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Gastrointestinal bleeding
- 1. Approach to GIBleeding Bayalpata Hospital CME Last updated: 2nd January, 2017 Contributors: Dr. Pawan KB Agrawal, MD General Practice & Dr. Stephen Mehanni, MD Internal Medicine
- 2. Objectives After this session,participants should be able to 1) Describe initial evaluation of GI bleeding 2) Distinguish upper from lower GI bleeding 3) Recognize common causes of GI bleeding 4) Describe acute management of GI bleeding 5) Recognize warning signs for GI malignancy 21/4/2017 Presentation by Dr. Pawan KB Agrawal
- 3. Clinical Case #1 A 45 years male is brought to emergency with repeated episodes of blood vomiting for 1 day. He is drowsy and can barely talk. His wife reports passing black colored stool this morning. 31/4/2017 Presentation by Dr. Pawan KB Agrawal
- 4. Clinical Case #1 A 45 years male is brought to emergency with repeated episodes of blood vomiting since night. He is drowsy and can barely talk. His wife reports passing black colored stool this morning. 41/4/2017 Presentation by Dr. Pawan KB Agrawal
- 5. Question for HAsand CMAs What is the first thing you would do for this patient? Fluid resuscitation 51/4/2017 Presentation by Dr. Pawan KB Agrawal
- 6. Question for StaffPhysicians What informations would you like to obtain further? Severity: Frequency, Amount Etiology: Smoking, Alcohol, Repeated history, Previous endoscopy finding 61/4/2017 Presentation by Dr. Pawan KB Agrawal
- 7. GI Bleed: InitialEvaluation Vitals assessment Resuscitation History • Hematemesis Vs Hemoptysis • Upper GI bleeding Vs Lower GI bleeding • Etiology • Severity 71/4/2017 Presentation by Dr. Pawan KB Agrawal
- 8. 81/4/2017 Presentation byDr. Pawan KB Agrawal
- 9. Key Point #1 Differentiatehematemesis from hemoptysis. 91/4/2017 Presentation by Dr. Pawan KB Agrawal
- 10. Question What is thecommonest cause of GI bleed? 1. Haemorrhoids 2. Esophageal varices 3. Peptic ulcer disease 4. Carcinoma ANSWER: Peptic ulcer disease 101/4/2017 Presentation by Dr. Pawan KB Agrawal
- 11. Upper Vs LowerGI Bleed A 45 years male is brought to emergency with repeated episodes of blood vomiting for 1 day. He is drowsy and can barely talk. His wife reports passing black colored stool this morning. How can we differentiate upper from lower GI bleeding? 111/4/2017 Presentation by Dr. Pawan KB Agrawal
- 12. Upper vs LowerGI Bleed Include information on how you can try to distinguish upper from lower GI bleed. You can include more advanced diagnostics if you think it would be helpful, but remember that the focus should be on what we can do at Bayalpata hospital. Upper GI Bleed Lower GI Bleed History 1.Vomiting of blood 1. Fresh blood in stool 2. Passing of black tarry stool ‘Malaena’ 2. Etiology 3. Etiology NG Tube Aspiration 1. Frank Blood or coffee colored blood 1. Food particles 121/4/2017 Presentation by Dr. Pawan KB Agrawal
- 13. Key Point #2 Whenin doubt, NG tube aspiration can differentiate upper GI bleed from lower GI bleed. 131/4/2017 Presentation by Dr. Pawan KB Agrawal
- 14. Clinical Case #2 • A 65 years old female presents to OPD with complain of passing black tarry stool for few days. History reveals that she has been on ibuprofen tablets for few months for her bilateral knee pain. 141/4/2017 Presentation by Dr. Pawan KB Agrawal
- 15. GI Bleed: RiskFactors • Smoking • Alcohol • NSAIDs • H.pylori • Warfarin • Old age 151/4/2017 Presentation by Dr. Pawan KB Agrawal
- 16. GI Bleed: Differential Includeinformation about the COMMON causes of GI bleed. Try not to focus on the very rare causes, or the diagnoses that are only possible to make in very advanced centers. As before, consider having the participants volunteer their answers before you show this information. 161/4/2017 Presentation by Dr. Pawan KB Agrawal
- 17. GI Bleed: Differential Causesof Lower GI bleeding: 1. Haemorrhoids 10% 2. Anal Fissures 3. Colitis 20% 4. Diverticular disease 60% 5. Carcinoma 10% 171/4/2017 Presentation by Dr. Pawan KB Agrawal
- 18. Key Point #3 Pepticulcer disease constitute majority of cases of upper GI bleed 181/4/2017 Presentation by Dr. Pawan KB Agrawal
- 19. Clinical Case #2 • A 65 years old female presents to OPD with complain of passing black tarry stool for few days. History reveals that she has been on ibuprofen tablets for few months for her bilateral knee pain. • While on inquiry, the old lady suddenly faints and is carried immediately to emergency. 191/4/2017 Presentation by Dr. Pawan KB Agrawal
- 20. Question • How willyou resuscitate? • Which medicines would you like to give her? 201/4/2017 Presentation by Dr. Pawan KB Agrawal
- 21. GI Bleed: Management •Upper GI Bleed • Fluid Resuscitation • Catheterization • PPI • Octreotide in variceal bleed • Blood transfusion • Next step?? •Monitoring 211/4/2017 Presentation by Dr. Pawan KB Agrawal
- 22. GI Bleed: Management •Lower GI Bleed • Fluid Resuscitation • Tranexamic acid • Catheterization • Stool softeners in anorectal disease • Blood transfusion • Next step?? •Monitoring 221/4/2017 Presentation by Dr. Pawan KB Agrawal
