UGI Tract Hemorrhage. GI Tract Emergencies. UGI Hemorrhage. David D. Markowitz, MD. UGI tract hemorrhage Comorbid disease

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1 UGI Tract Hemorrhage GI Tract Emergencies GI Hemorrhage David D. Markowitz, MD Associate Professor of Clinical Medicine Columbia University, College of Physicians & Surgeons Non variceal UGI hemorrhage Presentations Coffee ground emesis Melena Hematochezia Unexplained drop in hgb May be associated with hemodynamic instability UGI hemorrhage Initial evaluation Asses hemodynamic stability Provide adequate IV access Resuscitation with volume Type and Hold Transfuse only if necessary Decide on admission to floor vs. ICU Etiology:? Upper vs. lower;? diagnosis UGI tract hemorrhage Comorbid disease History taking essential Cirrhosis/ EtOH use? Varicealbleed Aortic graft aorto enteric fistula Hereditary hemorrhogic telangiectasia Hx of PUD/ H. pylori Surgical history: gastroneteric anastamosis CHF/ASCAD: re: volume resuscitation/tolerance of anemia Bleeding disorder; anti coagulants Aspiration risk Medications: NSAID; anticoagulants; anti platelets UGI hemomorrhage Look at the stool! More than just the hemoccult!! Hematochezia : 74% colonic 11% UGI 9% small intestinal Think UGI source if hemodynamically unstable Melena: 90% proximal to ligament of Trietz Vital Signs Resting tachycardia: moderate hypovolemia Orthostatic hypotension: 15% blood volume loss Supine hypotension: 40% volume loss

2 Labs CBC, BMP, hepatic fx In elderly or with chest pain: EKG and troponins T&H Serial hgb, q2 8 hrs depending on severity of bleed. Resucitation Volume resuscitation prior to endoscopy with normal saline Supplemental NC oxygen 2 large bore IVs Hemodynamically unstable patients to ICU If altered mental status or aspiration risk, consider intubation Use of blood products Generally maintain hgb >7 If at increased risk due to ASCAD; hgb>9 If active ongoing bleeding especially with hypotension, should be pro active given anticipated drop. Avoid over transfusion particularly with suspected variceal hemorrhage as this leads to increased risk of bleeding Villanueva et al; N Engl J Med Jan;368(1): adults with UGI bleed 1st group (restrictive) transfused to hgb>7 2 nd group (liberal) transfused to hgb>9 avoidance of transfusion: restrictive 51%; liberal 14% mortality: restrictive 5%; liberal 9% restrictive had less recurrent bleeding and other complications Blood products (cont d) Give FFP if INR>1.5 Platelets if <50K Consider FFP after every 4 units of PRBC Can endoscope while coagulopathy is being corrected Role of acid suppression Acid suppression: Empiric IV PPI (not H2 blockers) shown to reduce rates of PUD rebleed Chan et al. Br J Surg. 2011;98(5):640 Looked at IV omeprazole 40mg QD vs. 80 mg IV bolus with 8mg/hr continuous Rebleed rate: 3% vs. 16%

3 Medical therapy Somatostatin/octreotide May reduce risk of bleeding in non variceal bleeders Not recommended, however, for routine use in absence of varices If endoscopy not available, and patient needs to be stabilized prior, can consider use prior to excluding varices as a cause. Anticoagulants/antiplatelets Hold when possible Must weigh risk of thrombotic even vs. ongoing bleed How large a hemorrhage Likelihood of ongoing/recurrent hemorrhage Indication of anticoag/anti platelet Rx When to resume Rx ; with what and at what dose all must be individualized Diagnostic studies EGD in < 24 hrs in most patients Diagnosis Hemostasis Ulcers: Forrest Classification (prognosis) Increased risk in elderly and after MI Endoscopic stigmata of recent hemorrhage Forrest Classification Prevalence, Active arterial bleeding (Forrest Ia) Oozing without visible vessel (Forrest Ib) to 20 Non-bleeding visible vessel (Forrest IIa) Adherent clot (Forrest IIb) to 30 Risk of rebleeding on medical management, Flat spot (Forrest IIc) 10 7 to 10 Clean ulcer base (Forrest (III) 35 3 to 5 Actively Bleeding; Forrest I A Visible Vessel; Forrest IIA

4 Visible Vessel; Forrest IIA Adherent clot; Forrest IIB Flat pigmented spot; Forrest IIC Clean base; Forrest III UGI hemorrhage Therapy for PUD with hemorrhage Treatment reserved for lesions at high risk for ongoing bleeding and re bleeding Actively bleeding ulcers Visible vessels?ulcers with adherent clot Thermal therapy Bipolar cautery Heater probe Epinephrine injection (generally used in conjunction with 2 nd modality) Endoclip placement

5 Thermal Therapy Diagnostic studies (cont d) Barium UGI: contraindicated Tagged RBC study Angiography: only positive if actively bleeding at time of study; allows for Rx Albumin<3 INR >1.5 Altered MS Systolic BP <90 Age >60 Risk Stratification I Zero risk factors: 0.3 One risk factor: 1 Two risk factors: 3 Three risk factors: 9 Four risk factors: 15 Five risk factors: 25

