1
Q
Upper GI bleeding - etiologies
A
- Depends also on the hospital itself. For instance, highland its usually varices, etc. (Depends on the population you’re talking about)
- Upper GI Bleeding-Etiologies
- Most series demonstrate peptic ulcers to account for about 50% of upper gastrointestinal bleeds requiring hospitalization, with about half from duodenal and half from gastric ulcers. Gastric erosions, esophagitis and duodenitis each account for about 10%. The number with esophageal varices will depend on the patient population, however usually varices comprise 8-10%. In all series there are some patients presenting with upper gastrointestinal bleeding in whom, despite upper gastrointestinal endoscopy, no cause is found. These patients have an excellent prognosis. There may be multiple sites detected in a few patients.
2
Q
GIB: common, life threatening
A
- Over 300,000 hospitalizations/yr in US
- Incidence increases with age (Males: Females = 2 : 1)
- Most common emergent indication for upper GI endoscopy (EGD)
- Mortality 3-14%
- Two things get him out of the bed at 2 in the morning: GIB and foreign bodies
- Notes:
- Estimates of annual rate of hospitalization approaching 165 per 100,000
- More people admitted for UGIB than CHF or DVT
- One study (Longstreth) showed more than a 30 fold increase in UGIB between 3rd and 9th decades of life
- Despite advances in therapy, case fatality rate remains relatively unchanged at overall 7-10%. Probably related to older patient w comorbids
- Epidemiology of hospitalization for acute upper gastrointestinal hemorrhage: a population-based study.
3
Q
UGI bleeding - outcome
A
- Outcome of Acute GI Bleeding
- Most patients admitted to hospital with upper gastrointestinal bleeding will stop bleeding spontaneously and survive. However about 20% will have ongoing or recurrent bleeding. Overall, the mortality from upper GI bleeding is about 8%. This mortality rate has not changed over the last 40 years. The cause of death is rarely exsanguination, but usually decompensation of preexisting medical conditions. The aim of management of the patient presenting with an upper gastrointestinal bleed is to identify those at increased risk for recurrent bleeding and increased risk of dying. These patients can then have a more intensive, increased level of care compared to those in whom there is a lower mortality risk.
4
Q
UGI bleeding - initial rx
A
- Management of Bleeding - Level of Care
- All patients need to be adequately resuscitated during the initial assessment. In order to determine the level of care for an individual patient both clinical and endoscopic prognostic factors need to be assessed. These are presented in the following slides. The clinical features predictive of a worse outcome include those representing a severe initial bleed (shock, red hematemesis or hematochezia, failure of the nasogastric aspirate to clear) as well as advanced age and the presence of comorbid diseases. The presence of adverse clinical factors should prompt admission to an intensive care unit and early endoscopy. The adverse endoscopic prognostic signs include bleeding from varices, and active ulcer bleeding. For bleeding peptic ulcers the factors include size, the location of the ulcer and the presence of a visible vessel.
- Those at low risk (for example a young patient with no comorbid disease and an ulcer with a clean base) can be discharged early. Those at intermediate risk can be observed in hospital in a non-intensive care setting.
5
Q
initial assessment and management
A
- Initial Assessment = ABC’s (Can the patient protect their airway?, Is the patient in hemorrhagic shock?)
- Initial Management (2 large bore IV’s, Bolus NS (normal saline), Type & Cross Blood, Labs (which ones?), O2 and monitor)
6
Q
Adverse clinical prognostic factors
A
- Shock, red blood
- Cause of bleeding (varices or cancer)
- Comorbid disease
- Older age
- Onset in hospital
- Recurrent bleeding
- Adverse Clinical Prognostic Factors
- The outcome of patients with gastrointestinal bleeding is traditionally assessed by the number of units of blood transfused, the need for surgical intervention and mortality rate. Several clinical factors have been associated with a poor outcome. These include severe initial bleed as manifested by shock on presentation, bright red hematemesis (slide 9) or hematochezia, or failure of the nasogastric aspirate to clear. The mortality rate increases with the number of transfused units of blood (slide 10).
- There is a direct correlation with the number of comorbid diseases and mortality. For each comorbid disease there is a 10% increase in mortality (slide12).
- Most studies have demonstrated older age to be a risk factor. In the large ASGE National study of over 2000 patients the mortality for those less than 60 years old was 8.7% compared to 13.4% for those greater than 60. In another study the mortality rates were 0.5% for the younger patients and 10% for those greater than 60 years.