- 23. Question • When shouldwe transfuse blood? • Answer • <7 g/dl • <8 g/dl with major comorbidities like CAD • <10 g/dl if a procedure is planned. 231/4/2017 Presentation by Dr. Pawan KB Agrawal
- 24. Key Point #4 Fluid,PPI & blood transfusion are keys to save life in acute upper GI bleed 241/4/2017 Presentation by Dr. Pawan KB Agrawal
- 25. Clinical Case #3 A 62 years young male present to OPD with upper abdominal pain for 1 week. EHR showed he has visited BH several times over last one year and has been being diagnosed as acid peptic disease. 251/4/2017 Presentation by Dr. Pawan KB Agrawal
- 26. Question • What arethe red flag signs or ‘ALARM’ symptoms in acid peptic disease? 261/4/2017 Presentation by Dr. Pawan KB Agrawal
- 27. GI Malignancy: RedFlags 1. Anemia 2. Loss of weight 3. Abdominal lump 4. Recent onset after 50-60 years of age 5. Malaena Carcinoma 271/4/2017 Presentation by Dr. Pawan KB Agrawal
- 28. Key Point #5 Alwaysinquire for ALARM symptoms before prescribing for dyspepsia especially in old age. 281/4/2017 Presentation by Dr. Pawan KB Agrawal
- 29. Summary 1) It isessential to differentiate hematemesis from hemoptysis. 2) NG tube aspiration should be done if doubt exists to confirm upper GI bleeding. 3) Ulcer bleed is responsible for majority of cases of upper GI bleed. 4) Fluid, PPI & Blood transfusion can save life in acute upper GI bleed. 5) We should inquire for RED FLAG signs in old age with APD. 291/4/2017 Presentation by Dr. Pawan KB Agrawal
- 30. Questions? 301/4/2017 Presentation byDr. Pawan KB Agrawal
- 31. Thank you! 311/4/2017 Presentationby Dr. Pawan KB Agrawal
Editor's Notes
- #2 Rationale: Males were predominant (75%). Age ranged from 14 to 88 years, mean being 48.76+17.19. At presentation 86 patients (71.7%) had both hematemesis and malena, 24 patients (20%) had only malena and 10 patients (8.3%) had only hematemesis. Shock was detected in 21.7%The mortality of patients admitted to hospital is about 10%. Davidson.
- #6 Asking questions at two different levels can help keep more people engaged. Doctors stop paying attention if everything is too basic. And mid-level providers stop paying attention if everything is too advanced.
- #7 Asking questions at two different levels can help keep more people engaged. Doctors stop paying attention if everything is too basic. And mid-level providers stop paying attention if everything is too advanced.
- #8 In a nationwide study from Spain, UGIB was 6 times more common than lower GI bleeding. Lanas A, Perez-Aisa MA, Feu F, Ponce J, Saperas E, Santolaria S, et al. A nationwide study of mortality associated with hospital admission due to severe gastrointestinal events and those associated with nonsteroidal antiinflammatory drug use. Am J Gastroenterol. 2005 Aug;100(8):1685-93.
- #10 Please don’t change this key point. It’s one of the questions on the pre/ post-test for the curriculum.
- #11 Please don’t change this key point. It’s one of the questions on the pre/ post-test for the curriculum.
- #16 Try to get the audience engaged. You can use the white-board here if it would be helpful.
- #17 Gastric ulcer 23(25.6%) was the most common endoscopic fi nding, followed by oesophageal varices 14 (15.6%), acute erosive/haemorrhagic gastropathy 11 (12.2%), duodenal ulcer 9(10%), growth 7(7.8%), vascular lesions 3(3.3%), Mallory-Weiss tear 1(1.1%), fundal varices 1(1.1%) and, no cause was identifi ed in 21(23.3%) cases.Try to get the audience engaged. You can use the white-board here if it would be helpful. Gurung RB 2010 Of the 517 patients with UGIB, 29.8% had variceal and 70.2% non-variceal bleeding. Six factors were associated with variceal hemorrhage: cirrhosis (OR=10.74, 95% CI: 3.50-32.94, p<0.001), history of variceal hemorrhage (OR=13.11, 95%CI: 3.09-55.57, p<0.001), ascites (OR=4.41, 95% CI: 1.74-11.16, p=0.002), thrombocytopenia (OR=2.77, 95% CI: 1.18-6.50, p=0.01), elevated INR (OR=4.77, 95% CI:1.47-15.42, p=0.009) and elevated bilirubin levels (OR=2.43, 95% CI:1.01-5.84, p=0.04). Matei D, J Gastrointestin Liver Dis. 2013 Dec;22(4):379-84
- #18 In a review by Vernava and colleagues, patients with LGIB made up only 0.7% of all hospital admissions (17,941 patients); among the patients who underwent a diagnostic workup (4410 [24%]), the most common causes of bleeding were diverticular disease (60%), IBD (13%), and anorectal diseases (11%) Vernava AM, Longo WE, Virgo KS. A nationwide study of the incidence and etiology of lower gastrointestinal bleeding. Surg Res Commun. 1996. 18:113-20. Among 415 LGIB patients (males 62.2%, females 37.8%), the different etiologies of LGIB were as following: hemorrhoid 35.2%, non-specific colitis 24.8%, colon polyp 18.3%, inflammatory bowel disease (IBD) 10.4%, colon cancer 6.5%, diverticulosis 1.7%, unknown 1.4%, upper gastrointestinal bleeding 1.2% and radiation colitis 0.5%. Journal of Advances in Internal Medicine > Vol 3, No 2 (2014) > Shrestha UK.
- #24 PO iron replacement, and how to counsel patients to take it. (learning points below) Once daily dosing is all you need .Might cause constipation and upset stomach. Absorption is best when taken with Vitamin C (i.e. lime juice), or meat.