10/6- GI Hemorrhage

Question 1

What is “upper” GI bleeding?

• What percentage of GI bleeding cases does it account for?

Answer 1

Bleeding proximal to the ligament of Treitz

• 50% of admissions for GI bleeding

Question 2

Etiology of upper GI bleeding?

Answer 2

• Peptic ulcer – 38%
• Varices – 16%
• Esophagitis – 13%
• Malignancy – 7%
• AVM – 6%
• Mallory-Weiss Tear – 4%
• Erosions – 4%
• Dieulafoy’s – 2%
• Unknown – 8%

Question 3

What is this?

Answer 3

Esophageal cancer

Question 4

What is this?

Answer 4

Mallory-Weiss tear (GE junction)

Question 5

What is this?

Answer 5

NG tube trauma

Question 6

What causes the majority of peptic ulcer disease?

Answer 6

1. H. pylori infection
2. NSAID use

Question 7

What is the pathophysiology behind bleeding in cirrhosis?

Answer 7

Portal hypertension develops from:

• increased resistance to flow due to the architectural distortion of the liver along with
• intrahepatic vasoconstriction from decreased nitric oxide

Results in porto-systemic collaterals

• Hepatic venous pressure gradient (HVPG)
• Normal 3-5mmHg
• Esophageal varices develop above 10-12mmHG
• Varices present in 50% of cirrhotics, presence correlates with severity of liver disease
• Varices appear at 8% per year, small become large at 8% per year
• Variceal hemorrhage 5-15% per year, risk associated with large varices, decompensated cirrhosis, and red wale signs
• Variceal bleeding = 20% mortality at 6 weeks
• Gastric varices in 5-33% of patients with portal hypertension, 25% bleeding risk in 2 years

Question 8

What is portal hypertensive gastropathy?

Answer 8

Chronic slow blood loss/anemia

Question 9

What is gastric antral vascular ectasia?

Answer 9

Anemia; does not respond to TIPS/b-blockers

Question 10

What is this?

Answer 10

Snake skin appearance of portal hypertensive gastropathy

Question 11

What is this?

Answer 11

“Watermelon stomach” of gastric antral vascular ectasia

Question 12

What should be covered in the history for evaluating upper GI bleeding?

Answer 12

• Prior bleeding episodes, from what source?
• Alcohol use
• History of liver disease
• GERD
• Weight loss, N/V, family history malignancy

Question 13

What medications may contribute to upper GI bleeding?

Answer 13

• Ulcers can develop within a week of starting aspirin/NSAIDs

Combination antiplatelets/anticoagulants

• Aspirin and clopidogrel
• Aspirin and warfarin
• Aspirin, clopidogrel, and warfarin
• Dabigatran, rivaroxaban

Question 14

What should the physical exam cover in the evaluation of upper GI bleeding?

Answer 14

• Vital signs
• Tachycardia
• Orthostasis – at least 15% blood loss
• Supine hypotension – 40% blood loss
• Signs of chronic liver disease
• NG tube: possibly wash and see if blood comes back
• Stool examination

Question 15

What are the benefits of Fecal Occult Blood testing?

• What is it not diagnostic for?

Answer 15

• Has been shown to reduce mortality from colorectal cancer
• Cancer detection test – recommended as an alternative to patients who decline a cancer prevention test (colonoscopy)
• No role in evaluation of a patient presenting with GI bleeding

Question 16

What are the important lab results in evaluating upper GI bleeding?

Answer 16

• H/H - BUN (prerenal rise in BUN)
• PT/INR
• Evidence of chronic liver disease and/or portal hypertension (bilirubin, albumin, INR, platelets)

Question 17

What four questions should you ask yourself in the clinical assessment of someone with upper GI bleeding?

Answer 17

Is this a GI bleed?

• Combo of history, lab values, and vital signs which come together to make a believable story

Is this an active bleed?

• Ongoing hematemesis or melena, continued hemodynamic instability, failure to respond to transfusion (taking into account resuscitation)

Where is the source?

Is the patient stable?

Question 18

What signs point to the location of GI bleeding?

Answer 18

- Hematemesis/coffee ground emesis: upper GI source

- Melena: upper GI through proximal colon

- Hematochezia: brisk upper GI through rectal bleeding

• Negative NG lavage does NOT exclude an upper GI source

Question 19

What are prognostic scores of upper GI bleeding: Rockall?

Answer 19

0-3

• Based on age, shock, comorbidity, diagnosis, major SRH…

Question 20

What are prognostic scores of upper GI bleeding: Blatchford?

Answer 20

Based on:

• Blood urea
• Hemoglobin
• Systolic BP
• Other markers

Question 21

What are prognostic scores of upper GI bleeding: AIMS 65 Score?

Answer 21

1 point (5 max) for:

• Albumin under 3.0 mg/dL
• INR > 1.5
• Altered mental status
• SBP under 90 mmHg
• Age > 65 yo

Question 22

What is treatment for upper GI bleeding?

Answer 22

Hospitalization

• Admission
• ICU vs. floor
• Suspected variceal bleeding Intubation
• Encephalopathic cirrhotic
• Prophylactic for EGD?

Resuscitation!

Transfusion

Medical therapy

Endoscopy

Question 23

Adequate vs. inadequate resuscitation?

Answer 23

Left: inadequate

Right: adequate

Question 24

Transfusion strategies for upper GI bleed?

