GI Bleed

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  • NGT Positive: UGIB NGT Negative: bleeding stopped. Bleeding is beyong pylorus
  • BUN/Cr > 30 indicates GI bleed, prob UGIB.
  • *Pocket Medicine, 3rd edition **Barnet J and H Messmann H. Nat Rev Gastroenterol Hepatol 6, 637-646 (2009).
  • Mnemonic for: painful --> I = infectious, inflam, ischemic Ischemic colitis - usually elderly, transient hypoperfusion of mesenteric arteries, resulting in pain from episodic low BP or vasospasm. Water shed area: splenic flexure AND rectosigmoid.
  • Left: bleed Right: Fe defic anemia Colonoscopy better at detecting L cancer
  • Painless: internal Painful: external Hemorrhoids more common than anal fissures.
  • 80mg IVB, then 8mg/hr or 40mg BID
  • Gerson LB. Clin Gastroenterol & Hepatol 2009;7:828-833.
  • PE = proximal jejunum DE = distal ileum
  • GI Bleed

    1. 1. Gastrointestinal Bleeding Lutfiyah Haji, DO 2010
    2. 2. GI Bleeding <ul><li>Initial Evaluation </li></ul><ul><li>Approach to the Patient </li></ul><ul><li>Sources </li></ul><ul><li>Upper GI Bleeds </li></ul><ul><li>Lower GI Bleeds </li></ul><ul><li>Etiology </li></ul><ul><li>Management </li></ul><ul><li>Admission Orders </li></ul>
    3. 3. History <ul><ul><li>HPI </li></ul></ul><ul><ul><ul><li>Hematemesis (coffee grounds vs. bright red) </li></ul></ul></ul><ul><ul><ul><li>Hematochezia </li></ul></ul></ul><ul><ul><ul><li>Melena - dark, tarry stool </li></ul></ul></ul><ul><ul><ul><li>Pain symptoms </li></ul></ul></ul><ul><ul><li>PMHx </li></ul></ul><ul><ul><ul><li>ulcer disease, joints, skin </li></ul></ul></ul><ul><ul><li>Social Hx </li></ul></ul><ul><ul><ul><li>EtOH </li></ul></ul></ul><ul><ul><li>Medications </li></ul></ul><ul><ul><ul><li>NSAIDs, steroids, ASA, Plavix, Coumadin, Lovenox, Heparin, Iron </li></ul></ul></ul>
    4. 4. Physical Exam Including: <ul><li>HR, BP, tilt test, RR, O 2 saturation </li></ul><ul><li>General appearance, Mental status </li></ul><ul><li>Neck veins, oral mucosa </li></ul><ul><li>Skin temperature and color </li></ul><ul><li>Abdominal exam </li></ul><ul><li>Rectal </li></ul><ul><li>Stigma of Cirrhosis </li></ul><ul><li>NG Tube findings (upper vs. lower g.i. source) </li></ul><ul><li>Urine output </li></ul>
    5. 5. Work Up <ul><li>Labs </li></ul><ul><li>CBC </li></ul><ul><ul><ul><li>Serial HgB </li></ul></ul></ul><ul><ul><ul><li>Platelets </li></ul></ul></ul><ul><li>BMP </li></ul><ul><ul><ul><li>BUN, Cr </li></ul></ul></ul><ul><li>Type and Crossmatch </li></ul><ul><li>Coagulation studies </li></ul><ul><li>Stool WBCs to eval for infectious etiol </li></ul><ul><li>Imaging studies? </li></ul>
    6. 6. Sources of GI Bleeding <ul><li>Upper GI Tract </li></ul><ul><li>Proximal to the Ligament of Treitz </li></ul><ul><li>70% of GI Bleeds </li></ul><ul><li>Lower GI Tract </li></ul><ul><li>Distal to the Ligament of Treitz </li></ul><ul><li>30% of GI Bleeds </li></ul>
    7. 7. Localization of Bleeding <ul><li>History </li></ul><ul><li>NG Tube </li></ul><ul><li>EGD </li></ul><ul><li>Colonoscopy </li></ul><ul><li>Tagged RBC Scan </li></ul><ul><li>Angiography </li></ul>
    8. 8. Upper GI Bleed <ul><li>50% present with hematemesis </li></ul><ul><li>NGT with positive blood on aspirate </li></ul><ul><li>11% of brisk bleeds have hematochezia </li></ul><ul><li>Melena (black tarry stools)—this develops with approximately 150-200cc of blood in the upper GI tract. </li></ul><ul><ul><li>Stool turns black after 8 hours of sitting within the gut . </li></ul></ul>
