UGIB

Management of patient with Upper GI bleeding

1. Basics of GI Bleeding
Ron Thomas, MD
Fellow
Division of Gastroenterology and
Hepatology

2. Early July on ART 6W…
•Overnight admit
–69 yomale with recent melena and Hgbto 5 g/dl
–Prior perforated gastric ulcer with Graham patch
–Recent hemicolectomyfor colonic signet ring
adenoCA
–EGD two days prior with large nonbleedingulcer
extending from lesser curvature to incisura
–Was in rehab for a few hours before hematemesis

3. During Rounds
•“This patient was admitted for hematemesis”
•[Pause, quick glance at patient in room]
•“And he’s having active hematemesis now!!”

4. What do you do now?
•Assess hemodynamics
•Ensure large bore IV access
•Consider PPI infusion
•Could we be dealing with varices?
•Key labs: CBC, INR, BUN
•Think about NG lavage
•Don’t think about Fecal Occult

5. His EGD

10. Definitions
•Inpatient
–Overt
•Outpatient
–Occult
–Obscure
•UGIB
•LGIB

11. Magnitude
•Acute UGIB estimated to be 400,000 U.S.
hospital admissions per year
1
•80-90% of UGIB is nonvariceal
2
•Peptic ulcer bleeding
–Affects patients > 60 years old
3
–5-10% mortality
2,4
–$2B in U.S. health care spending per year
5
1
Lewis JD et al. Am J Gastroenterol2002; 97.
2
Barkun A et al. Am J Gastroenterol2004;99.
3
Ohmann C et al. ScandJ Gastroenterol2005; 40.
4
Lim CH et al. Endoscopy 2006;38.
5
Viviane A et al. Value Health2008;11.

12. Initial Steps
•Estimate hemodynamics
•Volume resuscitate
•Rectal exam
•Identify high risk patients
•Early endoscopy is key
–Within 24 hours
–High risk window 72 hours from presentation

13. Initial Steps
•Understand anti-coagulation history
•Assess level of care and airway
•Make a differential diagnosis
•Find old endoscopy reports

14. Melena
Courtesy of Joseph Thomas, MD

15. Hematochezia
Courtesy of Joseph Thomas, MD

16. Maroon Stools
Courtesy of Joseph Thomas, MD

17. UGIB: Brief DDx
•Peptic ulcer disease
–H. pylori
–NSAIDs
–Malignancy
•Mallory-Weiss tear
•Erosive esophagitis
•Erosive gastritis
•Esophageal ulcers

18. UGIB: Brief DDx
•Vascular malformations
–Angiodysplasiain CRI
–Dieulafoy’slesion (submucosalarteriole)
–GAVE
–PHG
•Miscellaneous
–AE fistula
–Pancreatic pseudoaneurysm
–Hemobilia

19. Varices
•Some adjustments to protocol
–Octreotidedrip
•Decrease splanchnic blood flow
•Reduce portal pressure
–Antibiotics
–Lower transfusion requirement
–Correcting coagulopathy if appropriate
–Intubate

20. LGIB: Brief DDx
•Diverticulosis
•Angiodysplasia
•Neoplastic disease
•Colitis
–Ischemia, infection, XRT, IBD
•Internal hemorrhoids
•Solitary rectal ulcer
•UGIB

21. Risk Stratification
•Important way to predict who might do poorly
•RockallScore
–Age
–Shock (HR, BP)
–Coexisting illness
–Add endoscopic component
•Diagnosis
•High risk stigmata

22. GralnekIM et al. NEJM2008; 359.

23. Endoscopic Stigmata of Bleeding Peptic Ulcer, Classified as High Risk or Low Risk.
Gralnek IM et al. N Engl J Med 2008;359:928-937.
GralnekIM et al. NEJM2008; 359.

24. Basic Endoscopic Therapy
•Injection AND
–Thermal (e.g. heater probe, APC) OR
–Mechanical (e.g. clip)
•Thermal or mechanical alone
•For varices,
–Band ligation

25. Why PPI’s?
•Goal of PPI therapy is to raise the gastric PH
•High dose PPI infusion decreases basal and stimulated
acid secretion by parietal cells
•Cochrane meta-analysis that included 6 RCT from 1992-
2007 found that IV PPI prior to endoscopy did NOT
experience any statistically significant differences in
outcomes of mortality, rebleeding, or progression to
surgery.
•However, analysis did show that PPI therapy resulted in
significantly reduced rates of high risk stigmata
identified on endoscopy and need for endoscopic
therapy.
Courtesy of Joseph Thomas, MD

26. Post-Endoscopy
•High risk lesions
–PPI infusion for 72 hours after endoscopic
hemostasis
–Technically
•Can advance diet to clears after 6 hours (if
hemodynamic instability)
•Can go to oral PPI after infusion complete
•Discuss with GI consultant
–No role for repeat endoscopy in 24 hours; relook if
rebleed

27. Post-Endoscopy
•Varices
–Octreotideinfusion for up to 5 days in conjunction
with band ligation
1
•Result of meta-analysis
•5 day period highest for re-bleed
–Antibiotics for 1 week
•For non-varicealbleeding
–H pyloritesting (preferably from mucosal biopsy)
1
Banales R et al. Hepatology2002; 305.

28. What if Endoscopy Fails?
•IR
–Tagged RBC scan
•Bleeding > 0.1 ml/min
–Angiography
•Need localization
•Renal contrast load
•Bleeding 0.5-1.5 ml/min (CT angiography)
•Can be therapeutic
–Embolization

29. What if Endoscopy Fails?
•Surgery
–Uncontrolled bleeding
–Recurrent diverticular bleeding
–Get on board early

30. GastroHepSlide Atlas, www.gastrohep.com

31. GastroHepSlide Atlas, www.gastrohep.com

32. GastroHepSlide Atlas, www.gastrohep.com

33. GastroHepSlide Atlas, www.gastrohep.com

34. GastroHepSlide Atlas, www.gastrohep.com

35. GastroHepSlide Atlas, www.gastrohep.com

36. GastroHepSlide Atlas, www.gastrohep.com

37. Summary
While “all bleeding eventually stops…”
•Assess
•Resuscitate
•Risk-stratify
•Form a differential diagnosis
•Be particularly vigilant in the first 24 hours