first filled with water Originated in the 1930s, first filled with water

not airnot air 1950 Sengstaken and Blakemore invented 1950 Sengstaken and Blakemore invented

double lumen balloondouble lumen balloon Modified by Linton, Nachlasm, Boyce and Modified by Linton, Nachlasm, Boyce and

EdlichEdlich Currently have:Currently have:

– Blakemore: 3 lumens – gastric, esoph and gastric Blakemore: 3 lumens – gastric, esoph and gastric suctionsuction

– Linton: as above with esoph aspiration port as wellLinton: as above with esoph aspiration port as well

Balloon tamponadeBalloon tamponade Roberts still recommends NG insertion in Roberts still recommends NG insertion in

all GI bleed..no real evidence for it…nice all GI bleed..no real evidence for it…nice in flight or if ongoing vomitingin flight or if ongoing vomiting

There is no evidence to support passage There is no evidence to support passage of an NG tube increases variceal bleedof an NG tube increases variceal bleed– Meeroff et al: Mangement of massive UGI Meeroff et al: Mangement of massive UGI

bleed Hosp Practice, 1984bleed Hosp Practice, 1984 Management of varices is substantially Management of varices is substantially

different from other causesdifferent from other causes

Balloon tamponadeBalloon tamponade Used when sclerotherapy not availableUsed when sclerotherapy not available Used when vasoconstrictor therapy is not Used when vasoconstrictor therapy is not

adequateadequate Can control bleeding in up to 80% of casesCan control bleeding in up to 80% of cases In the absence of endoscopyIn the absence of endoscopy

indications:indications:– pt with known portal hypertensionpt with known portal hypertension– prior variceal bleedprior variceal bleed– not responding to vasoconstrictor Rxnot responding to vasoconstrictor Rx

Balloon Tamponade of Balloon Tamponade of VaricesVarices

Use of GEBT has serious/lethal Use of GEBT has serious/lethal complicationscomplications

Overall complication rate higher than Overall complication rate higher than most other ED proceduresmost other ED procedures

Clear indications and complete Clear indications and complete understanding of placement is essentialunderstanding of placement is essential

““best placed by the individual most best placed by the individual most familiar with technique” (which is familiar with technique” (which is usually no-one including GI guys)usually no-one including GI guys)

GEBTGEBT Patient at risk re uncooperative, or Patient at risk re uncooperative, or

hepatic encephalopathyhepatic encephalopathy If patient is not awake, alert and fully If patient is not awake, alert and fully

cooperative should be intubated cooperative should be intubated – Roberts, Procedures in emergency Roberts, Procedures in emergency

medicinemedicine Patients at extremely high risk for Patients at extremely high risk for

regurg and aspirationregurg and aspiration Threshold for intubation should be Threshold for intubation should be

lower than usuallower than usual

GEBT ProcedureGEBT Procedure Unfamiliar to most docsUnfamiliar to most docs Gastric balloon holds 500 to 700 mL, Gastric balloon holds 500 to 700 mL,

test both balloons for patencytest both balloons for patency Patient at 45 degrees or in left lateral Patient at 45 degrees or in left lateral Anesthetize nose and post pharynx if Anesthetize nose and post pharynx if

necessarynecessary Deflate balloons and lock off, Deflate balloons and lock off,

lubricate tubelubricate tube

GEBT procedureGEBT procedure Pass through mouth is preferred Pass through mouth is preferred

(especially in intubated) but nose can (especially in intubated) but nose can be usedbe used

Pass tube to at least 50 cm mark or max Pass tube to at least 50 cm mark or max depth allowed by tube lengthdepth allowed by tube length

Suction to esoph and gastric ports to Suction to esoph and gastric ports to minimize aspiration risk even further minimize aspiration risk even further prior to inflationprior to inflation

Confirm radiographically prior to Confirm radiographically prior to inflationinflation

GEBT procedureGEBT procedure Once markers seen: can begin to Once markers seen: can begin to

inflate gastric ballooninflate gastric balloon Should monitor pressure in balloon as Should monitor pressure in balloon as

inflatedinflated Use AIR not waterUse AIR not water Repeat radiograph once inflatedRepeat radiograph once inflated Clamp air ports on tube and gently pull Clamp air ports on tube and gently pull

back on tube to snug up to GE junctionback on tube to snug up to GE junction

Indications to inflate the Indications to inflate the esophageal balloonesophageal balloon

