Practical Approach to Acute Gastrointestinal Bleeding

1
Practical Approach to Acute Gastrointestinal
Bleeding

• Christopher S. Huang MD
• Assistant Professor of Medicine
• Boston University School of Medicine
• Section of Gastroenterology
• Boston Medical Center

2
Learning Objectives

• UGIB
• Nonvariceal (PUD) and variceal
• Resuscitation, risk assessment, pre-endoscopy
  management
• Role of endoscopy
• Post-endoscopy management
• LGIB
• Risk assessment
• Role and timing of colonoscopy
• Non-endoscopic diagnostic and treatment options

3
Definitions

• Upper GI bleed arising from the esophagus,
  stomach, or proximal duodenum
• Mid-intestinal bleed arising from distal
  duodenum to ileocecal valve
• Lower intestinal bleed arising from colon/rectum

4
Stool color and origin/pace of bleeding

• Guaiac positive stool
• Occult blood in stool
• Does not provide any localizing information
• Indicates slow pace, usually low volume bleeding
• Melena
• Very dark, tarry, pungent stool
• Usually suggestive of UGI origin (but can be
  small intestinal, proximal colon origin if slow
  pace)
• Hematochezia
• Spectrum bright red blood, dark red, maroon
• Usually suggestive of colonic origin (but can be
  UGI origin if brisk pace/large volume)

5
Case Vignette CC

• 68 yo male presents with a chief complaint of a
  large amount of bleeding from the rectum

6
Case Vignette - HPI

• Describes bleeding as large volume, very dark
  maroon colored stool
• Has occurred 4 times over past 3 hours
• He felt light headed and nearly passed out upon
  trying to get up to go the bathroom

7
Case Vignette - HPI

• Denies abdominal pain, nausea, vomiting,
  antecedent retching
• No history of heartburn, dysphagia, weight loss
• No history of diarrhea or constipation/hard
  stools
• No prior history of GIB
• Screening colonoscopy 10 years ago no polyps,
  () diverticulosis

8
Case Vignette PMHx, Meds

• Hepatitis C
• CAD h/o MI
• PVD
• AAA s/p elective repair 3 years ago
• HTN
• Hypercholesterolemia
• Lumbago

• Medications
• Aspirin
• Clopidogrel
• Atorvastatin
• Atenolol
• Lisinopril

9
Case Vignette Physical Exam

• Physical examination
• BP 105/70, Pulse 100, () orthostatic changes
• Alert and mentating, but anxious appearing
• Anicteric
• Mid line scar, benign abdomen, nontender liver
  edge palpable in epigastrium, no splenomegaly
• Rectal examination no masses, dark maroon blood

10
Case Vignette - Labs

• Labs
• Hct 21 (Baseline 33)
• Plt 110K
• BUN 34, Cr 1.0
• Alb 3.5
• INR 1.6
• ALT 51, AST 76

11
Initial Considerations

• Differential diagnosis?
• What is most likely source?
• What diagnosis can you least afford to miss?
• How sick is this patient? (risk stratification)
• Determines disposition
• Guides resuscitation
• Guides decision re need for/timing of endoscopy

12
Differential Diagnosis Upper GIB

• Peptic ulcer disease
• Gastroesophageal varices
• Erosive esophagitis/gastritis/duodenitis
• Mallory Weiss tear
• Vascular ectasia
• Neoplasm
• Dieulafoys lesion
• Aortoenteric fistula
• Hemobilia, hemosuccus pancreaticus

Most common
Rare, but cannot afford to miss
13
Differential Diagnosis Lower GIB
Most common diagnosis

• Diverticulosis
• Angioectasias
• Hemorrhoids
• Colitis (IBD, Infectious, Ischemic)
• Neoplasm
• Post-polypectomy bleed (up to 2 weeks after
  procedure)
• Dieulafoys lesion