    9. 9. Upper GI Bleed <ul><li>Risk Factors </li></ul><ul><li>NSAID use </li></ul><ul><li>H. pylori infection </li></ul><ul><li>Increased age </li></ul><ul><li>Upper GI Bleeding accounts for approximately 350,000 hospitalizations per year. </li></ul>
    10. 10. Upper GI Bleed <ul><li>Etiology of Upper Bleeds </li></ul><ul><li>Duodenal Ulcer-30% </li></ul><ul><li>Gastric Ulcer-20% </li></ul><ul><li>Varices-10% </li></ul><ul><li>Gastritis and duodenitis-5-10% </li></ul><ul><li>Esophagitis-5% </li></ul><ul><li>Mallory Weiss Tear-3% </li></ul><ul><li>GI Malignancy-1% </li></ul><ul><li>Dieulafoy Lesion </li></ul><ul><li>AV Malformation-angiodysplasia </li></ul>
    11. 11. Duodenal Ulcer
    12. 12. Varices
    13. 13. Esophagitis
    14. 14. GI Malignancy <ul><li>Esophageal Tumor </li></ul>
    15. 15. GI Malignancy <ul><li>Gastric Carcinoma </li></ul>
    16. 16. Angiodysplasia
    17. 17. Lower GI Bleed <ul><li>Acute LGIB: <3d </li></ul><ul><li>Chronic LGIB: > several days </li></ul><ul><li>Hematochezia </li></ul><ul><li>Blood in Toilet </li></ul><ul><li>Clear NGT aspirate </li></ul><ul><li>Normal Renal Function </li></ul><ul><li>Usually Hemodynamically stable </li></ul><ul><ul><li><200ml : no effect on HR** </li></ul></ul><ul><ul><li>>800ml: SBP drops by 10mmHg, Hr increases by 10 </li></ul></ul><ul><ul><li>>1500ml: possible shock </li></ul></ul><ul><ul><li>OR </li></ul></ul><ul><ul><li>10% Hct: tachycardia* </li></ul></ul><ul><ul><li>20% Hct: orthostatic hypotension </li></ul></ul><ul><ul><li>30% Hct: shock </li></ul></ul><ul><li>Stops spontaneously (80 - 85% of the time) </li></ul>
    18. 18. Lower GI Bleed <ul><li>Etiology of hematochezia </li></ul><ul><li>Diverticular-17-40% </li></ul><ul><li>Angiodysplasia-9-21% </li></ul><ul><li>Colitis (ischemic, infectious, chronic IBD, radiation injury)-2-30% </li></ul><ul><li>Neoplasia, post-polypectomy-2-26% </li></ul><ul><li>Anorectal Disease (including rectal varices)-4-10% </li></ul><ul><li>Upper GI Bleed-0-11% </li></ul><ul><li>Small Bowel Bleed-2-9% </li></ul>Barnet J and H Messmann H. Nat Rev Gastroenterol Hepatol 6, 637-646 (2009).
    19. 19. Diverticulosis
    20. 20. Diverticulitis-NOT A CAUSE OF GI BLEEDING
    21. 21. Colonic Polyps
    22. 22. Malignancy <ul><li>Colon Carcinoma </li></ul>
    23. 23. Hemmorrhoids
    24. 24. Management of GI Bleed <ul><li>Oxygen </li></ul><ul><li>IV Access-central line or two large bore peripheral IV sites </li></ul><ul><li>Isotonic saline for volume resuscitation </li></ul><ul><li>Start transfusing blood products if the patient remains unstable despite fluid boluses. </li></ul><ul><li>Airway Protection </li></ul><ul><li>Altered Mental Status and increased risk of aspiration with massive upper GI bleed. </li></ul>
    25. 25. Management of GI Bleed <ul><li>ICU admit indications </li></ul><ul><li>Significant bleeding (>2u pRBC) with hemodynamic instability </li></ul><ul><li>Transfusion </li></ul><ul><li>Brisk Bleed, transfusing should be based on hemodynamic status, not lab value of Hgb. </li></ul><ul><li>Cardiopulmonary symptoms-cardiac ischemia or shortness of breath, decreased pulse ox </li></ul><ul><li>1 unit PRBC increases Hgb by 1mg/dL and increase Hct by 3% </li></ul><ul><li>FFP for INR greater than 1.5 </li></ul><ul><li>Platelets for platelet count less than 50K </li></ul>
