Ce diaporama a bien été signalé.
Nous utilisons votre profil LinkedIn et vos données d’activité pour vous proposer des publicités personnalisées et pertinentes. Vous pouvez changer vos préférences de publicités à tout moment.
Department of Gastroenterology and Nutrition
Memorial Sloan-Kettering Cancer Center
September 17, 2015
Management of Acute...
Clinical Case
 76F w/ Stage IV NSCLC w/ mets to bone on erlotinib, DVT on
lovenox, diverticulosis, naproxen for back pain...
Clinical Case cont.
 ROS
 +Back pain, no fever/chills, no lightheadedness/dizziness,
denies melena, BRBPR, hematemesis, ...
Clinical Case cont.
 Labs
 Na 128, K 4.6, Cl 94, CO2 26, BUN 12, Cr 0.5, Gluc 106
 Nml LFTs
 INR 1.1
 WBC 9.9, Hb 6.5...
Upper GI Bleed
 History
 PUD, prior bleeds, EtOH, prior surgical/endoscopic interventions
(marginal ulcers), liver disea...
Upper GI Bleed
 Clinical Signs
 Hematemesis (30%) – vomiting of bright red blood or coffee grounds
 50% of pts w/ docum...
The Role of FOBT
 Occult blood loss (by definition, a small amount)
 Guaiac relies on peroxidase reaction to identify Hb...
Etiology of Upper GI Bleed
 PUD (50%)
 Esophageal varices
(30%)
 AVMs (6%)
 Mallory-Weiss tear (5%)
 Trauma (post-op)...
Other Etiologies
Photo Courtesy of Dr. Cavell
Other Etiologies
Lower 3rd of esophagus
Other Etiologies
Risk Stratification
 Rockall score (1996)
 Blatchford score (2000)
A score of less than 2 is associated with low risk of further bleeding
or death
Initial Management
 ABCs
 Include orthostatics – indicates ≥15% acute blood loss
 IV access
 2 large bore IVs (16G or ...
Initial Management
 NPO
 STAT labs (CBC, coags, Type & Screen)
 Monitor CBC q4-6hrs
 Goal Hb >8 (lower goal is better)...
Acid Suppression w/ PPI
 Clot formation requires pH > 6.8
 IV H2-blockers raise gastric pH, but tolerance leads to
pH 3-...
NG Lavage
 No benefit to mortality,
LOS, or tsf requirement
 Confirm UGI source
 Assess briskness of bleed
 Negative l...
Calling a GI Consult
 Place order in computer
 Know the patient
 Know the question you’re asking
 Make sure the patien...
Management of Upper GI Bleed
 EGD – 1st line therapy, can locate and treat source
 Non-variceal UGIB >90% success in sto...
Assessment of Upper GI Ulcers
 Forrest Classification
 Class 1a-Spurting hemorrhage
 Class 1b-Oozing hemorrhage
 Class...
Class Ia Class IIa
Class IIb Class III
Lower GI Bleed
 Same initial management as UGIB (+/- PPI drip)
 11% with suspected LGIB have upper source
 Signs – maro...
Lower GI Bleed
 Diverticulosis
 Acute, painless, maroon or BRBPR
 Melena w/ slower R sided bleeds
 Diverticular bleeds...
Management of Lower GI Bleed
 Colonoscopy – 1st line therapy, dx yield 74-90%,
ability to intervene. Usually EGD 1st to r...
Endoscopic Therapy
 Injection w/ epinephrine
 Cautery
Endoscopic Therapy
 Argon Plasma Coagulation (APC)
Endoscopic Therapy
 Clips
Endoscopic Therapy
 Variceal banding
Endoscopic Therapy
 Variceal banding
Endoscopic Therapy
 Capsule endoscopy
Endoscopic Therapy
 Single/Double Balloon Enteroscopy
Clinical Case Follow-up
 76F w/ Stage IV NSCLC adeno ca w/ mets to bone on
erlotinib, DVT on lovenox, diverticulosis, nap...
Clinical Case Follow-up
 CT abd/pelvis w/o con
Conclusions
 Take careful history and physical exam (including rectal)
 No role for FOBT in the inpatient setting
 ABCs...
Questions
Gi bleed
Gi bleed
Prochain SlideShare
Chargement dans…5
×