14
History and Physical

• History

• Physical Examination

• Vital signs, orthostatics
• Abdominal tenderness
• Skin, oral examination
• Stigmata of liver disease
• Rectal examination
• Objective description of stool/blood
• Assess for mass, hemorrhoids
• No need for guaiac test

• Localizing symptoms
• History of prior GIB
• NSAID/aspirin use
• Liver disease/cirrhosis
• Vascular disease
• Aortic valvular disease, chronic renal failure
• AAA repair
• Radiation exposure
• Family history of GIB

15
History and Physical

• History

• Physical Examination

• Vital signs, orthostatics
• Abdominal tenderness
• Skin, oral examination
• Stigmata of liver disease
• Rectal examination
• Objective description of stool/blood
• Assess for mass, hemorrhoids
• No need for guaiac test

• Localizing symptoms
• History of prior GIB
• NSAID/aspirin use
• Liver disease/cirrhosis
• Vascular disease
• Aortic valvular disease, chronic renal failure
• AAA repair
• Radiation exposure
• Family history of GIB

16
Take Home Point 1
Always get objective description of stool
Avoid noninformative terms such as grossly
guaiac positive
17
Take Home Point 2
If you need a card to tell you whether theres
blood in the stool, its NOT an acute GIB
18
Narrowing the DDx Upper or Lower Source?

• Predictors of UGI source
• Age lt50
• Melenic stool
• BUN/Creatinine ratio
• If ratio 30, think upper GIB

J Clin Gastroenterol 199012500 Am J
Gastroenterol 1997921796 Am J Emerg Med
200624280
19
Utility of NG Tube

• Most useful situation patients with severe
  hematochezia, and unsure if UGIB vs. LGIB
• Positive aspirate (blood/coffee grounds)
  indicates UGIB
• Can provide prognostic info
• Red blood per NGT predictive of high risk
  endoscopic lesion
• Coffee grounds less severe/inactive bleeding
• Negative aspirate not as helpful 15-20 of
  patients with UGIB have negative NG aspirate

Ann Emerg Med 200443525 Arch Intern Med
19901501381 Gastrointest Endosc 200459172
20
Take Home Point 3
Upper GI bleed must still be considered in
patients with severe hematochezia, even if NG
aspirate negative
21
Initial Assessment

• Always remember to assess A,B,Cs
• Assess degree of hypovolemic shock

Class I Class II Class III Class IV
Blood loss (mL) 750 750-1500 1500-2000 gt2000
Blood volume loss () lt 15 15-30 30-40 gt40
Heart rate lt100 gt100 gt120 gt140
SBP No change Orthostatic change Reduced Very low, supine
Urine output (mL/hr) gt30 20-30 10-20 lt10
Mental status Alert Anxious Aggressive/drowsy Confused/unconscious
22
Resuscitation

• IV access large bore peripheral IVs best (alt
  cordis catheter)
• Use crystalloids first
• Anticipate need for blood transfusion
• Threshold should be based on underlying
  condition, hemodynamic status, markers of tissue
  hypoxia
• Should be administered if Hgb 7 g/dL
• 1 U PRBC should raise Hgb by 1 (HCT by 3)
• Remember that initial Hct can be misleading (Hct
  remains the same with loss of whole blood, until
  re-equilibration occurs)
• Correct coagulopathy

23
Resuscitation

• IV access large bore peripheral IVs best (alt
  cordis catheter)
• Use crystalloids first
• Anticipate need for blood transfusion
• Threshold should be based on underlying
  condition, hemodynamic status, markers of tissue
  hypoxia
• Should be administered if Hgb 7 g/dL
• 1 U PRBC should raise Hgb by 1 (HCT by 3)
• Remember that initial Hct can be misleading (Hct
  remains the same with loss of whole blood, until
  re-equilibration occurs)
• Correct coagulopathy

24
Transfusion Strategy

• Randomized trial
• 921 subjects with severe acute UGIB
• Restrictive (tx when Hgblt7 target 7-9) vs.
  Liberal (tx when Hgblt9 target 9-11)
• Primary outcome all cause mortality rate within
  45 days