    26. 26. Basic Admission Orders <ul><li>Admit to ICU/intermediate care/telemetry s/o … </li></ul><ul><li>Dx: Upper/Lower G.I. Bleed </li></ul><ul><li>Condition: </li></ul><ul><li>VS: </li></ul><ul><li>Allergies: </li></ul><ul><li>Activity: Bedrest </li></ul><ul><li>Nursing: Is/Os, ? Foley </li></ul><ul><li>Diet: NPO </li></ul>
    27. 27. Basic Admission Orders (Cont.) <ul><li>IVF: NSS @ ?cc/h </li></ul><ul><li>Medications: I.V. Protonix, convert medications to i.v., hold anti-hypertensives </li></ul><ul><li>Labs: serial H/H, type and cross, coags, Chem 7, LFTs </li></ul><ul><li>Consults: GI, +/- Surgery </li></ul>
    28. 28. Obscure GI Bleed <ul><li>Present: Fe Defic anemia </li></ul><ul><li>Etiology: </li></ul><ul><ul><li>Younger than 40 </li></ul></ul><ul><ul><ul><li>Tumors </li></ul></ul></ul><ul><ul><ul><li>Meckel’s diverticulum </li></ul></ul></ul><ul><ul><ul><li>Dieulafoy’s lesion </li></ul></ul></ul><ul><ul><ul><li>Crohn’s Disease </li></ul></ul></ul><ul><ul><ul><li>Celiac Disease </li></ul></ul></ul><ul><ul><li>Greater than 40 </li></ul></ul><ul><ul><ul><li>Angioectasia </li></ul></ul></ul><ul><ul><ul><li>NSAID enteropathy </li></ul></ul></ul><ul><ul><ul><li>Celiac </li></ul></ul></ul>Gerson LB. Clin Gastroenterol & Hepatol 2009;7:828-833.
    29. 29. Obscure GI Bleed <ul><li>Work Up </li></ul><ul><ul><li>EGD, Colonoscopy both neg </li></ul></ul><ul><ul><li>Repeat </li></ul></ul><ul><ul><li>CE, PE or DE, </li></ul></ul><ul><ul><li>angiography </li></ul></ul>
    30. 30. PillCam SB Latest Generation <ul><ul><li>PillCam SB </li></ul></ul><ul><ul><li>11 mm x 26 mm </li></ul></ul><ul><ul><li>1 camera </li></ul></ul><ul><ul><li>2 frames per second </li></ul></ul><ul><ul><li>Std optics / 1 lens </li></ul></ul><ul><ul><li>Standard lighting control </li></ul></ul><ul><ul><li>Standard angle of view (AOV) 140 ° </li></ul></ul><ul><ul><li>Depth of field 0-30 mm </li></ul></ul><ul><ul><li>PillCam SB 2 </li></ul></ul><ul><ul><li>11 mm x 26 mm </li></ul></ul><ul><ul><li>1 camera </li></ul></ul><ul><ul><li>2 frames per second </li></ul></ul><ul><ul><li>New optics / 3 lenses </li></ul></ul><ul><ul><li>Advanced Automatic Light Control </li></ul></ul><ul><ul><li>Extra wide angle of view (AOV) 156 ° </li></ul></ul><ul><ul><li>Depth of field 0-30 mm </li></ul></ul>
    31. 31. Image Spectrum: PillCam Capsule Endoscopy <ul><li>Bleeding </li></ul>Celiac Disease Tumors Suspected Crohn’s
    32. 32. References <ul><li>Harrison’s Principles of Internal Medicine 14 th edition </li></ul><ul><li>Gastrointestinal Atlas.com endoscopy photos </li></ul><ul><li>Pocket Medicine, 3rd edition </li></ul><ul><li>Barnet J and H Messmann H. Diagnosis and management of lower gastrointestinal bleeding. Nat Rev Gastroenterol Hepatol 6, 637-646 (2009). </li></ul><ul><li>Gerson LB. Recurrent Gastrointestinal Bleeding After Negative Upper Endoscopy and Colonoscopy. Clin Gastroenterol & Hepatol 2009;7:828-833. </li></ul><ul><li>Melmed GY and Simon KL. Capsule Endoscopy: Practical Applications. Clin Gastrolenterol & Hepatology 2005;3:411-422. </li></ul><ul><li>AGA Institute. AGA Institute Medical Position Statement on Obscure Gastrointestinal Bleeding. Gastroenterology 2007;133:1694-1696. </li></ul>
    33. 33. <ul><li>THE END </li></ul>

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