Gi bleed

Gi bleed

  • Identifiez-vous pour voir les commentaires

Gi bleed

  1. 1. Department of Gastroenterology and Nutrition Memorial Sloan-Kettering Cancer Center September 17, 2015 Management of Acute Gastrointestinal Bleeding
  2. 2. Clinical Case  76F w/ Stage IV NSCLC w/ mets to bone on erlotinib, DVT on lovenox, diverticulosis, naproxen for back pain, now presents from SAR w/ back pain and anemia. Hb 10.2 -> 6.5 over 1 week.  PMH  CAD s/p PCI, HTN, HL  Meds  Omeprazole, amlodipine, atorvastatin, candesartan, erlotinib, klonopin, oxycodone, therapeutic lovenox, senna, colace, fentanyl patch, gabapentin  Allergies  Clindamycin, PCN, sulfa drugs  SH/FH  Denies tobacco, EtOH, illicit drug use  Grandmother w/ colon ca
  3. 3. Clinical Case cont.  ROS  +Back pain, no fever/chills, no lightheadedness/dizziness, denies melena, BRBPR, hematemesis, abdominal pain  PE  Vitals: BP 126/74, HR 93, RR 20, T 36.8C  Gen: NAD  HEENT: OP clear, MMM  Cards: nls1s2, rrr, no mrg  Pulm: cta b/l  Abd: obese, soft, nt, nd, +bs  Rectal: guaiac positive, dark brown stool  Ext: no edema
  4. 4. Clinical Case cont.  Labs  Na 128, K 4.6, Cl 94, CO2 26, BUN 12, Cr 0.5, Gluc 106  Nml LFTs  INR 1.1  WBC 9.9, Hb 6.5, Plt 432  FOBT +  Is this patient stable or unstable?  What is the differential diagnosis?  What is the likely source of her anemia?
  5. 5. Upper GI Bleed  History  PUD, prior bleeds, EtOH, prior surgical/endoscopic interventions (marginal ulcers), liver disease (varices), tumor, prior radiation  Meds – NSAIDs, anti-platelets, anticoagulation  ROS – epigastric pain (PUD), retching (Mallory-Weiss tear), odynophagia/dysphagia (esophageal ulcer)  Physical Exam  Look for evidence of hypovolemia (tachycardia/hypotension)  Abdominal exam  Rectal exam  Guaiac?!  Accurate H&P allows for proper assessment of bleeding severity, volume status, risk factors, and triage decision
  6. 6. Upper GI Bleed  Clinical Signs  Hematemesis (30%) – vomiting of bright red blood or coffee grounds  50% of pts w/ documented varices bleed from another source  Melena (20%) – black and tarry stools  Caused by enzymatic degradation and oxidation of Fe in Hb during passage through ileum and colon  Foul smelling, black (not dark)  Make sure pt not on iron or bismuth  Hematochezia (5%) – passage of BRBPR or maroon stools  Usually lower GI or brisk upper GI bleed (≥1L blood loss)  BUN/Cr – usually >30:1 ratio  Secondary to blood protein absorption or pre-renal azotemia  +Guaiac
  7. 7. The Role of FOBT  Occult blood loss (by definition, a small amount)  Guaiac relies on peroxidase reaction to identify Hb  Overt blood loss should be obvious from history and exam  Primary role of FOBT is in colon cancer screening  Sensitive, but specificity varies  False-positive results  Dietary peroxidases – rare meats, raw broccoli, turnips, cauliflower, radishes, cantaloupe  Other – diarrhea/colitis, recent endoscopy, bleeding gums, hemoptysis, epistaxis, menstruation, hemorrhoids, fissures  FOBT HAS NO SIGNIFICANT INPATIENT ROLE
  8. 8. Etiology of Upper GI Bleed  PUD (50%)  Esophageal varices (30%)  AVMs (6%)  Mallory-Weiss tear (5%)  Trauma (post-op)  Tumors (4%)  Dieulefoy lesion (1%)  Other
  9. 9. Other Etiologies Photo Courtesy of Dr. Cavell
  10. 10. Other Etiologies Lower 3rd of esophagus
  11. 11. Other Etiologies
  12. 12. Risk Stratification  Rockall score (1996)  Blatchford score (2000)
  13. 13. A score of less than 2 is associated with low risk of further bleeding or death
  14. 14. Initial Management  ABCs  Include orthostatics – indicates ≥15% acute blood loss  IV access  2 large bore IVs (16G or larger), consider central access  Flow proportional to 4th power of catheter radius (you want short, large bore catheter)  22G  35cc/min  20G  60cc/min  18G  105cc/min  16G  205cc/min  14G  333cc/min  Run fluids wide open (NOT THROUGH PUMP!!!)