NEJM 201336811-21
25
Restrictive Strategy Superior
Restrictive Liberal P value
Mortality rate 5 9 0.02
Rate of further bleeding 10 16 0.01
Overall complication rate 40 48 0.02
Benefit seen primarily in Child A/B cirrhotics
NEJM 201336811-21
26
Resuscitation

• IV access large bore peripheral IVs best (alt
  cordis catheter)
• Use crystalloids first
• Anticipate need for blood transfusion
• Threshold should be based on underlying
  condition, hemodynamic status, markers of tissue
  hypoxia
• Should be administered if Hgb 7 g/dL
• 1 U PRBC should raise Hgb by 1 (HCT by 3)
• Remember that initial Hct can be misleading (Hct
  remains the same with loss of whole blood, until
  re-equilibration occurs)
• Correct coagulopathy

Weigh risks and benefits of reversing
anticoagulation Assess degree of
coagulopathy Vitamin K slow acting, long-lived
FFP fast acting, short lived - Give 1 U FFP
for every 4 U PRBCs
27
Resuscitation

• Early intensive resuscitation reduces mortality
• Consecutive series of patients with
  hemodynamically significant UGIB
• First 36 subjects Observation Group (no
  intervention)
• Second 36 subjects Intensive Resuscitation
  Group (intense guidance provided) goal was to
  decrease time to correction of hemodynamics, Hct
  and coagulopathy

Am J Gastroenterol 200499619
28
Early Intensive Resuscitation Reduces UGIB
Mortality
Intervention Faster correction of hemodynamics,
Hct and coags. Time to endoscopy similar
Am J Gastroenterol 200499619
(groups are essentially the same)
29
Early Intensive Resuscitation Reduces UGIB
Mortality

• Observation group
• 5 MI
• 4 deaths
• Intense group
• 2 MI
• 1 death (sepsis)

Am J Gastroenterol 200499619
30
Causes of Mortality in Patients with Peptic Ulcer
Bleeding

• Patients rarely bleed to death
• Prospective cohort study gt10,000 cases of peptic
  ulcer bleed
• Mortality rate 6.2
• 80 of deaths not related to bleeding

Am J Gastroenterol 201010584
31
Causes of Mortality in Patients with Peptic Ulcer
Bleeding

• Most common causes of non-bleeding mortality
• Terminal malignancy (34)
• Multiorgan failure (24)
• Pulmonary disease (24)
• Cardiac disease (14)

Am J Gastroenterol 201010584
32
Take Home Point 4
Early resuscitation and supportive measures are
critical to reduce mortality from UGIB
33
Risk Stratification

• Identify patients at high risk for adverse
  outcomes
• Helps determine disposition (ICU vs. floor vs.
  outpatient)
• May help guide appropriate timing of endoscopy

34
Rockall Scoring System

• Validated predictor of mortality in patients with
  UGIB
• 2 components clinical endoscopic

Variable 0 1 2 3
Age lt60 60-79 80
Shock No SBP 100 Plt100 Tachy- SBP 100 Pgt100 Hypotension- SBP lt100
Comorbidity No major Cardiac failure, CAD, other major Renal failure, liver failure, malignancy
Gut 199638316
35
Clinical Rockall Score Mortality Rates
36
AIMS65

• Simple risk score that predicts in-hospital
  mortality, LOS, cost in patients with acute UGIB

Albumin lt3.0 INR gt 1.5 Mental status
altered Systolic BP lt90 65 years old
Gastrointest Endosc 2011741215
37
AIMS65
Gastrointest Endosc 2011741215
38
Blatchford Score

• Predicts need for endoscopic therapy
• Based on readily available clinical and lab data
• Can use UpToDate calculator

Lancet 20003561318
39
Blatchford Score
Gastrointest Endosc 2010711134
40
Blatchford Score

