A Bloody Mess Upper GI Bleeding Tim Pfanner, MD, COL, USAR(ret) Asst Professor of Medicine Chief,...

A Bloody MessUpper GI Bleeding

Tim Pfanner, MD, COL, USAR(ret)

Asst Professor of Medicine

Chief, Section of IBD & Nutrition

Case

• 85 year old male– Presents with Melena

& Dizziness– PMHx:

• CHF• CADz• Etoh

– PE: passes the eyeball test

• Vital signs all look good• Is NOT tilt positive, Hbg

8, INR 1, Plts 300k

Case

• Now that you have done an initial survey, what other questions might you want to ask?– Any history of prior gi bleeding?– Any history of liver disease?– What meds is the patient on?

The following questions enter your mind(or should)

• What should I do to manage the pt now?

• Where should the pt go & how do I decide?– Home, ward, icu– Are there admission/home Criteria???

• What are the causes of his GI bleed?

More Questions enter your inquisitive mind

• How good is the therapy?– What medical Rx should I order?

• How good is it?• When should it begin?

– How good is endoscopy?• Risk stratification• Therapeutic mgmt

– When should I get others involved?• Surgery &/or interventional radiology?

So Here is what we are talking about

Duodenal ulcerDuodenal ulcer

Gastric Ulcer with bleeding Visiblevessel

NOW HERE’S A HAPPY CROWD VISITING FRIENDS

So Why Focus on Peptic Ulcer Bleeding?

• Majority of all gi bleeds are from upper gi source• 90% of all ugi bleeds are non-variceal• 400,000 admissions yearly• In-hospital direct medical costs = 2.5 billion• Mortality is still high

– 5-10% mortality from peptic ulcer bleeding

• More common in Men by 3:2 ratio• Mortality in UK

– 3% in pts <60– 20% in pts >80

So what are you thinking about the source of bleeding here?

• Esophageal varicies– Maybe he is a drinker

• gastric varicies


• Mallory-weiss tear

• Horrible ulcer(guess)• Syphilitic Ulcer


• AVMs

• Polyps


• Gastric Ulcer

• Duodenal ulcer

Clinical Presentation

• Most commonly with:– Melena– Hematemesis

• Think about serious signs of intravascular volume status:– Hypotension & resting tachycardia

• <100mmHg systolic & >100bpm

– Orthostatic changes(tilts)-20mmHg/20bpm


• Initial Tx: What is it?– Restore hemodynamic stability

• Place 2 large bore iv & fluids

– Supplemental oxygen esp in elderly– Consider: blood/correcting coagulopathy

• Place an NG tube-does this really help– 15% with negative ng aspirate have high risk

leisons on endoscopy


• Helping the patient & Gastroenterologist?– Orogastric tube placement– Do not guiac– Erythromycin 250mg iv

• 30 to 60 min prior to egd

– ?iv ppi• 80mg bolus followed by 8mg/hour• Has not definitely been shown to help prior to egd

how might I determine where they go?

Clinical Risk Stratification

• Pre-endoscopic scoring systems– Blatchford Score -Neural network– Rockall Score

• General components– Systolic BP -heart rate– Hemoglobin -melena– Co-morbid conditions– Age -?etoh

Forrest ClassificationEndoscopic Stigmata of Bleeding Peptic Ulcer, Classified as High Risk or Low Risk

Gralnek I et al. N Engl J Med 2008;359:928-937

Grade 1a Grade 1b

2a2b

2c3

Clinical Risk Stratification

• Systems combining clinical and endoscopic parameters– Rockall– Baylor bleeding score– Cedar Sinai

Clinical Risk StratificationSo How should I use all this stuff?

• Look at the patient and use your common sense– How did the pt present

• syncope, orthostatic

– Are they elderly– Do they have other serious diseases– What meds are they on(coumadin, NSAIDs)– Is the hemoglobin <10– Is the BUN >25– If you use scoring,

• Rockall>5 is high risk, <2 is low risk


• High Clinical Risk– To the MICU & resuscitate– Call GI to scope within 24 hours– Does early endoscopy(before admit) change

what the managing provider does?– Does early endoscopy save money?