If continuous bloody aspirate from If continuous bloody aspirate from gastric suctiongastric suction

Absolutely must be done with Absolutely must be done with manometer guidancemanometer guidance

Pressure at lowest level that stops Pressure at lowest level that stops bleeding and should not exceed 45 mm bleeding and should not exceed 45 mm HgHg

If ongoing bleeding with both balloons If ongoing bleeding with both balloons up, likely gastric and NOT esophageal up, likely gastric and NOT esophageal sourcesource

GEBT tractionGEBT traction Use if inflation of balloons has been Use if inflation of balloons has been

done and active gastric bleeding done and active gastric bleeding persistspersists

External traction on the tubeExternal traction on the tube Foam rubber block often included in Foam rubber block often included in

the kitthe kit Various traction mechanismsVarious traction mechanisms

GEBT ComplicationsGEBT Complications Occur in 8-16% of patientsOccur in 8-16% of patients Mortality considered in about 3%Mortality considered in about 3% Variceal hemorrhage itself carries 40-Variceal hemorrhage itself carries 40-

80% mortality80% mortality One study reported GEBT directly One study reported GEBT directly

casued death in 22% of pts in which casued death in 22% of pts in which it was usedit was used

GEBT complicationsGEBT complications Major occur in 8-16%Major occur in 8-16% Mortality around 3%Mortality around 3%

– CommonCommon Aspiration pneumoniaAspiration pneumonia Asphyxiation (balloon migration, cut the tubes)Asphyxiation (balloon migration, cut the tubes) Esophageal necrosisEsophageal necrosis

– UncommonUncommon Esophageal perforation (overinflation or duration tube)Esophageal perforation (overinflation or duration tube) Duodenal ruptureDuodenal rupture Tracheobronchial ruptureTracheobronchial rupture Periesophageal abcessPeriesophageal abcess mediastinitismediastinitis

GEBT ComplicationsGEBT Complications MinorMinor

– CommonCommon Gastroesophageal ulcerationGastroesophageal ulceration RegurgitationRegurgitation Chest discomfortChest discomfort Back painBack pain Pressure necrosis re: tractionPressure necrosis re: traction

– UncommonUncommon EpistaxisEpistaxis Pharyngeal erosionsPharyngeal erosions Pressure necrosis of tonguePressure necrosis of tongue hiccupshiccups

Problems at the bottom endProblems at the bottom end

Lower GI bleedsLower GI bleeds defined as blood loss that originates from a defined as blood loss that originates from a

source distal to the ligament of Treitzsource distal to the ligament of Treitz results in hemodynamic instability or results in hemodynamic instability or

symptomatic anemiasymptomatic anemia approximately 10% to 15% of patients presenting approximately 10% to 15% of patients presenting

with acute severe hematochezia have an upper with acute severe hematochezia have an upper gastrointestinal source of bleedinggastrointestinal source of bleeding

most common causes of lower gastrointestinal most common causes of lower gastrointestinal bleeding are diverticulosis, hemorrhoids, ischemic bleeding are diverticulosis, hemorrhoids, ischemic colitis, and angiodysplasiacolitis, and angiodysplasia

lower gastrointestinal bleeding ceases lower gastrointestinal bleeding ceases spontaneously in most casesspontaneously in most cases

LGI bleed, does colonoscopy LGI bleed, does colonoscopy affect outcome?affect outcome?

management of lower-GI hemorrhage management of lower-GI hemorrhage remains controversial largely because remains controversial largely because outcomes data are lackingoutcomes data are lacking

Hypothesized that clinical factors, such as Hypothesized that clinical factors, such as comorbidity, hemodynamic instability, and comorbidity, hemodynamic instability, and timing of colonoscopy, are associated with timing of colonoscopy, are associated with hospital lengths of stayhospital lengths of stay

Retrospective review of LGI hospitalized, Retrospective review of LGI hospitalized, 1993 to 2000 (selection bias)1993 to 2000 (selection bias)

regression model was constructed to explore regression model was constructed to explore associations between time to discharge (i.e., associations between time to discharge (i.e., length of stay) and clinical parameters.length of stay) and clinical parameters.