• Most useful for safely discriminating low risk
  UGIB patients who will likely NOT require
  endoscopic hemostasis
• Fast track Blatchford patient at low risk if

BUN lt 18 mg/dL Hgb gt 13 (men), 12 (women) SBP
gt100 HR lt 100
41
Pre-endoscopic Pharmacotherapy

• For Non-Variceal UGIB
• IV PPI 80 mg bolus, 8 mg/hr drip
• Rationale suppress acid, facilitate clot
  formation and stabilization
• Duration at least until EGD, then based on
  findings

42
Pre-endoscopy PPI

• Reduces the proportion of patients with high risk
  endoscopic stigmata (downstages lesion)
• Decreases need for endoscopic therapy
• Has not been shown to reduce rebleeding, surgery,
  or mortality rates

High risk
Low risk
Endoscopic treatment required Omeprazole 19
(23 of PUD) Placebo 28 (37 of PUD)
N Engl J Med 20073561631
43
Endoscopy - Nonvariceal UGIB

• Early endoscopy (within 24 hours) is recommended
  for most patients with acute UGIB
• Achieves prompt diagnosis, provides risk
  stratification and hemostasis therapy in
  high-risk patients

J Clin Gastroenterol 199622267 Gastrointest
Endosc 199949145 Ann Intern Med 2010152101
44
When is Endoscopic Therapy Required?

• 80 bleeds spontaneously resolve
• Endoscopic stigmata of recent hemorrhage

Stigmata Continued/rebleeding rate
Active bleeding 55-90
Nonbleeding visible vessel 40-50
Adherent clot Variable, depending on underlying lesion 0-35
Flat pigmented spot 7-10
Clean base lt 5
major
45
Major Stigmata Active Spurting
Kelsey, PB (Dec 04 2003). Duodenum - Ulcer,
Arterial Spurting, Treated with Injection and
Clip. The DAVE Project. Retrieved Aug, 1, 2010,
from http//daveproject.org/viewfilms.cfm?film_id
39
46
Major Stigmata - NBVV
47
Adherent Clot

• Role of endoscopic therapy of ulcers with
  adherent clot is controversial
• Clot removal usually attempted
• Underlying lesion can then be assessed, treated
  if necessary

48
Minor Stigmata

• Flat pigmented spot

• Clean base

Low rebleeding risk no endoscopic therapy needed
49
Endoscopic Hemostasis Therapy

• Epinephrine injection
• Thermal electrocoagulation
• Mechanical (hemoclips)
• Combination therapy superior to monotherapy

Kelsey, PB (Nov 08 2005). Stomach - Gastric
Ulcer, Visible Vessel. The DAVE Project.
Retrieved Aug, 1, 2010, from http//daveproject.or
g/viewfilms.cfm?film_id306
Baron, TH (May 01 2007). Duodenum - Bleeding
Ulcer Treated with Thermal Therapy, Perforation
Closed with Hemoclips. The DAVE Project.
Retrieved Aug, 1, 2010, from http//daveproject.or
g/viewfilms.cfm?film_id620
50
Nonvariceal UGIB Post-endoscopy management

• Patients with low risk ulcers can be fed
  promptly, put on oral PPI therapy.
• Patients with ulcers requiring endoscopic therapy
  should receive PPI gtt x 72 hours
• Significantly reduces 30 day rebleeding rate vs
  placebo (6.7 vs. 22.5)
• Note there may not be major advantage with high
  dose over non-high dose PPI therapy

N Engl J Med 2000343310 Arch Intern Med
2010170751
51
Nonvariceal UGIB Post-endoscopy management

• Determine H. pylori status in all ulcer patients
• Discharge patients on PPI (once to twice daily),
  duration dictated by underlying etiology and need
  for NSAIDs/aspirin
• In patients with cardiovascular disease on low
  dose aspirin restart as soon as bleeding has
  resolved
• RCT demonstrates increased risk of rebleeding
  (10 v 5) but decreased 30 day mortality (1.3 v
  13)