• GI Endoscopy 2004;60:1-8 NO

• Low Risk in the United Kingdom can go home with no endoscopy

Low Risk patients



• If endoscopy has been performed and low risk leisons seen may consider outpatient Rx

• Intermediate risk & low risk can go to ward• Usually keep high & intermediate for 72

hours– This is when risk for rebleed is highest

• Octreotide if with cirrhosis/etoh• ppi

Clinical Risk StratificationSo, What do I do?

• In general do endoscopy within 24 hours

• If we see:– high risk Rx & 24 h

MICU, then 48h hospitalization

– Ulcer >2cm, vessel > 2mm are high risk

– Low risk Rx & consider home/early discharge

Oh!, those places you will go!

Management

• Medical– octreotide– Goal-pH >6.0– H2RA- not effective– PPIs-very effective

• Endoscopic

• Surgical RX-much less common

• Interventional Radiology

Management

• Medical– PPIs Decrease:

• rebleed risk(odds ratio =.40)• surgery risk(odds ratio = .50)• Death (odds ratio=.53)

– PPI Dosing• Iv- 80mg bolus and 8mg/hour for 72 hours(most

effective dosing method)• High dose oral effective in Asian populations

Effect of Proton-Pump Inhibition in Peptic-Ulcer BleedingFrom Leontiadis GI, etal. Cochrane Database Syst Rev 2006;1


Management

Helicobacter Pylori

Yep, you wanna test For me.

Managementtesting for H. Pylori

Management of H. pylori +

• Initial Rx:– Clarithromycin 500mg bid– Amoxicillin 1000mg bid– PPI bid – All for 10-14 days, then PPI qd x4-8 wks’

• Healing of DU takes 3-4 wks & GU 6-8 wks

• Salvage Rx:– Bismuth 120mg qid– Metronidazole 500mg tid– Tetracycline 500mg qid– PPI bid– All for 14 days

So does RX of H. Pylori work?

• Eradication of H. Pylori reduces the 1 year recurrence of ulcers from 75% to 15-20%.

• H. pylori has been strongly associated with gastric cancer– Japanese eradication trials = no gastric cancer

• Eradication in MALT lymphoma– Regression in 70-80%

• Eradication prior to NSAIDs can reduce ulcer risk

NSAID’s & PUD

• 33 million commonly use NSAIDs

• Ulcers found in 5-20% of chronic users

• Only a third of chronic NSAID users have normal EGD’s

• Gastric ulcers more common than duodenal

• NSAID’s increase risks of ulcer complication – bleeding, obstruction and perforation– .5%-4% per year risk– >50% May present as a

“silent” hemorrhage

Perforating gastric ulcer

Perforating gastric ulcer

Bleeding gastric ulcer with visible vessel

Bleeding gastric ulcer with visible vessel

AFTER ALL, don’t we all want to be LONGHORNS?

Endoscopic Management

• Most studies use emergent endoscopy with 12-24 hours of admission

• Identifies bleeding site & stigmata of recent hemorrhage

• Able to predict likelihood of continued or recurrent bleeding

• Early treatment reduces hospital costs and length of stay

We can burn it!

We can inject it!

We can clip it!

Endoscopic Tx for PUD bleedingSo, How good are we?

Lesion Rebleed Risk Risk after Tx

clean base 3%

pigmented spot 7%

Oozing 10-27%

Adherent clot 12-33% 5%

visible vessel 50% 15-30%

actively bleeding 90% 15-30%

Repeat endoscopic therapy is effective in approximately 70% of recurrent bleeders

ManagementBut, what does the literature say?

