Post on 13-Dec-2015
Management of Gastrointestinal Bleeding in 2015
WITH SPECIAL FOCUS ON GI BLEEDING IN PATIENTS WITH LEFT VENTRICULAR ASSIST DEVICES (LVAD)
Gastrointestinal Bleeding is a Common Medical Condition
250K-500K hospital admissions per year UGI bleeding incidence is 100/100,000 adults
Incidence increases 20-30 fold from the third to ninth decade of life
LGI bleeding incidence 20/100,000 adults Overwhelmingly disease of the elderly
GI bleeding stops spontaneously in 80%
Costs
Average hospital costs exceed $5000 per admission
Most of this for hospital bed and ICU stays rather than physician fees, blood products, diagnostic tests and medications
Goal is to reduce hospital admission and LOS in order to reduce costs
Morbidity Data
Majority will receive blood transfusions 2-10% require urgent surgery to arrest the
bleeding Average LOS 4-7 days Mortality rates for UGI bleeding 2-15% Mortality for patients who develop bleeding
after admission to hospital for another reason is 20-30%
Causes of acute upper gastrointestinal bleeding
CommonGastric ulcerDuodenal ulcerEsophageal varicesMallory-Weiss tear
Less commonGastric erosive/gastropathyEsophagitisCameron lesionsDieulafoy lesionTelangiectasiasPortal hypertensive gastropathyGastric antral vascular ectasia (watermelon stomach)Gastric varicesNeoplasms
RareDuodenitis, esophageal ulcer, aortoenteric fistula, Crohn's disease, hemobilia, pancreatic disease
Causes of acute lower gastrointestinal bleedingCommonColonic diverticulaAngioectasiaLess commonColonic neoplasms (including post polypectomy bleeding)Inflammatory bowel diseaseColitisIschemicRadiationUnspecified (infectious or non specific)HemorrhoidsSmall bowel sourceUpper gastrointestinal source
RareDieulatory lesion, Colonic ulcerations, Rectal varices
Facts about UGI bleeding
Hematemesis occurs 25% of the time Melena alone occurs 25% of the time--require
50cc -100cc of blood to have melena Hematochezia occurs only 15% in a massive
UGI bleed Elevated BUN out of proportion to the creatinine
is a good marker for an UGI bleed NGT may miss an active bleeding duodenal
ulcer bleed
Facts about Lower GI bleeding
Frank red blood indicates a brisk LGI bleed
Melena can mean a right sided bleed
Most lower GI bleeding is self limited
Lower GI bleeding is mostly painless
Diverticulosis is the main cause for significant LGI bleeding
Assessment of Patient with Acute GI Bleeding
Assess hemodynamics and resuscitate Keep Hgb >= 7 gm/dL Assess level of risk
Timing of endoscopy
Timing of discharge
Level of care
Possible discharge from ED based on certain criteria: BUN <18.2 mg/dL
Hgb > 13 mg/dL (M)/ 12 mg/dL (F)
SBP > 110 mm Hg and HR < 100
absence of melena, syncope, cardiac failure, and liver disease
<1% of need for intervention
Glascow-Blatchford Bleeding Score
Endoscopic Clipping
Endoscopic Banding
Argon Plasma Coagulator
Watermelon Stomach (GAVE- gastric antral vascular ectasia)
Treatment of GAVE
Bleeding Ulcer
Bleeding Colonic Diverticulum
CT Angiography
Angiography
Congestive Heart Failure and Ventricular Assist Devices
500, 000 new cases a year Interagency Registry For Mechanical Circulatory
Support (INTERMACS)--1400+ LVAD were placed between 2006 and 2009. That number is rising
At Medstar Washington Hospital Center we placed over 70 devices in 2014 and we are projecting more in 2015
It is clear LVAD are becoming a mainstay for advanced heart failure
Major Causes of Mortality after VAD Placement
Cardiac Failure 22% Infection 16% CNS 14% Multi-organ failure 10% Respiratory failure 5% GI bleed 1%
Mechanisms for GI bleeding in LVAD patients
Use of antiplatelet therapy and anticoagulation Acquired Von Willebrand Syndrome
fragmentation of high-molecular-weight multimers of vWF by the shear forces of the HVAD
chronic low pulse pressure intestinal hypoperfusion from reduced pulse pressure leads to
regional hypoxia, vascular dilation, and subsequent
angiodysplasia Similar situation seen in Aortic Stenosis
Gastrointestinal Bleeding in Recipients of the HeartWare Ventricular Assist SystemDaniel J. Goldstein, MD,* Keith D. Aaronson, MD, et al., JACC: Heart Failure, Vol 3, No 4, April 15, 2015:303-313
Looked at 382 patients enrolled over 30 center b/w 2008-2012
Average age was 53 yrs old, predominantly male (70%)
Majority were 96% NYHA Heart Failure
15% of the patients had GI bleeding (59 of the 382)
Clinical characteristics—high BMI, diabetic, ischemic etiology of HF, elevated creatinine
Most GI bleeds occurred after 30 days of implantation
Mean INR at presentation was 2.2
34% of the bleeding patients had 2 or more GI bleeding events
At 1 year, 84 % had no further bleeding
The most common lesion was an AVM Second was an ulcer Most common lesion site was the small bowel then
stomach LVAD support was longer in patients with GI bleed No deaths related to GI bleeding Incidence of GI bleeding was 16% or .27 GIB/yr Survival doesn’t seem to be affected by GI bleeding