LGI, colonoscopy continuedLGI, colonoscopy continued 565 hospitalizations, mean length of stay was 6.7 days565 hospitalizations, mean length of stay was 6.7 days Colonoscopy was performed during 415 hospitalizationsColonoscopy was performed during 415 hospitalizations 1/3 discharged within 48 hours after colonoscopy1/3 discharged within 48 hours after colonoscopy Regression model, decreased likelihood of discharge if:Regression model, decreased likelihood of discharge if:

– hemodynamic instabilityhemodynamic instability– higher comorbidityhigher comorbidity– performance of a tagged red blood cell nuclear scanperformance of a tagged red blood cell nuclear scan– surgery for hemostasissurgery for hemostasis

Colonoscopy at any timepoint associated with an increased Colonoscopy at any timepoint associated with an increased likelihood of being discharged likelihood of being discharged – hazard ratio 1.5: 95% CI [1.2, 1.8].hazard ratio 1.5: 95% CI [1.2, 1.8].

Mean lengths of stay for colonoscopy within 24 hours of Mean lengths of stay for colonoscopy within 24 hours of hospitalization was shorterhospitalization was shorter– 5.4 vs. 7.2 days; p<0.0085.4 vs. 7.2 days; p<0.008

Early colonoscopy for acute lower GI bleeding predicts shorter hospital stay: a retrospective study of experience in a single center.Schmulewitz N, Fisher DA, Rockey DC.

Predictors of severe LGI Predictors of severe LGI bleedbleed

Harvard groupHarvard group Goal to determine risk factors for severe acute LIBGoal to determine risk factors for severe acute LIB 252 consecutive patients admitted with acute LIB 252 consecutive patients admitted with acute LIB Data were collected on 24 clinical factors available Data were collected on 24 clinical factors available

in the first 4 hours of evaluationin the first 4 hours of evaluation outcome was severe bleeding, which was defined as:outcome was severe bleeding, which was defined as:

– continued bleeding within the first 24 hours of continued bleeding within the first 24 hours of hospitalization documented by transfusion of > or = 2 units hospitalization documented by transfusion of > or = 2 units of blood and/or hematocrit decrease of > or = 20%) of blood and/or hematocrit decrease of > or = 20%)

– recurrent bleeding after 24 hours of stability (additional recurrent bleeding after 24 hours of stability (additional transfusions, further hematocrit decrease of > or = 20%, or transfusions, further hematocrit decrease of > or = 20%, or readmission for LIB within 1 week of discharge)readmission for LIB within 1 week of discharge)

Severe LGI bleeding occurred in 123 pts (49%)Severe LGI bleeding occurred in 123 pts (49%)

Predictors of Severe LGI Predictors of Severe LGI bleedbleed

Independent correlates of severe bleeding were as follows: Independent correlates of severe bleeding were as follows: Heart rate, Heart rate, >> 100/min 100/min

– OR 3.67 (1.78-7.57)OR 3.67 (1.78-7.57) Systolic blood pressure, Systolic blood pressure, << 115 mm Hg 115 mm Hg

– OR 3.45 (1.54-7.72) OR 3.45 (1.54-7.72) SyncopeSyncope

– OR 2.82 (1.06,7.46)OR 2.82 (1.06,7.46) Nontender abdominal examinationNontender abdominal examination

– OR 2.43 (1.22-4.85) OR 2.43 (1.22-4.85) Bleeding per rectum during the first 4 hours of evaluationBleeding per rectum during the first 4 hours of evaluation

– OR, 2.32 (1.28-4.20) OR, 2.32 (1.28-4.20) Aspirin use Aspirin use

– OR, 2.07 (1.12-3.82) OR, 2.07 (1.12-3.82) More than 2 active comorbid conditionsMore than 2 active comorbid conditions

– OR, 1.93 (1.08-3.44)OR, 1.93 (1.08-3.44) Strate LL, Orav EJ, Syngal S. Arch Intern Med. 2003 Apr 14;163(7):838-43.

So, who can be discharged So, who can be discharged from the ED?from the ED?

Lit search = 0 Lit search = 0 papers, so we are papers, so we are adrift on this oneadrift on this one

Questions?Questions?

Can you differentiate based on Can you differentiate based on stool color?stool color?

Now, here was a fun trial….Now, here was a fun trial…. Subjective reporting of the color of blood passed Subjective reporting of the color of blood passed

per rectum has been used to predict the location per rectum has been used to predict the location of gastrointestinal bleedingof gastrointestinal bleeding

validity of this clinical approach has never been validity of this clinical approach has never been evaluated systematicallyevaluated systematically

this study determined the spectrum of patient and this study determined the spectrum of patient and physician descriptors used to characterize the physician descriptors used to characterize the color of blood passed per rectumcolor of blood passed per rectum

evaluated prospectively if an objective test of stool evaluated prospectively if an objective test of stool color would correlate with or improve upon color would correlate with or improve upon subjective descriptions in predicting bleeding subjective descriptions in predicting bleeding locationslocations

I know you can hardly wait for the results... I know you can hardly wait for the results...