Answer 24

Restrictive strategy (7 g/dL to goal 7-9) was better than liberal (9 g/dL to goal 9-11) strategies

Hazard ratios with restrictive strategy:

• Death within 45 days 0.55 (95% CI 0.33 – 0.92)
• Further bleeding 0.62 (0.43 – 0.91)
• Adverse events 0.73 (0.56 – 0.95)

Question 25

What is medical therapy prior to endoscopy in a non-cirrhotic patient with an upper GI bleed?

Answer 25

**Proton pump inhibitor drip** (omeprazole, esomeprazole, pantoprazole) **Reduce acid** - Allow normal platelet aggregation for hemostasis - Allow ulcer/esophagitis to heal

Question 26

What is medical therapy prior to endoscopy in a cirrhotic patient with an upper GI bleed?

Answer 26

**Octreotide** (somatostatin analog) - Reduce portal pressures **Antibiotics** (ceftriaxone or ciprofloxacin) - Prophylaxis against spontaneous bacterial peritonitis (SBP) and bacteremia PPI – cirrhotics can also have ulcers

Question 27

What is the goal of antisecretory therapy? How is it accomplished?

Answer 27

Goal is pH \> 6 to allow normal platelet aggregation - IV PPI bolus/infusion is the most effective

Question 28

What is the most important medical treatment in upper GI bleeds?

Answer 28

Antibiotics in the cirrhotic patient - This actually improves mortality

Question 29

What is the significance of timing with an endoscopy?

Answer 29

- Generally low quality evidence - Earlier endoscopy = more likely to find high risk stigmata -\> more likely to receive endoscopic therapy - Patients with UGIB should undergo endoscopy within 24 hours - Patients with high risk features may have improved clinical outcomes with endoscopy within 12 hours

Question 30

What is the purpose of performing an endoscopy?

Answer 30

- Diagnosis - Risk stratification - Endoscopic therapy

Question 31

What are conditions requiring post-endoscopy meds?

Answer 31

- Peptic ulcer diseas - Varices

Question 32

What is seen here?

Answer 32

Clean base

Question 33

What is seen here?

Answer 33

Flat red spots; low risk

Question 34

What is seen here?

Answer 34

Adherent plaque; need to remove and find ulcer

Question 35

What is seen here?

Answer 35

Visceral area; protuberant instead of flat - Much higher risk

Question 36

What is seen here?

Answer 36

Left: adherent clot Right: treated?

Question 37

What is seen here?

Answer 37

Actively bleeding/oozing ulcer

Question 38

What is seen here?

Answer 38

Active arterial spurting; very high risk

Question 39

**T/F**: IV PPI after endoscopic treatment of bleeding ulcers improves need for surgery and 30 day mortality

Answer 39

**False**; does neither

Question 40

What are some other considerations after treatment of bleeding ulcers?

Answer 40

**Ensure follow-up of H. pylori testing** (serology or biopsy) with treatment and confirmation of eradication - Amox/clari/metro/PPI - Bismuth/tetracycline/metro/PPI **Restart aspirin** prior to discharge in patients who have a good indication

Question 41

What is seen here?

Answer 41

Whale sign; visible vessel

Question 42

What is seen here?

Answer 42

We treat peptic ulcers with banding (?)

Question 43

What is after treatment for varices?

Answer 43

- Continue prophylactic antibiotics to complete a maximum of 7 days - Continue octreotide to complete 3-5 days - PPI for prophylaxis against banding ulcer bleeding - Repeat endoscopy for ablation of varices

Question 44

What should be done when endoscopy fails?

Answer 44

Refractory ulcer bleeding - High risk ulcers Refractory variceal bleeding - Gastric varices when cyanoacrylate not available - Esophageal varices that fail endoscopic therapy Interventional radiology and surgery

Question 45

What are the main causes of lower GI bleeding?

Answer 45

- Diverticulosis (30%) - Hemorrhoids (14%) - Ischemic (12%) - IBD (9%) - Post-polypectomy (8%) - Colon cancer/polyps (6%) - Rectal ulcer (6%) - Vascular ectasia (3%) - Radiation colitis/proctitis (3%) - Other (6%)

Question 46

What should be considered in the history when evaluating a lower GI bleed?

Answer 46

- Abdominal pain, diarrhea, weight loss - History of IBD (Crohn’s, ulcerative colitis) - History of GI malignancy - Recent colonoscopy (with polypectomy) - Radiation to prostate - Abdominal aortic aneurysm _Consider upper GI source_ - 15% of cases of hematochezia from upper GI source - Significant hematochezia with orthostasis or hypotension requires EGD - Consider NG lavage Can have melena from small bowel or right colon (may also need colonoscopy, especially if EGD negative)

Question 47

What is management for lower GI bleeding?

Answer 47

**Resuscitation, transfusion** **Colonoscopy** - Therapeutic - Can find non-bleeding stigmata - Visualization may be limited by blood **Tagged RBC scan** (0.04 mL/min) - Safe, only diagnostic - Requires active bleeding **Angiography** (0.5 mL/min) - Therapeutic - Requires active bleeding - Risks of contrast dye **Surgery** - Need to localize and identify source prior to surgery - Malignancy - Recurrent diverticular bleeding

Question 48

Endoscopy treatment for varices and ulcers?

Answer 48

Varices: banding Ulcers: - Metal clip - Epenephrine