Lower Gastrointestinal Bleeding_ICEM 2019 Presentation
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This presentation was presented in 2019 International Conference on Emergency Medicine at Seoul, Korea. Review the assessment, management, diagnosis, treatment and disposition of lower gastrointestinal bleeding patient.
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Lower Gastrointestinal Bleeding_ICEM 2019 Presentation
- 1. Lower Gastrointestinal Bleeding Treatment and Discharge from ED Ching-Hsing Lee, M.D. Chang Gung Memorial Hospital, Taiwan June 14, 2019
- 2. No financial conflict of interest to disclose No financial conflict of interest to disclose
- 3. •Symptoms and signs •Assessment •Management •Diagnostic evaluation •Therapy •Discharge prediction rule
- 4. The story starts from here…… Hematochezia Melena
- 6. “Hematochezia from either the colon or the rectum”
- 7. Initial Assessment • Focused history taking • color, amount, frequency, duration • Medications history • NSAID, antiplatelet, anticoagulants • Blood test: BUN/Cr > 30:1
- 8. Risk factors for adverse outcomes • Hypotension • Tachycardia • Ongoing bleeding • Age > 60 years • Creatinine > 1.7 mg/dL • Clinically significant coexisting conditions
- 9. Initial Managment • Resuscitation • Hemoglobin level > 7 g/dL • Hemoglobin level > 9 g/dL (ischemic heart)
- 10. Diagnostic Evaluation within 24 hours
- 12. Radionuclide technetium-99m–labeled red-cell scintigraphy Radionuclide technetium-99m–labeled red-cell scintigraphy
- 13. Therapies • Endoscopic Therapy • Injection diluted epinephrine • Thermal devices • Mechanical therapies
- 14. Embolization • Slow bleeding (<0.5 ml/min) or intermittent may be negative • 1 to 4% bowel ischemia
- 15. Surgery When endoscopic and radiographic treatment failed
- 16. To be Discharged or Not? NOreliable scoring system decide which patients with LGI bleeding may be discharged home safely
- 17. To Use or Not to Use? • 72 y/o male LGI bleeding patient • Underwent LAD stenting 2 weeks ago • Currently taking aspirin and ticagrelor Shall we DC aspirin and ticagrelor?
- 18. • Aspirin • Secondary prophylaxis: should NOT be interrupted • Primary prophylaxis: should be avoided • Dual antiplatelet therapy • Stenting within 30 days, ACS within 90 days: continue • Others: DC the 2nd antiplatelet agent for 1 to 7 days
- 19. LGI Bleeding in Summary • Focused history, physical, resuscitation • Colonscopy within 24 hours • Endoscopic therapy, embolization, surgery • Comorbidity medication adjustment
- 20. References
- 22. Welcome to Taiwan ICEM 2024 19-23 June Glocalization of Emergency Medicine Global Wisdom, Local Solutions
Editor's Notes
- Hello, everyone. I am Dr Ching-Hsing Lee from Taiwan. Thanks the ICEM organizing committee that I may have the opportunity to talk about LGI bleeding and management in the ED
- First off all, I have no financial conflict of interest to disclose. Second, there is no groundbreaking advancement in LGI bleeding in the past 10 years, This talk summarized the general management principle of LGI bleeding.
- We will go through from the S/S, assessment, management, diagnostic and therapeutic methods, and disposition.
- The LGI bleeding story starts from here When patient noted blood pass through the rectum, which refers to “Hematochezia” ( maroon or red blood passed through the rectum) Or tarry stool, which refers to “Melena” black, tarry stools Most of the time, tarry stool come from UGI bleeding, bloody stool comes from LGI bleeding But when the bleeding amount from UGI tract is large and quick, there may be bloody stool
- The GI tack is meters long, where is the lower GI begin? The traditional definition defined lower GI as distal to the ligament of Treitz
- In the 2016 ACG guideline, the LGI bleeding was focused on bloody stool originating from either the colon or the rectum
- When any symptoms that may suggest lower gastrointestinal bleeding. We should take a focused Hx on amount, frequency, duration of the bleeding, Medication hx of NSAID, antiplatelet or anticoagulant use. Abdominal pain with diarrhea may suggest inflammatory, ischemic, or infectious-type colitis, whereas altered bowel habits, iron-deficiency anemia, or unexplained weight loss may suggest colorectal cancer.
- There are several risk factors for poor outcomes Any condition that require intensive care unit admission
- Resuscitate with IV fluid or blood transfusion as indicated to keep the Hgb level above 7g/dl Above 9 for ischemic heart patient
- Colonscopy is the most important diagnostic and therapeutic method. Performed within 24 hours from presentation. Observational studies have shown a higher frequency of definitive diagnoses and a shorter length of stay among patients with lower gastrointestinal bleeding undergoing early colonoscopy (within 12 to 24 hours after presentation) than among those undergoing colonoscopy at a later time
- Multidetector CT angiography is indicated when patient is hemodynamically unstable and intolerant to colonoscopy prepare To localized bleeding CTA has a bleeding detection rate threshold (0.3 ml per minute) can be used immediately before angiographyto guide selective or superselective contrast injection and therapy during angiography. angiography may be negative if the bleeding is slow (<0.5 ml per minute) or inter mittent.
- indicated when patient is hemodynamically unstable and intolerant to colonoscopy prepare To localized bleeding technetium- 99m–labeled red-cell scintigraphy can detect bleeding rates as low as 0.1 ml per minute
- Colonscopy is both diagnostic and therapeutic method Clipping, band ligation, thermal coagulation, dilute epinephrine injection are choice of hemostasis method The choice of hemostasis method is generally guided by the cause of bleeding location of bleeding operator experience. Diverticulosis, angioectasias, and postpolypectomy bleeding are the sources of lower gastrointestinal bleeding that are most likely to benefit from endoscopic hemostasis. endoscopic clips, is preferred for diverticular bleeding Argon plasma coagulation for Colonic angioectasias, radiation proctopathy Clipping, band ligation, thermal coagulation, dilute epinephrine injection for postpolypectomy bleeding
- Angiography is also both diagnostic and therapeutic method indicated when patient is hemodynamically unstable and intolerant to colonoscopy prepare diagnosis often must be confirmed with colonoscopy 1 to 4% bowel ischemia atfer embolization
- Surgery when endoscopy and embolization failed
- Currently, studies focused risk-factors of adverse outcome No reliable predict which patient can be discharged and treat as outpatient. models based on these predictors are less well studied than models for upper gastrointestinal bleeding, were not developed to identify patients appropriate for outpatient management,
- Let’ make a quick survey. DC aspirin? Not DC aspirin? DC ticagrelor? Not DC ticagrelor?