Stool color continued (how’s Stool color continued (how’s that breakfast going?)that breakfast going?)

objective test employed was a card objective test employed was a card containing five numbered colors that typify containing five numbered colors that typify the spectrum of stool blood colorsthe spectrum of stool blood colors

120 pts used 23 different descriptors or 120 pts used 23 different descriptors or terms to verbalize the color of blood they terms to verbalize the color of blood they passed per rectumpassed per rectum

in 22% of cases there was a seeming in 22% of cases there was a seeming discrepancy between their verbalized color discrepancy between their verbalized color and the color they pointed to on the test and the color they pointed to on the test cardcard

Stool color resultsStool color results Pts pointing to black card resulted in closer matching Pts pointing to black card resulted in closer matching

to an upper bleeding source than physicians using to an upper bleeding source than physicians using terminology such as melena or tarry stools, p <0.02terminology such as melena or tarry stools, p <0.02

Pts picking the brightest red colors resulted in closer Pts picking the brightest red colors resulted in closer matching to a coloanorectal bleeding source than matching to a coloanorectal bleeding source than physicians using the terms hematochezia or bright red physicians using the terms hematochezia or bright red blood per rectum, p <0.02blood per rectum, p <0.02

PPV of the black card for UGI bleed was very high both PPV of the black card for UGI bleed was very high both when patients pointed to this color or when it was when patients pointed to this color or when it was determined from the available stool (0.95 and 0.98, determined from the available stool (0.95 and 0.98, respectively)respectively)

PPV of brightest red card for LGI bleed was 100% PPV of brightest red card for LGI bleed was 100% when patients picked it than and 0.83 if stool was when patients picked it than and 0.83 if stool was directly compared.directly compared.

Anyone want to order cards?Anyone want to order cards?

Hematochezia vs melena and Hematochezia vs melena and outcome…outcome…

Consecutive patients in AtlantaConsecutive patients in Atlanta August 1, 1990 - September 31, 1994August 1, 1990 - September 31, 1994 ProspectiveProspective Vital signs and stool color were recorded Vital signs and stool color were recorded

on admission to EDon admission to ED Endoscopy was performed in all patients, Endoscopy was performed in all patients,

usually within 48 h of admissionusually within 48 h of admission Cause of bleeding determined by Cause of bleeding determined by

endoscopy, surgery, or autopsy.endoscopy, surgery, or autopsy.

Hematochezia results…Hematochezia results… 727 pts727 pts 104 (14%) presenting with hematochezia (18 with 104 (14%) presenting with hematochezia (18 with

bright red blood and 86 with maroon blood). bright red blood and 86 with maroon blood). In those with hematochezia most common causes In those with hematochezia most common causes

of bleeding were duodenal ulcer (44%) and of bleeding were duodenal ulcer (44%) and gastric ulcer (20%)gastric ulcer (20%)

Hematochezia vs melena: patients with Hematochezia vs melena: patients with hematochezia were older (55 vs 50 yr, p < 0.01) hematochezia were older (55 vs 50 yr, p < 0.01) and more likely to present with duodenal ulcer and more likely to present with duodenal ulcer bleeding (43 vs 25%, p < 0.01)bleeding (43 vs 25%, p < 0.01)

No differences in vital signs, including prevalence No differences in vital signs, including prevalence of shock, or admission Hb concentration were of shock, or admission Hb concentration were found b/t hematochezia vs melena. found b/t hematochezia vs melena.

ConclusionsConclusions Transfusion requirements:Transfusion requirements:

– 5.4 vs 4.0 units, p = 0.015.4 vs 4.0 units, p = 0.01 Need for surgeryNeed for surgery

– 11.7 vs 5.7%, p = 0.03 11.7 vs 5.7%, p = 0.03 MortalityMortality

– 13.6 vs 7.5%, p = 0.05 13.6 vs 7.5%, p = 0.05 All significantly higher in patients with All significantly higher in patients with

hematochezia than in those with melenahematochezia than in those with melena Wilcox CM, Alexander LN, Cotsonis G Am J Gastroenterol. 1997 Feb;92(2):231-5