6 Risk stratification Hemodynamic instability: BP<100, P >100 Hgb <10 Active bleeding at EGD Large Ulcer >1 3 cm Forrest Classification Who can be discharged?? Have no comorbidities Have a negative NGT aspiration Have stable vital signs Have a normal hemoglobin Have a likely bleeding source identified on upper endoscopy Have a source of bleeding that is not associated with a high risk of rebleeding (eg, variceal bleeding, active bleeding, bleeding from a Dieulafoy's lesion, or ulcer bleeding with high risk stigmata) Common causes Gastric and/or duodenal ulcers Esophagogastric varices Esophagitis Severe or erosive gastritis/duodenitis Mallory Weiss syndrome Angiodysplasia, including gastric antral vascular ectasia (GAVE) Mass lesions (polyps/cancers) Dieulafoy's lesion No lesion identified Dieulafoy s Lesion Dilated aberrant submucosal vessel that erodes the overlying mucosa No ulcer present Non branching artery; dilated vessel Location: Proximal stomach along lesser curve within 5 cm of GE junction Have been seen throughout GI tract Dieulafoy s Lesion (cont d) Diagnosis EGD Arterial pulsing w/o ulcer or mass Can confirm with EUS Treatment Epinephrine injection, thermal therapy, hemoclips Angio with embolization Surgical wedge resecton Dieulafoy s Lesion

7 Mallory Weiss Tear Mallory Weiss Tear Longitudinal mucosal laceration in distal esophagus Associated with forceful retching Represent 5% of UGI bleeds Bleeding usually self limited, but may be massive Dx: EGD with tear at GE jx extending into cardia Most heal spontaneously Rx: If actively bleeding: epinephrine injection; bipolar cautery; heater probe; endo clips; band ligation Gastric Antral Vascular Ectasia (GAVE) Gastric Antral Vascular Ectasia (GAVE) GAVE or Watermelon stomach Often confused with portal hypetensive gastropathy Longitudinal rows of flat red stripes radiating from the pylorus that represent ectatic mucosal vessels Most idiopathic, but associated with cirrhosis and Scleroderma Bleeding often chronic Treatment: Heater probe, bipolar cautery, APC Uncommon causes Hemobilia Hemosuccus pancreaticus Aortoenteric fistula Cameron lesions Lower GI hemorrhage Causes Anatomic Diverticulosis Vascular Angiodysplasia Ischemic RT induced Inflammatory Infectious IBD Neoplastic Post procedure (eg. polypectomy)

8 LGI hemorrhage Typically presents with hematochezia Beware rapid transit of UGI bleeder (13%) General principles of resuscitation as per UGI bleeding If severe, early involvement of GI, surgery and IR Give FFP /plts as per UGI bleed LGI bleeding High risk features Hemodynamic instability (hypotension, tachycardia, orthostasis, syncope) Persistent bleeding Significant comorbid illnesses Advanced age Bleeding that occurs in a patient who is hospitalized for another process A prior history of bleeding from diverticulosis or angiodysplasia Current aspirin use A non tender abdomen Anemia An elevated blood urea nitrogen level An abnormal white blood cell count LGI bleed Role of colonoscopy Potential to precisely localize source Can potentially tell etiology of source Can make diagnosis even in absence of active bleeding Can treat many causes: diverticular bleeding, angiodysplasias, post polypectomy, RT Disadvantages: Need for bowel prep Poor visualization Risks of sedation LGI bleed Role of colonoscopy (cont d) Urgent vs. semi elective colonoscopy controversial Urgent colonoscopy improved rate of diagnosis No clear demonstration of reduced mortality, need for surgery or transfusion requirements Bowel prep does not increase bleeding Definitive or potential bleeding source identified in 45 90%; often more than one LGI hemorrhage Radionuclide imaging Can detect bleeding at rate of ml/min Can detect bleeding anywhere in GI tract 2 types: 99mTc sulfur colloid cleared in minutes 99m Tc pertechnetate labled rbc lasts 24 hours Allows for repeat scanning for intermittent bleeders Disadvantages: Not helpful if patient not actively bleeding Localization may be poor:blood can move prograde and retrograde and colonic anatomy is variable LGI bleeding Tagged RBC study

9 LGI hemorrhage CT angiography Recently being evaluated Pros: Fast Widely available Minimally invasive Anatomic detail Cons: Radiation exposure Contrast nephropathy No Rx possibility LGI hemorrhage Angiography Require active bleeding of ml.min SMA evaluated first, then IMA, then celiac axis Successful: % Use of pre angio nuclear studies is controversial No bowel preparation required Permits therapeutic intervention Superselective embolization is feasible in 80% with control of bleeding in 97% Re bleeding occurs in up to 56% Risk of bowel infraction in 20% Risk of contrast nephropathy Colonic diverticular bleeding Most common cause of brisk LGI hemorrhage Accounts for 35 50% Stops spontaneously in most If persists, may require endoscopic, radiologic or surgical Rx Unlike diverticulitis, hemorrhage is right sided in 50 90% Diverticular hemorrhage Natural history Bleeding stops spontaneously in 75% Bleeding stops spontaneously in 99% who receive less than 4 units on first day Risk of recurrent bleeding 14 38% After 2 nd bleed, risk of further bleeding 21 50% With multiple bleeds, surgery should be considered Given elderly population, morbidity/mortality in 10 20% range Diverticular hemorrhage Pathogenesis of bleeding Bleeding Diverticulum

10 Diverticular hemorrhage Endoscopic treatment Diverticular Hemorrhage Role of Surgery Required in 18 25% of patients who require blood transfusions Segmental colectomy if bleeding localized by colonoscopy/angiography: has rebleed rate of 0 14%. Mortality rate 8.6% vs. 37% for emergency subtotal colectomy Subtotal colectomy reserved for ongoing bleeding without documented site. Blind segmental resection not indicated due to rebleeding rates of 40% and mortality rates of 57%