Gastrointestinal Emergencies

Dr Richard Warner

SpR Gastroenterology

September 2005

GI emergencies

GI bleeding

Paracetamol Overdose

Severe ulcerative colitis/Crohn’s colitis

Liver Failure

Upper GI Bleeding

Incidence 100/100,000

Mortality - 1947 9.9%, 1995 11% (6%), 33% (17%) in hospitalised patients

Higher MR in elderly with co-morbidity

Causes of Upper GI Bleeding

peptic ulceration (35-50%)

oesophagitis, gastritis, duodenitis (5-15%)

gastroduodenal erosions (8-15%)

Mallory Weiss tear (15%)

varices (5-10%)

tumour (1%)

angiodysplasia, telangiectasia (2-3%)

vascular ectasia, Dieulafoy’s lesion(1-2%)

Varices

Varices

Varices

Oesophagitis

Mallory Weiss Tear

Gastric ulceration

Angiodysplasia

Duodenal Ulceration

Symptoms at Presentation

haematemesis/melaena/both

breathlessness, chest pain

collapse

Management of Upper GI Bleed

Resuscitation

Assessment of vital signs

wide bore venous cannulae/?central line

crystalloid, colloid/blood

blood tests and cross match

monitoring - bp, hr, urine output, ?cvp

early endoscopy and inform surgeons

high dose iv ppi for peptic ulcers

Factors in History

NSAIDs, clopidogrel, steroids

alcohol history

liver disease

anticoagulants

family history

severe vomiting

Severe UGI Bleed/ High risk

Haematemesis and melaena

cardiovascular compromise

age>65

co-existing cardiorespiratory disease

Hb <10g/l

Rockall Scoring System(Risk of rebleeding and death)

0 1 2 3

Age <60 60-79 80

Shock No shock tachycardiabp >100

hypotension

Comorbidity Nil major Major co-morbidity,heart failure,ihd

Renal, liverfailuremetastaticdisease

Diagnosis MW tear, nolesion

All otherdiagnoses

Upper GImalignancy

Major SRH None or dark spot

High riskstigmata

Rockall Scoring System 2

Score less than 3 = excellent prognosis

?fast tracked for discharge

score > 8 = high mortality risk

close monitoring

stratified post endoscopy

Endoscopy for UGI Bleeding

Diagnostic and therapeutic

Peptic ulceration - injection, heater probe, haemoclips

high risk - actively bleeding vessel (0-75%)

non-bleeding visible vessel (4-27%)

adherent clot

therapy rebleeding, surgery, mortality

Evidence for Intravenous Omeprazole

Lau et al 2000 (NEJM)

15-20% rebleeding rate for peptic ulcers

80mg bolus, 8mg/hour for 72 hours, 20mg

orally for 8 weeks

adrenaline+thermocoagulation, randomised to ppi (120) or placebo (120) (30 day FU)

rebleeding in placebo 22.5% (20% ), omeprazole 6.7% (4%)

Variceal Bleeding

Mortality 30-80% (average 50%)

?Severity underlying liver disease (A<B<C)

50% rebleed in 10 days

30-50% cirrhotics have a variceal bleed

40-80% rebleed in 1 year

33% survive 3 years

no bleed if portal pressure <12mmHg

Therapy for Varices

Endoscopic - banding or sclerotherapy

Medical - terlipressin, octreotide

Tamponade - Sengstaken-Blakemore tube

Surgery - shunts, oesophageal transection

TIPSS

Endoscopic Therapy of Varices

Sclerotherapy control of bleeding

Band Ligation 1995 Lo demonstrated band ligation better than sclerotherapy (94%:80%)1998 Stiegmann demonstrated control of bleeding decreased rate of complications, decreased MR compared to sclerotherapy

Medical Therapy of Bleeding Varices

vasopressin/glypressin +/- GTN increased rate control of bleeding, no benefit survival

somatostatin/octreotide increased rate control of bleeding, improved survival

somatostatin=sclerotherapy=tamponade

Sengstaken

Primary and Secondary Prevention of Variceal

BleedingBetablockers - propanolol 40-80mg bd

Primary - screen cirrhotics

?prophylactic banding (Gastro 2002)