- Onset of bleeding in hospital carried a 33% mortality compared to 7% for those whose bleeding started prior to admission in the ASGE study, while recurrent bleeding increased the mortality from 8% to 30%
7
Q
UGI bleeding - risk of death by number of comorbidities
A
- Mortality Related to Comorbid Disease
- In addition to the etiology and severity of the gastrointestinal bleeding, another major determinant of the outcome of the GI bleeding is the presence of comorbid disease. Patients with 3, 4 or more comorbid conditions have a significantly higher mortality than those with none or only 1 associated problem. The major comorbid problems include renal disease, respiratory failure, hepatic disease, coagulopathy, etc. When the number of these associated problems reaches 5 or 6, the mortality is in the range of 50% from each episode of upper gastrointestinal bleeding. One other significant factor leading to a worsened prognosis from upper GI bleeding is the acute onset of bleeding in the hospital setting. This has essentially the same implication as an additional comorbid condition.
- Influence of Diagnosis on Outcome
- Both the mortality and the rebleeding rate vary greatly depending on the etiology of the upper gastrointestinal bleeding. Most surveys have found that bleeding from the esophageal varices has a significantly higher mortality and rebleeding rate. When no diagnosis can be established on the initial evaluation of the bleeding, the immediate prognosis is good, presumably because the bleeding has stopped and the major lesions have been ruled out by endoscopy.
8
Q
NG tube pros
A
- Withdrawal of blood is diagnostic for UGIB
- Insight as to acuity/ severity of bleed (coffee grounds, BRB, negative)
- Allows for clearance of stomach which can:
- Reduce risk of aspiration
- Clears the view for EGD
- Easy to place with little risk of complication
9
Q
NG tube cons
A
- Uncomfortable
- Potential false negative if post-pyloric source
- Risk for sinusitis or bronchus placement
10
Q
stool color
A
- We want to know: Black – bacteria in your gut oxidizes the hemoglobin, Red – if its coming out red, it hasn’t had time to come in contact with the bacteria, Anything else
- The only time you have red blood from upper GI is when you have a crap ton of bleeding – overwhelms the contact with the bacteria and comes out red
- If you have colon cancer from a slow, high colon bleed, it could come out black
- Acholic stool = white. VERY RARE!!
11
Q
Melena
A
- “Black, tarry stools”
- Oxidation of iron in hemoglobin
- Only 50-100cc blood needed
- Can last up to a week
- 70-90% melena is from an UGI source (how could one get melena from LGIB?)
- Consider acuity in the clinical context
12
Q
UGI bleeding - by stool color
A
- Mortality Related to Stool and NG Aspirate Color
- In the ASGE study of over 2000 patients in the United States, melena and a clear nasogastric aspirate was associated with a 5% mortality while red blood in the aspirate and hematochezia had a 30% mortality. This demonstrates how the initial severity of the bleeding episode can be used as a prognostic indicator. It must be pointed out that this study was performed prior to the widespread use of therapeutic endoscopy.
13
Q
UGI bleeding - what does EGD tell us
A
- Role of Endoscopy
- WHY? Endoscopy should be performed to obtain a diagnosis and to obtain prognostic information. This allows determination of the level of care of the patient, and a decision as to whether therapeutic endoscopy is indicated.
- WHERE? The procedure should be performed at a site where the patient can be adequately monitored and resuscitated, and where experienced endoscopy and nursing staff are available for assistance. Endoscopic accessories must be available for therapeutic endoscopy. These requirements are usually met in an intensive care unit or an endoscopy unit, rarely in an office setting or even an emergency room.
- WHEN? The timing of the emergency procedure should be determined by the clinical status of the patient. After resuscitation and intubation, if necessary, actively bleeding patients should be endoscoped earlier rather than later. Most emergency endoscopy is performed within 6 to 8 hours.
- WHO? In view of the potential need for therapy, the procedure should be performed by an endoscopist trained or experienced in therapeutic endoscopy.
14
Q
etiologies: peptic ulcer disease
A
- Most common cause of UGIB
- Gastric > Duodenal
- 4 major Risk Factors (NSAIDs/ Aspirin, Helicobacter pylori infection, Physiologic Stress (i.e. hospitalized patients with life threatening illness), Gastric Acid)
15
Q
ulcer prevalence of stigmata
A
- Stigmata of Recent Hemorrhage - Prevalence
- The prevalence of various ulcer stigmata for patients with peptic ulcer bleeding is shown on this slide. The most common finding is a clean based ulcer, occurring in about 40% of cases. Very high risk stigmata, active bleeding and non-bleeding visible vessels, occur in about 35-40% of cases. Adherent clots, flat pigmented spots, and oozing from the edge of the ulcer all occur less frequently. The distribution of the prevalence rates varies between individual studies because of differences in patient populations as well as differences in the endoscopic interpretation or definition of stigmata. In addition, high risk stigmata are found more frequently when endoscopy is performed within 12 to 18 hours of hospital admission.