• Endoscopic– Overall Effectiveness

• Active bleeding-NNT=2• Visible vessel-NNT=5

– Injection of epi should not be done alone• NNT=9

– Burn the vessel• NNT=5

– Clip the vessel• NNT = 4-5

– Combination appears most effective• NNT = 4-5

– What about when rebleeding occurs?• NNT 4-5

Laine, et al; Endoscopic Therapy for Bleeding Ulcers: An Evidence-Based Approach Based onn Meta-Analyses of Randomized Controlled Trials, Clinical Gastro & Hep 2009;7:33-47

Management

• Does endoscopic Rx lower rates of Surgery?– Surgical rates before and after Endoscopic Rx

Before After

Active Bleeding 35% 7%

Visible Vessel 34% 6%

Adherent Clot 10% 2%

Flat Spot 6% <1%Laine L. Et al: Bleeding Peptic Ulcer NEJM;331:717, 1994

Honduras, 2007

Management

• Surgery– Surgical rates

• Prior to the 1980’s – operative rate 20-27%

– Mortality 5%, 20% in recurrent bleeds

• Now the rate is 6.5-7.5%

• What happened in the 1980’s?

Management

• Surgery– Indications:

• Bleeding continues after 2nd Endoscopy• Pt cannot be stabilized • Pts who cannot tolerate recurrent or worsening

bleeding• After the first endoscopic RX

– Pts with ulcers >2cm or large vessels(>2mm)– WHY? This is associated with endoscopic Tx failure

Management

• Surgery- Operations commonly used– Vagotomy with pyloroplasty

& oversew– Vagotomy with Antrectomy

& oversew• Recent cohort studies

indicate equivalencyDe la Fuente SG, et al: Comparative analysis of

vagotomy and drainnage versus vagotomy and resection procedures for bleedinng peptic ulcer disease: results of 907 patients from the Dept of VA National Surgical QI Program Database.

J Am Coll Surg 2006;202:78-86

• Surgical success:– 23% recurrent bleeding– 31% additional surgery– 20% mortality is possible

Honduran Jurassic Park

Management

• Interventional Radiology– Angiography with transcatheter embolization

This uses:• gelfoam, coils, super glue, polyvinyl alcohol

– Usually reserved for high risk who– Failed endoscopic Tx– Too high risk for surgery– In other words: The sickest of the sick who failed all

other attempts at treatment

Here is what the little springs look like

Management

• How good is Interventional Radiology– Technical success is 52-94%– Uncontrolled trials-reduces bleeding & death

• Recurrent bleeding rate=29%• Mortality=26%• Additional surgery=16.1%

– Problems: – ischemic bowel– secondary duodenal stenosis– Infarct of liver, spleen or stomach

Since payments are decreasing, this is the future

of GI

Summary

• PUDz accounts for most Acute significant UGI bleeds

• It is a very common and expensive problem

• Identify high risk clinical criteria:– Old age -hemoglobin <10 -etoh– Syncope -elevated BUN– Tilt positive -comorbities

Summary

• After Endoscopy risk stratify– Active bleeding -visible vessel– Adherent clot– LOW RISK: clean based ulcer, pigmented

spot

• Realize that endoscopic Tx is not always effective

• Use iv PPI for 72 hours in high risk patients

Summary

• Iv PPI do not work as well in the absence of endoscopic Tx

• If rebleed, call GI again for endoscopic treatment attempt

• Then if this fails, call the surgeon

• Get interventional involved if all else fails

• Test for H. Pylori and Rx if positive

• Avoid NSAIDs, etc

QUESTIONS?????????

My cold happy My cold happy crewcrew

My cold happy My cold happy crewcrew

At Granmda’sHome in Springville, New York

A Bloody Mess Upper GI Bleeding Tim Pfanner, MD, COL, USAR(ret) Asst Professor of Medicine Chief,...

Documents

Transcript of A Bloody Mess Upper GI Bleeding Tim Pfanner, MD, COL, USAR(ret) Asst Professor of Medicine Chief,...