Secondary - once bleed settled

Aiming portal pressure <12mmHg/ 20%

Role of Beta-blockers

Decrease portal pressure, splanchnic vasoconstriction

Primary 9 RCT, 1 meta-analysis

significant decrease in risk of bleeding

cirrhotics screened, if varices start blocker

Secondary755 patients in 11 trials significant decrease in rebleeding rates

TIPPS

Transjugular Intrahepatic Porto-systemic Shunt

Refractory variceal bleeding

refractory ascites

Budd-Chiari

95-100% success rate

0-2% procedural mortality, 10% morbidity

30 day mortality 5-15%

bridge to transplantation

Complications of TIPSS

Restenosis, occlusion (rebleeding)

thromboembolism

hepatic encephalopathy (13-55%)

haemorrhage, haemobilia, cholangitis

stent migration

heart failure, liver failure

infection

Variceal Bleed Treatment Plan

Resuscitation and early endoscopy

Banding +/-sclerotherapy

?haemostasis repeat 5-7 days

?failed iv vasoconstrictor +/-tamponade

?failed endoscopy x2/medical Rx ?TIPSS

Lower GI Bleeding

Diverticular disease

Adenoma/Carcinoma

Colitis

Angiodysplasia

Vasculitis

Ischaemia

Haemorrhoids

Paracetamol Overdose

15g potentially lethal

conjugates sulphate and glucuronidetoxic metabolite NAPQI binds glutathioneexcreted as cysteine conjugateN-acetyl cysteine/methionine releases glutathione

High risk paracetamol overdoses

Pre-existing liver disease

high alcohol intake

enzyme inducing medication

Paracetamol OD Symptoms

Usually after 24 hours

anorexia, nausea, vomiting

day 2 abdominal pain, liver tenderness

liver damage detectable>18 hours

maximal liver damage 72-96hours

Complications of Paracetamol Overdose

Jaundice and FHF

renal failure (ATN)

hyperlactataemia (mild early, late severe)

metabolic acidosis

hypophosphataemia, hypo/hyperglycaemia

cardiac arrhythmias

pancreatitis, GI bleeding, cerebral oedema

Management of Paracetamol OD

? level 4hours

lower significant level if high risk

? gastric lavage

iv n-acetyl cysteine

IV fluids ++

Antibiotics

early liaison with liver unit, ? renal dialysis

liver transplantation

Prognostic factors

PTT >100s (PTT >180s < 8% survival)

pH <7.30 (15% survival)

creatinine >300 (23% survival)

factor VIII/V close correlation prediction survival

Severe Ulcerative colitis

Truelove and Witt’s Criteria of severity

bowel frequency >6/day, bloody diarrhoea

heart rate >90/min

ESR >30mm/hr

temperature >37.5

Hb <10g/dl

Symptoms severe UC

? systemically unwell

Fever

Abdominal pain

dehydration

electrolyte imbalance

Assessment of severe UC

Stool cultures

Blood tests - FBC, U&Es, ESR, LFTs, albumin, CRP

AXR - toxic megacolon, mucosal islands small bowel loops

flexible sigmoidoscopy - severity ulceration

Management of Severe UC

Joint physician/surgeons

high dose intravenous steroids

rectal steroid

ivi

free fluids/light diet

close monitoring

Course of Severe UC

25% severe colitics considered for colectomy

urgent colectomy if complications

daily AXR if abnormal

regular blood tests

If at day 3 CRP >45 or bowel frequency >8/day & CRP <45 = 83% risk colectomy

?role for iv/oral cyclosporin

Crohn’s colitis

High dose iv steroids +/- rectal steroids

Antibiotics - metronidazole

role for anti-TNF

Liver Failure/DecompensationHistory is crucial

Establish Childs score

Ascites, Albumin, Bilirubin, PT, Encephalopathy.