Ann Intern Med 20101521
52
Nonvariceal UGIB Post-endoscopy management

• Determine H. pylori status in all ulcer patients
• Discharge patients on PPI (once to twice daily),
  duration dictated by underlying etiology and need
  for NSAIDs/aspirin
• In patients with cardiovascular disease on low
  dose aspirin restart as soon as bleeding has
  resolved
• RCT demonstrates increased risk of rebleeding
  (10 v 5) but decreased 30 day mortality (1.3 v
  13)

Not dying is more important than not rebleeding
Ann Intern Med 20101521
53
Variceal Bleeding

• Occurs in 1/3 of patients with cirrhosis
• 1/3 initial bleeding episodes are fatal
• Among survivors, 1/3 will rebleed within 6 weeks
• Only 1/3 will survive
• 1 year or more

54
Predictors of large esophageal varices

• Severity of liver disease (Child Pugh)
• Platelet count lt 88K
• Palpable spleen
• Platelet count/spleen diameter (mm) ratio lt909

Gut 2003521200 J Clin Gastroenterol
201044146 J Gastroenterol Hepatol
2007221909 Arch Intern Med 20011612564 Am J
Gastroenterol 1999943103
55
VARICEAL Bleed

• Vasoconstrictor therapy
• Antibiotics
• Resuscitation
• ICU level care
• Endoscopy
• ALternative/Rescue therapies
• Beta blockade

56
Vasoconstrictor therapy

• Goal Reduce splanchnic blood flow
• Terlipressin only agent shown to improve
  control of bleeding and survival in RCTs and
  meta-analysis
• Not available in US
• Vasopressin nitroglycerine too many adverse
  effects
• Somatostatin not available in US
• Octreotide (somatostatin analogue)
• Decreases splanchnic blood flow (variably)
• Efficacy is controversial no proven mortality
  benefit
• Standard dose 50 mcg bolus, then 50 mcg/hr drip
  for 3-5 days

Gastroenterology 2001120946 Cochrane Database
Syst Rev 200816CD000193 N Engl J Med
1995333555 Am J Gastroenterol 2009104617
57
Antibiotics

• Bacterial infection occurs in up to 66 of
  patients with cirrhosis and variceal bleed
• Negative impact on hemostasis (endogenous
  heparinoids)
• Prophylactic antibiotics reduces incidence of
  bacterial infection, significantly reduces early
  rebleeding
• Ceftriaxone 1 g IV QD x 5-7 days
• Alt Norfloxacin 400 mg po BID

Hepatology 200439746 J Korean Med Sci
200621883 Hepatogastroenterology 200451541
58
Resuscitation

• Promptly but with caution
• Goal maintain hemodynamic stability, Hgb 7-8,
  CVP 4-8 mmHg
• Avoid excessively rapid overexpansion of volume
  may increase portal pressure, greater bleeding

59
Endoscopy

• Should be performed as soon as possible after
  resuscitation (within 12 hours)
• Endotracheal intubation frequently needed
• Band ligation is preferred method

Layer, L. Jaganmohan, S. Raju, GS DuPont,
AW (Oct 28 2009). Esophagus - Band Ligation of
Actively Bleeding Gastroesophageal Varices. The
DAVE Project. Retrieved Aug, 2, 2010, from
http//daveproject.org/viewfilms.cfm?film_id715
60
ALternative/Rescue therapies

• TIPS Transjugular Intrahepatic Portosystemic
  Shunt
• Early placement of shunt (within 24-72hrs)
  associated with improved survival among high-risk
  patients
• Preferred treatment for gastric variceal bleeding
  (rule out splenic vein thrombosis first)

Fan, C. (Apr 25 2006). Vascular Interventions in
the Abdomen New Devices and Applications. The
DAVE Project. Retrieved Aug, 2, 2010, from
http//daveproject.org/viewfilms.cfm?film_id497
Hepatology 200440793 Hepatology
200848Suppl373A N Engl J Med. 2010 Jun
243622370
61
TIPSembolization of gastric varices
62
ALternative/Rescue therapies

