GI Bleed - Gastrointestinal Bleeding Emergencies...

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Unformatted text preview: Gastrointestinal Bleeding Emergencies Emergencies Quick & Dirty Quick Clinical Points & Cases Cases David Riley, MD David Director of Emergency Ultrasonography & Ultrasonography Resident Didactics Resident Department of Emergency Medicine Department St. Luke’s Roosevelt Hospital Center St. Columbia University College of Physicians & Surgeons Surgeons Gastrointestinal Bleeding Emergencies Emergencies Upper or Lower ? Upper Admit or Go Home ? Home If Admit: where ? If – Floor – Step Down – ICU GI Bleeding: Scope of the Problem Problem UGI Bleed Incidence 100/100,000 100/100,000 LGI Bleed Incidence 25/100,000 25/100,000 4-10% Mortality 80% of UGI & LGI bleeds stop spontaneously spontaneously Big Problems: massive bleeding & rebleeding rebleeding Upper GI Bleeding Upper Originates proximal to the ligament of Treitz Treitz Male > Female Male Common: Peptic ulcer disease, esophageal varices=#1 severe & varices=#1 persistant bleeding, persistant bleeding, erosive gastritis( ASA,NSAIDS, Mallory Weiss tears Weiss Varices=30% mortality Varices Upper GI Bleeding Upper Risk for rebleeding: rebleeding stress ulcers, active bleeding on presentation, shock, ulcer >1cm, liver disease, stigmata of hemorrhage on endoscopy endoscopy Upper GI Bleeding: H & P the %’s the hematemesis: 50% hematemesis “coffee ground emesis”-melena: emesis” 80% 80% hematochezia: 20% hematochezia syncope: 14% syncope: jaundice: 5.2% BUT if present, mortality increases from 10 to 38% to Upper GI Bleeding: Prognostic Indicators Prognostic age age HR HR SBP: SBP: orthostatics orthostatics color of stool or emesis color anticoagulants anticoagulants comorbid conditions comorbid Upper GI Bleeding: Prognostic Indicators: HR & BP BP American Society for Gastrointestinal Endoscopy: Shock Endoscopy Shock = HR>100, SBP<100 SBP<100 mortality 20-30 % mortality rebleeding rebleeding – 2% w/o shock – 18% w/ HR>100 – 48% w/ HR>100 48% & SBP<100 SBP<100 Upper GI Bleeding: Prognostic Indicators: Orthostatics Orthostatics American Society for Gastrointestinal Endoscopy: defined positive testing as Endoscopy defined pulse increase of 20 pulse positive orthostatics = 14% mortality orthostatics negative orthostatics = 8% mortality orthostatics Upper GI Bleeding: Prognostic Indicators: Stool Color Stool Hematochezia from an Hem from UGI source = 14% greater mortality rate compared to melena, melena increased transfusion requirements, need for surgery (doubled) surgery Melena: in 18% of Melena in patients with Lower GI Bleeding GI Upper GI Bleeding: Prognostic Indicators: Comorbid Conditions Comorbid American Society for Gastrointestinal Endoscopy: cardiac, Endoscopy cardiac, CNS, GI, hepatic, neoplastic, neoplastic pulmonary, renal pulmonary, No comorbid: 2% comorbid 2% mortality mortality 6 comorbid comorbid conditions: 67% conditions: mortality mortality Upper GI Bleeding: LABS Upper Hb/Hct: Hemoglobin Hb/Hct Hemoglobin < 10 g/dL iincreased g/dL ncreased the mortality rate from 11% to 19%, and the rebleeding rebleeding rate from 12% to rate 23% 23% BUN/Cr: if the ratio is >36 = suggestive of >36 suggestive a UGIB, <36 is not helpful helpful Upper GI Bleeding: Diagnosis Upper Upper GI Bleeding: Diagnosis Diagnosis NG: clear unlikely gastric bleed yet still could have duodenal bleed Presence of bile in the lavage lavage increases the increases sensitivity of the lavage to r/o a lavage to UGIB UGIB Upper GI Bleeding: Diagnosis Diagnosis NG Aspirate: 10% FALSE NEGATIVE RATE when the aspirate is clear clear Use Gastroccult slide Gastroccult slide because unlike the hemoccult slide it is hemoccult slide not affected by the low pH (urine dips are pH independent) independent) Upper GI Bleeding: Diagnosis Diagnosis Nasogastric Nasogastric Aspirate: % with Aspirate: active bleeding or oozing on endoscopy endoscopy Clear: 10% Clear: “Coffee ground”: 30% 30% Red Blood: 48% Red Upper GI Bleeding: Diagnosis Diagnosis ENDOSCOPY: Gold Standard, both Diagnostic, Prognostic & Therapeutic: MUST STABILIZE PATIENT FIRST FIRST “Stigmata of Bleeding”: red flags for rebleeding: rebleeding oozing, adherent clot, visible vessel, ulcer >1cm >1cm Upper GI Bleeding: Treatment Treatment Medical RX: ABC’C Medical T&C Blood, NS & 2 large bore IV’s large H+ Blockers (omperazole) iis better s than H2 Blockers (pepcid) Octreotide: decreases Octreotide decreases portal venous pressures portal Fresh Frozen Plasma if coagulopathy coagulopathy Upper GI Bleeding: Treatment Treatment Non-Variceal Non Bleeds: Endoscopic Bleeds: Endoscopic iinjection of njection 1:10,000 epi epi solutions & solutions sclerosants, sclerosants hemoclips in nonhemoclips variceal bleeds Upper GI Bleeding: RxUpper Varices Variceal Bleeds: Variceal Bleeds: sclerotherapy & sclerotherapy ligation & clipping are ligation clipping best best Transjugular Transjugular Intrahepatic Portacaval Shunt Shunt (TIPS) (TIPS) Sengstaken Sengstaken Blakemore or Linton Blakemore Tubes (intubate 1st) Tubes Upper GI Bleeding: RxUpper Surgery? More than 5 units of blood transfused of Refractory shock Refractory Age >60 and continued bleeding continued 2nd Rebleed Rebleed Failure to Respond to Endoscopic Endoscopic Therapy Upper GI Bleeding: Dispo? Dispo Go Home? : Young drinkers with probable gastritis, without evidence of liver disease or blood loss (no orthostatic changes & Hb>10) who have Hb>10) been observed for 6 hours: D/C w/H+& H2 blockers & antacids blockers Upper GI Bleeding: Dispo? Dispo ICU Admits:BLEED: ANY ONE = ADMIT ANY B: ongoing bleeding B: L: low SBP <100 L: E: elevated PT(liver disease) disease) E: erratic mental state state D: disease co morbid diseases, elderly elderly Upper GI Bleeding: Dispo? Dispo Floor/Step Down: everyone else, not a young drinker who can go home, and not a BLEED candidate for ICU admission admission Upper GI Bleeding Upper Necrotizing Necrotizing Duodenitis Duodenitis Upper GI Bleeding Upper Pyloric Channel Ulcer Ulcer Lower GI Bleeding Lower Defined as bleeding distal to the Ligament of Treitz Treitz Elderly tend to bleed from diverticulosis, diverticulosis angiodysplasia & CA angiodysplasia Younger pateints: pateints hemorrhoids, fissures & IBD IBD Renal Failure: AVM’s Renal Lower GI Bleeding Lower Hx: PAIN + LGIB = Hx PAIN inflammatory bowel disease, ischemic bowel, and aneurysmal aneurysmal rupture Maroon stool: small bowel & colon bowel Stool streaked w/blood : descending colon descending Blood outside stool: fissures fissures Lower GI Bleeding: Diagnosis Diagnosis Melena & Hematochezia Melena Hematochezia may be due to UGIB: may ALL Pts NEED NG LAVAGE LAVAGE Call Surgery Call Anoscopy then Anoscopy then Sigmoidoscopy iif Sigmoidoscopy f patient stable then Colonoscopy Colonoscopy If unstable surgery If Lower GI Bleeding: Dx & Dx Rx Rx Stable patient with negative scopes: nuclear scan (0.1cc/min bleed) or angiography (embolization)(0.5c (embolization)(0.5c c/min bleed) c/min candidate; CT scan is last test before surgery surgery Lower GI Bleeding Lower Diverticula of the Diverticula of colon colon Lower GI Bleeding Lower External Hemorrhoids Hemorrhoids Lower GI Bleeding Lower Internal Hemorrhoids Hemorrhoids Lower GI Bleeding Lower AVM’s of the Right Colon Colon Lower GI Bleeding Lower Sigmoid Diverticulosis Diverticulosis Lower GI Bleeding Lower Ulcerative Colitis Ulcerative Lower GI Bleeding Lower Ulcerative Colitis Ulcerative Lower GI Bleeding Lower Colon Diverticula Diverticula Lower GI Bleeding Lower Crohn’s Disease Crohn’s Lower GI Bleeding Lower External Thrombosed Thrombosed Hemorrhoids Lower GI Bleeding Lower Prolapsed internal hemorrhoids hemorrhoids References References Kollef, MH, et. Al.: BLEED: A classification tool Kollef MH, to predict outcomes in patients with upper and lower gastrointestinal hemorrhage. Crit. Care Crit Care Med. 1997; 25: 1125-32 Med. Peter, DJ, Dougherty, JM: Evaluation of the patient with gastrointestinal bleeding: an evidence based approach. Emer. Med. Clin. N. Emer Med. Clin N. Am. 1999; 17(1):239-61 Am. Talbot-Stern, JK: Gastrointestinal bleeding. Talbot Stern, Emer. Med. Clin. N. Am. 1996; 14(1): 173-84 Emer Med. Clin ...
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