GI Bleed. Steven Lichtenstein, D.O. Chief, Division of Gastroenterology Mercy Health System. Director, Endoscopy/GI Lab Mercy Fitzgerald Hospital

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1 October 3, 2015 GI Bleed Steven Lichtenstein, D.O. Chief, Division of Gastroenterology Mercy Health System Director, Endoscopy/GI Lab Mercy Fitzgerald Hospital Clinical Associate Professor of Medicine Philadelphia College of Osteopathic Medicine

2 Upper GI bleed Commonly presents with: Hematemesis Melena

3 Upper GI bleed Differential Diagnoses: Peptic ulcer disease: 21% Varices: 15% Esophagitis/inflammation: 12% AVM: Mallory-Weiss tear: <5% each Tumors: Dieulafoy s:

4 Upper GI bleed Peptic ulcer disease Four major risk factors: H. pylori NSAIDs Stress Gastric acid

5 Upper GI bleed PUD Stratified into high vs. low risk for re-bleeding depending on endoscopic appearance Forrest classification:

6 Upper GI bleed Endoscopic appearance (stigmata) Active bleeding 90% Non-bleeding visible vessel 50% Adherent clot 25-30% Oozing without visible vessel 10-20% Flat spots 7-10% Clean, white based ulcer 3-5% Risk of re-bleeding without therapeutic endoscopy

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13 Upper GI bleed Treatment: IV proton pump inhibitor 40mg IV bid Appears no advantage with CI IV ppi drips Consider NG tube placement/lavage Consider erythromycin infusion 3mg/kg IV over min Consider IV octreotride/somatostatin Consider airway protection Endotracheal intubation

14 Upper GI bleed Treatment (continued): Labs needed: Hgb/Hct, Plts, Coags, T+C, +/- BUN Hgb >7 or 9 Plts >50 INR <1.5 After resuscitation and stabilization: EGD test of choice, usually within 24 hours Diagnostic and therapeutic

15 Upper GI bleed Treatment (continued): Injection Diluted epinephrine Thermal Bicap Heater probe Coaptive coagulation APC (less effective for ulcer bleeds) Mechanical Clips

16 Upper GI bleed Combination therapy recommended Injection therapy alone not advised Combine injection with thermal or clipping Promising agents on the horizon: Hemostatic nanopowder Becomes cohesive and adhesive with moisture contact Forms a stable mechanical barrier

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21 Traditional definition Distal to the ligament of Treitz Currently, considered more colonic bleeding Usually presents with hematochezia Stool color not always absolute

22 Anatomical Diverticulosis Vascular Angiodysplasia Radiation-induced telangiectasia Inflammatory Infectious Ischemic IBD radiation Neoplastic Polyp Carcinoma Other Hemorrhoid Ulcer Post polypectomy

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26 Resuscitation and stabilization Labs needed: Hgb/Hct, Plts, Coags, T+C, +/- BUN Hgb >7 or 9 Plts >50 INR <1.5 As with all GI bleeds, hemodynamic instability warrants an ICU admission

27 Up to 11% of patients with hematochezia will have an upper GI bleeding site Consider NG tube lavage Consider EGD early on Guidelines issued by the ACG, AGA, ASGE recommend colonoscopy as the procedure of choice for the diagnosis and treatment of lower GI bleeding

28 Colonoscopy Diagnostic accuracy 72-86% during active bleeding Advantages Localize bleeding site Obtain pathologic specimens Perform therapeutics Reduce risk of rebleeding with therapeutics

29 Colonoscopy Disadvantages Poor visualization with active bleeding and unprepped colon Risks of sedation in an acutely bleeding patient Risk of perforation with active colitis

30 Colonoscopy If significant abd pain, should obtain imaging study, ie plain abdominal radiograph and/or CT scan abd/pelvis

31 Radionuclide imaging (bleeding scan) Advantages Most sensitive radiographic test Detects bleeding of 0.1 to 0.5 cc/min Noninvasive Disadvantages Poorly accurate, 24-91%

32 CT Angiography Advantages Second most sensitive behind bleeding scan, 0.3 to 0.5 cc/min Up to 100% accurate, specific Widely available, minimally invasive, fast Disadvantages Lacks therapeutic capability Radiation exposure, IV contrast risks

33 Angiography Advantages 100% specific No bowel preparation Allows for therapeutic intervention Disadvantages Least sensitive, 1 to 1.5 cc/min Bowel infarction, renal failure, arterial thrombosis, hematomas, contrast rxns Complications overall 9-20%

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43 Small bowel evaluation If egd and colonoscopy are negative Consider: Push enteroscopy Capsule endoscopy CT enterography MR enterography

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45 Nobody can go back and start a new beginning, but anyone can start today and make a new ending. -Maria Robinson-

46 THANK YOU