• Sengstaken-Blakemore Tube

• Very effective for immediate, temporary control
• High complication rate aspiration, migration,
  necrosis perforation of esophagus
• Use as bridge to TIPS within 24 hours
• Airway protection strongly recommended

63
ALternative/Rescue therapies

• Self-Expanding Metal Stent

• Specially designed covered metal stent
• Tamponades distal esophageal varices
• Removable does not require airway protection
• Very limited data

Gastrointest Endosc 20107171
64
Beta blockade

• Reduces risk for recurrent variceal hemorrhage
• Use nonselective beta blocker (e.g. Nadolol
  splanchnic vasoconstriction, decrease cardiac
  output) and titrate up to maximum tolerated dose,
  HR 50-60
• Start as inpatient, once acute bleeding has
  resolved and patient shows hemodynamic stability

65
Lower GI Bleed

• Bleeding arising from the colorectum
• In patients with severe hematochezia, first
  consider possibility of UGIB
• 10-15 of patients with presumed LGIB are found
  to have upper GIB

66
Lower GI Bleed

• Differential Diagnosis

Large volume, painless
- Diverticulosis ( 1 cause) - Angioectasias -
Hemorrhoids - Colitis (IBD, Infectious,
Ischemic) - Neoplasm - Post-polypectomy -
Dieulafoys lesion
Smaller volume, pain, diarrhea
67
LGIB Risk Stratification

• Predictors of severe LGIB

0 factors 6 risk 1-3 factors 40 gt3
factors 80

• HRgt100
• SBPlt115
• Syncope
• nontender abdominal examination
• bleeding during first 4 hours of evaluation
• aspirin use
• gt2 active comorbid conditions

Arch Intern Med 2003163838 Am J Gastroenterol
20051001821
Defined as continued bleeding within first 24
hours (transfusion of 2 Units, decline in HCT of
20) and/or recurrent bleeding after 24 hours of
stability
68
LGIB Risk Factors for Mortality

• Age
• Intestinal ischemia
• Comorbid illnesses
• Secondary bleeding (developed during admission
  for a separate problem)
• Coagulopathy
• Hypovolemia
• Transfusion requirement
• Male gender

Clinical Gastro Hepatol 200861004
69
Role of Colonoscopy

• Like UGIB, 80 of LGIBs will resolve
  spontaneously of these, 30 will rebleed
• Lack of standardized approach
• Traditional approach
• elective colonoscopy after resolution of
  bleeding, bowel prep low therapeutic benefit
• Angiography for massive bleeding, hemodynamically
  unstable patient
• Urgent colonoscopy approach
• Similar to UGIB identify stigmata of
  hemorrhage, perform therapy

70
Urgent Colonoscopy

• Within 6-12 hours of presentation
• Requires rapid purge prep with 5-6 L Golytely
  administered 1L every 30-45 minutes
• Colonoscopy performed within 1 hour after
  clearance of stool, blood and clots
• Need for bowel prep and risks of procedural
  sedation may be prohibitive in unstable patient

71
Endoscopic Therapy
Srinivasan, R. Luthra, G. Raju, GS (Jul 17
2007). Colon - Endoscopic Hemostasis of
Diverticular Bleed. The DAVE Project. Retrieved
Aug, 3, 2010, from http//daveproject.org/viewfilm
s.cfm?film_id63
72
Urgent Colonoscopy

• Limited high quality evidence of benefit
• Establishes diagnosis earlier, shorter length of
  stay
• Landmark study supporting urgent colonoscopy
  for diverticular bleed published in 2000
• 2 consecutive prospective, non-randomized studies
• Group 1 (n73) urgent colonoscopy, surgical
  therapy
• Group 2 (n48) urgent colonoscopy, endoscopic
  therapy