16
Q
risk of rebleeding by stigmata
A
-Despite a decrease in PUD in the developed world, the prevalence of bleeding peptic ulceration has not changed
17
Q
UGI bleeding - the famed “visible vessel”
A
- Course of the Visible Vessel
- The course of the vessel in the ulcer cannot be predicted endoscopically. It may be running from the right to the left, from the top to the bottom, or any other direction. In addition, in most cases the vessel is relatively deep within the base of the ulcer except where it penetrates up to the surface. This is why thermal therapy is directed directly at the protuberance and injection therapy is directed around it.
- Most ulcers are Clean base
- Visible vessel means that the tissue has eroded down to the artery and it is now exposed
18
Q
methods of endoscopic hemostasis
A
-Bipolar coagulation, heater probe, endo clip, epi injection
19
Q
Adherent clots
A
-You could peel the clot off and there could be a totally clean base, or you could take off clots and it could spurt again
20
Q
Peptic ulcer - therapeutic endoscopy
A
- Outcome of Therapeutic Endoscopy
- Initial control of hemorrhage approaches 100%. Control is permanent in 80%, however about 20% of patients will rebleed. For those who do rebleed, a further attempt at endoscopic therapy is worthwhile because this is successful in 50% of patients. Failed endoscopic therapy will require either surgery or angiographic therapy.
21
Q
interventions in UGIB
A
- Does endoscopic therapy help? For sure:
- Provides effective triage/prognostication: Early discharge possible for 20-40% with ‘low risk’ lesions (rebleeding <3%), with low morbidity, Appropriate use of resources, such as ICU beds, Saves money (>$2000 per UGIB case)
- And decreases rebleeding rates by 50%
- BUT, doesn’t decrease rebleeding completely, and no effect demonstrated on mortality…..can we do more?
22
Q
PPIs in the treatment of PUD bleeding
A
- Strongest class of acid reducers that we have today
- PPIs reduce rebleeding and need for surgery, but do not effect mortality compared to control
23
Q
indications for surgery
A
- Pre-endoscopic era (Shock on admission, Unconctrolled bleeding, Onset of bleeding in hospital, Endoscopic appearance of ulcer, Recurrent episodes of bleeding, Over 60 years old)
- Endoscopic era (Failure of therapy)
24
Q
acute variceal bleeding
A
- Another common cause of acute UGIB
- Occurs in up to 25% patients with cirrhosis and known varices
- Mortality approx 30%
- Initial Management Strategies (Resuscitation, IV somatostatin analogues, Antibiotics, Endoscopic therapy)
25
varices
- the valves in the veins are not working as well so the venous blood pools and swells the veins
- Increase in diameter over time (7-8%/year)
- Normally the blood goes through the liver, but if the pressure in the liver (cirrhotic) then the blood can back up and then the varices can pop
26
octreotide and variceal bleeding
- Octreotide is a long acting analog of somatostatin (only US available agent)
- Inhibits release of vasodilator hormones (ie glucagon) which indirectly causes splanchnic vasoconstriction, decreasing portal flow while increasing MAP
- No clear cut impact on mortality
- AASLD Guidelines: “Octreotide . . .should be initiated as soon as variceal hemorrhage is suspected and continued for 3-5 days after diagnosis is confirmed.”
- This is an adjunct treatment
27
AVMs
- Also called telangectasias
- Congenital, malformations of the blood vessels
- Blood from cancers bleed slowly and microscopically – cancers don’t generally hemorrhage
28
Occult GI Bleeding
- Fecal Occult Blood Tests (FOBT); GAUIAC test (older, peroxidase based, non-specific), FIT (Fecal Immunohistochemical Test); more specific for human Hg
- Used for outpatient colon cancer screening (ANY positive requires colonic evaluation, Little role in inpatient use, nor single use on DRE)
- If occult blood loss suspected (chronic IDA, ongoing occult bleeding, tx requiring) we’ll often evaluate small bowel as well
- This is not OVERT bleeding that you can see – occult is kind of microscopic
- The large majority of blood in colon is false positive for colon cancer
29
Upper GI bleeding
- Use clinical and endoscopic signs to determine timing and triage
- Endoscopic Rx for high-risk lesions
- PPI Rx for high-risk PUD lesions
- Octreotide for variceal bleeding
- H2RAs or PPIs for prophylaxis in ICU patients at high risk for SRMD
30
Lower GI bleeding
- Supportive care initially
- ‘Urgent’ colonoscopy after prep to
- Define cause, rule out CA, potentially Rx
- Nuclear medicine, angiography, surgery.
- No pharmacologic Rx
31
Occult GI bleeding
- Less common, but often morbid (slowly)
| - Capsule endoscopy, enteroscopy options
Medicine 3
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