GI Bleed
Transcript of GI Bleed
Gastrointestinal Bleeding
Lutfiyah Haji, DO
2010
GI Bleeding• Initial Evaluation• Approach to the Patient• Sources• Upper GI Bleeds• Lower GI Bleeds• Etiology• Management• Admission Orders
History– HPI
• Hematemesis (coffee grounds vs. bright red)• Hematochezia• Melena - dark, tarry stool• Pain symptoms
– PMHx• ulcer disease, joints, skin
– Social Hx• EtOH
– Medications• NSAIDs, steroids, ASA, Plavix, Coumadin, Lovenox, Heparin,
Iron
Physical Exam Including:• HR, BP, tilt test, RR, O2 saturation• General appearance, Mental status• Neck veins, oral mucosa• Skin temperature and color• Abdominal exam• Rectal• Stigma of Cirrhosis• NG Tube findings (upper vs. lower g.i. source)• Urine output
Work Up
• Labs
• CBC• Serial HgB• Platelets
• BMP• BUN, Cr
• Type and Crossmatch• Coagulation studies• Stool WBCs to eval for infectious etiol• Imaging studies?
Sources of GI Bleeding
• Upper GI Tract• Proximal to the Ligament of Treitz• 70% of GI Bleeds
• Lower GI Tract• Distal to the Ligament of Treitz• 30% of GI Bleeds
Localization of Bleeding
• History
• NG Tube
• EGD
• Colonoscopy
• Tagged RBC Scan
• Angiography
Upper GI Bleed• 50% present with hematemesis
• NGT with positive blood on aspirate
• 11% of brisk bleeds have hematochezia
• Melena (black tarry stools)—this develops with approximately 150-200cc of blood in the upper GI tract. – Stool turns black after 8 hours of sitting within the
gut.
• 50% present with hematemesis
• NGT with positive blood on aspirate
• 11% of brisk bleeds have hematochezia
• Melena (black tarry stools)—this develops with approximately 150-200cc of blood in the upper GI tract. – Stool turns black after 8 hours of sitting within the
gut.
Upper GI Bleed
• Risk Factors• NSAID use• H. pylori infection• Increased age
• Upper GI Bleeding accounts for approximately 350,000 hospitalizations per year.
Upper GI Bleed
• Etiology of Upper Bleeds• Duodenal Ulcer-30%• Gastric Ulcer-20%• Varices-10%• Gastritis and duodenitis-5-10%• Esophagitis-5%• Mallory Weiss Tear-3%• GI Malignancy-1%• Dieulafoy Lesion• AV Malformation-angiodysplasia
Duodenal Ulcer
Varices
Esophagitis
GI Malignancy
• Esophageal Tumor
GI Malignancy
• Gastric Carcinoma
Angiodysplasia
Lower GI Bleed• Acute LGIB: <3d• Chronic LGIB: > several days• Hematochezia• Blood in Toilet• Clear NGT aspirate• Normal Renal Function• Usually Hemodynamically stable
– <200ml : no effect on HR**– >800ml: SBP drops by 10mmHg, Hr increases by 10– >1500ml: possible shockOR– 10% Hct: tachycardia*– 20% Hct: orthostatic hypotension– 30% Hct: shock
Stops spontaneously (80 - 85% of the time)
Lower GI Bleed
• Etiology of hematochezia• Diverticular-17-40%
• Angiodysplasia-9-21%
• Colitis (ischemic, infectious, chronic IBD, radiation injury)-2-30%
• Neoplasia, post-polypectomy-2-26%
• Anorectal Disease (including rectal varices)-4-10%
• Upper GI Bleed-0-11%
• Small Bowel Bleed-2-9%
Barnet J and H Messmann H. Nat Rev Gastroenterol Hepatol 6, 637-646 (2009).
Diverticulosis
Diverticulitis-NOT A CAUSE OF GI BLEEDING
Colonic Polyps
Malignancy
• Colon Carcinoma
Hemmorrhoids
Management of GI Bleed
• Oxygen
• IV Access-central line or two large bore peripheral IV sites
• Isotonic saline for volume resuscitation• Start transfusing blood products if the patient remains unstable
despite fluid boluses.
• Airway Protection• Altered Mental Status and increased risk of aspiration with
massive upper GI bleed.
Management of GI Bleed• ICU admit indications• Significant bleeding (>2u pRBC) with hemodynamic instability
• Transfusion• Brisk Bleed, transfusing should be based on hemodynamic
status, not lab value of Hgb.• Cardiopulmonary symptoms-cardiac ischemia or shortness of
breath, decreased pulse ox
• 1 unit PRBC increases Hgb by 1mg/dL and increase Hct by 3%• FFP for INR greater than 1.5• Platelets for platelet count less than 50K
Basic Admission Orders• Admit to ICU/intermediate care/telemetry s/o
…• Dx: Upper/Lower G.I. Bleed• Condition:• VS:• Allergies:• Activity: Bedrest• Nursing: Is/Os, ? Foley• Diet: NPO
Basic Admission Orders (Cont.)
• IVF: NSS @ ?cc/h
• Medications: I.V. Protonix, convert medications to i.v., hold anti-hypertensives
• Labs: serial H/H, type and cross, coags, Chem 7, LFTs
• Consults: GI, +/- Surgery
Obscure GI Bleed• Present: Fe Defic anemia• Etiology:
– Younger than 40• Tumors• Meckel’s diverticulum• Dieulafoy’s lesion• Crohn’s Disease• Celiac Disease
– Greater than 40• Angioectasia• NSAID enteropathy• Celiac
Gerson LB. Clin Gastroenterol & Hepatol 2009;7:828-833.
Obscure GI Bleed
• Work Up– EGD, Colonoscopy both neg– Repeat – CE, PE or DE,– angiography
PillCam SB Latest Generation
PillCam SB
– 11 mm x 26 mm
– 1 camera
– 2 frames per second
– Std optics / 1 lens
– Standard lighting control
– Standard angle of view (AOV) 140°
– Depth of field 0-30 mm
PillCam SB 2
– 11 mm x 26 mm
– 1 camera
– 2 frames per second
– New optics / 3 lenses
– Advanced Automatic Light Control
– Extra wide angle of view (AOV) 156°
– Depth of field 0-30 mm
Image Spectrum: PillCam Capsule Endoscopy
Bleeding
Celiac DiseaseTumors
Suspected Crohn’s
References
• Harrison’s Principles of Internal Medicine 14th edition• Gastrointestinal Atlas.com endoscopy photos• Pocket Medicine, 3rd edition• Barnet J and H Messmann H. Diagnosis and management of lower gastrointestinal bleeding. Nat Rev
Gastroenterol Hepatol 6, 637-646 (2009).• Gerson LB. Recurrent Gastrointestinal Bleeding After Negative Upper Endoscopy and Colonoscopy. Clin
Gastroenterol & Hepatol 2009;7:828-833.• Melmed GY and Simon KL. Capsule Endoscopy: Practical Applications. Clin Gastrolenterol & Hepatology
2005;3:411-422.• AGA Institute. AGA Institute Medical Position Statement on Obscure Gastrointestinal Bleeding.
Gastroenterology 2007;133:1694-1696.
THE END