Look for why Decompensated

Decompensation

GI Bleed

Sepsis

Drugs

Constipation

Dehydration

End Stage

?? Head injury

Investigations

FBC/MCV

Clotting

U+Es

Albumin + LFTs

CRP/ESR

AFP + USS (? PV thrombosis/hepatoma)

Hep screen if not previously done

Investigations

Ascitic diagnostic tap

Blood Cultures

Urine Cultures

Consider OGD

Treatment

Stop all sedating/toxic drugs

Laxatives

Antibiotics

Vitamin K / Thiamine/Pabrinex

Decide ITU/Transplant candidate

Consider NG tube

High protein / Low Salt diet

Avoid Saline !!!!!!

Ascites is not just a Cosmetic Problem !

Median Survival 2 years from onsetSurvival depends mainly on Liver FunctionSBP occurs ~25%Low urinary Na+ & SBP predict high mortality

SBP

No Set Rules!

? Drain

3 x 100mls 20% salt poor HAS day 1+2

2 x 100mls 20% HAS day 3

Antibiotics long term

Consider transplant

Hepatorenal syndrome

Splanchnic vasodilatation

Effective underfilling

Salt and water retentionVasoconstrictor systems

Renal vasoconstriction

Hepatorenal syndrome

Ascites

Hepatorenal syndrome

DiagnosisDiagnosisDiagnosis according to strict criteria (IAC 1996)

Renal failure in context of liver failure in absence of other cause associated with low urinary sodium

Type 1Rapidly progressive renal failure.

Median survival 15 daysType 2

Slowly progressive but patients at risk of deterioration to Type 1.

Treatment optionsVasoconstrictorsTerlipressinNoradrenalineMidodrine and octreotide

Increase central blood volumeAlbuminTIPSS

Transplantation

Hepatorenal syndromeTerlipressin with albuminTerlipressin with albumin

Long acting vasopressin analague, splanchnic vasoconstrictor

21 patients with Type 1 HRS Terlipressin (0.5-2mg IV Q4hrly) + Albumin

(1g/kg then 20-30g/day) 15 days or until creatinine normal 12/21 (57%) complete response 12/21 (57%) complete response (historically 15%) CR 77% with albumin Vs 25% if no albumin (CR 77% with albumin Vs 25% if no albumin (P<0.03P<0.03)) 17% relapsed after withdrawal drug CR associated with increased survival

Ortega, Hepatology, 2002

Hepatorenal syndromeNoradrenaline

N=12 0.5-3mg/h + albumin + frusemide 10+/-3days Aim CrCl > 40ml/min, creatinine < 133micmol/L Reversal 10/12

association with increase MAP, decrease renin-aldosterone

3 OLT, 4 “more stable”, 5 “early deaths”

Duvoux Hepatol 2002

Hepatorenal syndromeMidodrine and octreotide

N= 13 Type 1 HRS

Oral midodrine (oral vasoconstrictor)+ S/C octreotide Vs M+O+DA to increase MAP >15mmHg for 20 days

Small study but improved survival in M+O Vs +DAAngeli

1999

Hepatorenal syndromeTIPSS

41 non transplant candidates ( non randomised)31 TIPSS (21 type 1, 10 type 2)

Maximal benefit takes 2 weeks

Increased creatinine clearance, salt excretionSurvival 3/12: 81% Vs 10%

Brensing Gut 2000

Hepatorenal Syndrome

TIPSSType 2 HRS

N=18 Type 2 HRS CP CNo HE resistant to medical therapyComplete remission of ascites Improved renal function

Testino, Hepatogastro 2003

Hepatorenal Syndrome

Medical therapy as a Bridge to TIPSS

N=14, Type 1 HRS, M+O 14 days10/14 improved renal function and sodium

handling5/10 - TIPSS

Normal renal function, Na handling and no ascites at 1 year

Wong Hepatol 2004

Hepatorenal syndrome

Effect of HRS upon outcome of OLT

N=9 HRS with terlipressin RxN=27 without HRS

Same 3 year survivalSame renal function post OLT, time in

hospital and ITU post OLT

Restuccia T, J Hepatol 2004

Hepatorenal syndrome

SummaryTerlipressin with plasma expansion Increasing role of TIPSS in

Transplant candidatesType 2 HRSMedical therapy as bridge to TIPSS/ OLT

Consider transplantation