N Engl J Med 200034278
73
Urgent Colonoscopy

• Group 1 17 pts with definite diverticular bleed
• 9 had recurrent/persistent bleeding
• 6 required emergency surgery
• Group 2 10 pts with definite diverticular bleed
• All 10 patients treated endoscopically
• 0 had recurrent bleed, complications, further
  transfusions, or surgery

N Engl J Med 200034278
74
Urgent Colonoscopy

• Two RCTs published to date
• Compared urgent colonoscopy (within 8 hours) vs.
  standard management

Standard Management Algorithm
Am J Gastroenterol 20051002395
75
Urgent Colonoscopy RCT1
Definite bleeding source identified more
frequently (42 vs 22)
But no significant difference in important
outcomes (but underpowered)
Am J Gastroenterol 20051002395
76
Urgent Colonoscopy RCT2

• 85 patients with serious hematochezia
  (hemodynamically significant, Hgb drop gt 1.5
  g/dL, blood transfusion)
• EGD performed within 6 hours
• If EGD negative, randomized to urgent (lt12 hr) or
  elective (36-60 hr) colonoscopy
• Primary endpoint further bleeding

Am J Gastroenterol 20101052636
77
Urgent Colonoscopy RCT2

• EGD positive in 15
• No evidence of improved clinical outcomes with
  urgent colonoscopy but prespecified sample size
  not reached

Am J Gastroenterol 20101052636
78
Urgent Colonoscopy

• In published series, endoscopic therapy is
  applied in 10-40 of patients undergoing
  colonoscopy for LGIB
• Taken together, evidence suggests that
  colonoscopy should be performed within 12-24
  hours in stable patients
• However, it is unclear how faster timing affects
  major clinical outcomes

79
Radiographic Studies

• Tagged RBC scan

• Noninvasive, highly sensitive (0.05-0.1 ml/min)
• Ability to localize bleeding source correctly
  only 66
• More accurate when positive within 2 hours
  (95-100)
• Lacks therapeutic capability

Coordinate with IR so that positive scan is
followed closely by angiography
80
Radiographic Studies

• Angiography

• Detects bleeding rates of 0.5-1 ml/min
• Therapeutic capability embolization with
  microcoils, polyvinyl alcohol, gelfoam
• Complications bowel infarction, renal failure,
  hematomas, thromboses, dissection

Recommended test for patients with brisk bleeding
who cannot be stabilized or prepped for
colonoscopy (or have had colonoscopy with failure
to localize/treat bleeding site)
81
Radiographic Studies

• Multi-Detector CT (CT angio)

• Readily available, can be performed in ER within
  10 minutes
• Can detect bleeding rate of 0.5 ml/min
• Can localize site of bleeding (must be active)
  and provide info on etiology
• Useful in the actively bleeding but
  hemodynamically stable patient

Gastrointest Endosc 201072402
82
Role of Surgery

• Reserved for patients with life-threatening bleed
  who have failed other options
• General indications hypotension/shock despite
  resuscitation, gt6 U PRBCs transfused
• Preoperative localization of bleeding source
  important

83
Algorithmic Evaluation of Patient with
Hematochezia
Hematochezia
Assess activity of bleed
active
inactive
NG lavage
Prep for Colonoscopy
Positive
Negative
No risk for UGIB
Risk for UGIB
EGD
Hemodynamically stable?
negative
Treat lesion
positive
84
Algorithmic Evaluation of Patient with
Hematochezia
Active Lower GIB
85
Take Home Points

• Always get objective description of stool color
  (best way examine it yourself)
• Dont order guaiac tests on inpatients
• Severe hematochezia can be from UGIB, even if NG
  lavage is negative

86
Take Home Points

• All bleeding eventually stops (and majority of
  nonvariceal bleeds will stop spontaneously, with
  the patient alive)
• Early resuscitation and supportive care are key
  to reducing morbidity and mortality from GIB