  15. 15. Initial Management  NPO  STAT labs (CBC, coags, Type & Screen)  Monitor CBC q4-6hrs  Goal Hb >8 (lower goal is better), Plts >50, INR <1.5  Don’t over-transfuse variceal bleeders  No need to wait for labs to hang blood products  Acute bleeders may have normal Hb  Hold anticoagulation  IV PPI (protonix) – 80mg bolus, then 8mg/hr  Consider octreotide if variceal bleed (50mcg bolus, then 50mcg/hr)  Pre-procedure prokinetics-use in pts with high probability of clot or fresh blood in stomach  ICU consult – recurrent hematemesis, active bleeding, hemodynamic instability, respiratory distress, comorbidities
  16. 16. Acid Suppression w/ PPI  Clot formation requires pH > 6.8  IV H2-blockers raise gastric pH, but tolerance leads to pH 3-5 within 24hrs  PPI can keep gastric pH >6.8 for over 24hrs  80mg bolus w/ 8mg/hr infusion raises pH >6 in 20 min  PPI before endoscopy accelerates clot formation, stabilizes existing clots, reduces bleeding, need for endoscopic therapy, LOS, and initiates healing (Lau et al, NEJM 2007).  Decrease also seen in rebleeding rates and need for repeat endoscopy w/ PPI Laine L and Jensen DM. ACG Practice Guidelines 2012.
  17. 17. NG Lavage  No benefit to mortality, LOS, or tsf requirement  Confirm UGI source  Assess briskness of bleed  Negative lavage  Bleeding stopped  Source distal to closed pylorus  May be feculent material  Irrigate stomach to facilitate endoscopy  Remove residual blood, gastric contents  Decrease risk of aspiration
  18. 18. Calling a GI Consult  Place order in computer  Know the patient  Know the question you’re asking  Make sure the patient knows GI is being called
  19. 19. Management of Upper GI Bleed  EGD – 1st line therapy, can locate and treat source  Non-variceal UGIB >90% success in stopping initial bleed  <20% re-bleed rate, 75% stopped w/ 2nd endoscopy  Tumor bleeding is generally not amenable to endoscopic therapy  Angiography (IR) – actively bleeding (0.5-1cc/min)  Tagged RBC scan (>0.1cc/min)  Surgery
  20. 20. Assessment of Upper GI Ulcers  Forrest Classification  Class 1a-Spurting hemorrhage  Class 1b-Oozing hemorrhage  Class IIa-Nonbleeding visible vessel  Class IIb-Adherent clot  Class IIc-Flag pigmented spot  Class III-Clean ulcer base
  21. 21. Class Ia Class IIa Class IIb Class III
  22. 22. Lower GI Bleed  Same initial management as UGIB (+/- PPI drip)  11% with suspected LGIB have upper source  Signs – maroon stools, hematochezia  Etiology  Anatomic – diverticular disease (30-50%)  Vascular – AVMs (10%), ischemia, radiation, hemorrhoids  Inflammatory (15%) – IBD, infections (C. diff, CMV)  Malignancy (13%)  Procedural – post-polypectomy
  23. 23. Lower GI Bleed  Diverticulosis  Acute, painless, maroon or BRBPR  Melena w/ slower R sided bleeds  Diverticular bleeds usually stop spontaneously (10-40% recur)  AVMs  More common in elderly  Associated w/ aortic stenosis (Heyde’s syndrome)  Radiation proctitis  Occurs in 5-20% of pts receiving pelvic XRT (prostate, rectum, bladder, cervix)  Risk factors: high radiation dose, age, concurrent chemo  Treatment: APC, cautery, cryotherapy, RFA
  24. 24. Management of Lower GI Bleed  Colonoscopy – 1st line therapy, dx yield 74-90%, ability to intervene. Usually EGD 1st to r/o UGIB.  Angiography (IR) – actively bleeding (0.5-1cc/min)  Tagged RBC scan (>0.1cc/min)  Surgery
  25. 25. Endoscopic Therapy  Injection w/ epinephrine  Cautery
  26. 26. Endoscopic Therapy  Argon Plasma Coagulation (APC)
  27. 27. Endoscopic Therapy  Clips
  28. 28. Endoscopic Therapy  Variceal banding
  29. 29. Endoscopic Therapy  Variceal banding
  30. 30. Endoscopic Therapy  Capsule endoscopy
  31. 31. Endoscopic Therapy  Single/Double Balloon Enteroscopy
  32. 32. Clinical Case Follow-up  76F w/ Stage IV NSCLC adeno ca w/ mets to bone on erlotinib, DVT on lovenox, diverticulosis, naproxen for back pain, now presents from SAR w/ back pain, guaiac positive brown stools, and anemia. Hb 10.2  6.5 over 1 week.  What’s the diagnosis?
  33. 33. Clinical Case Follow-up  CT abd/pelvis w/o con
  34. 34. Conclusions  Take careful history and physical exam (including rectal)  No role for FOBT in the inpatient setting  ABCs  IV access is critical  IV PPI for UGIB  Consider NG tube placement  Tumor bleeding is not amenable to endoscopic therapy  EGD/colonoscopy is not a risk-free procedure  Active bleeder – call ICU, involve GI ASAP
  35. 35. Questions

×