D|agnos|s & Management of L|fe

1hreaten|ng Gastro|ntesnna| 8|eed|ng

uouglas 8. WhlLe, Mu, MAS
AssoclaLe rofessor
ueparLmenL of Crlucal Care Medlclne
unlverslLy of lusburgh School of Medlclne
Iacu|ty D|sc|osures
no poLenual CCls relevanL Lo Lhls Lalk
CVLkVILW
1. lnlual 8esusclLauon & 1rlage
2. uCl8 evaluauon & LreaLmenL
epuc ulcer ulsease
varlceal 8leedlng
3. LCl8 Lvaluauon & 1reaLmenL
4. SLress ulcer rophylaxls ln lCu auenLs
1. In|na| kesusc|tanon and 1r|age
key Aspects of n|story
Assess hemodynamlc sLablllLy -> move qulckly Lo
resusclLauon
lmporLanL polnLs on Px:
ASA/nSAluS
PlsLory of uu
LLCP, llver dz, varlceal bleedlng
Cn coumadln?
WelghL loss, dysphagla
AAA, vascular gra
1r|age of anents w|th GI 8|eeds
lCu vs lloor?
lndlcauons for lCu admlsslon:
Pemodynamlc lnsLablllLy (shock, orLhosLasls)
uecrease ln PcL of >6, Lransfuslon of >2 unlLs 88Cs
Acuve bleedlng (hemaLemesls, brlghL red blood per nasogasLrlc Lube,
or hemaLochezla)
Severe comorbldlues
lnLubauon?
Cngolng hemaLemesls
AMS, 8esplraLory compromlse
laclllLaLe Lndoscopy


kesusc|tanon
What k|nd of IV Access?
ShorL and faL!
2- 18 gauge or larger lvs
1rlple lumen cenLral caLheLer ls
lnadequaLe
A-llne for hemodynamlc
monlLorlng and frequenL lab
draws
IV Gauge Flow rate (ml/
min)
22g 38
20g 63
18g 110
16g 215
TLC
! 16g
! 18g
! 18g
98
52
22
24
RIC 8.5F 600
kesusc|tanon
Vo|ume Status:
lsoLonlc sallne bolus Lo malnLaln lnLravascular volume
A-llne/Cv monlLorlng lf hemodynamlc lnsLablllLy

When to tranfuse k8Cs?
8emember LhaL sLandard Lransfuslon Lhresholds ln lCus uC nC1 apply Lo pauenLs wlLh
acuve Cl8s.
lor pauenLs wlLh CAu or severe co-morbldlues, malnLaln PcL>30
1ransfuslon Lhreshold:
Cllnlcal [udgmenL cruclal
eg: donL use Lhe PcL as sole gulde ln pL wlLh masslve hemaLemesls
When to correct coagu|opathy?
ln8>1.3
laLeleLs<30k


Is th|s an UGI8 or LGI8?
C|ass|c S|gns can m|s|ead
uCl8: PemaLemesls/melena
LCl8: PemaLochezla
ulsuncuons based on sLool color are noL absoluLe, slnce melena can be seen wlLh
proxlmal LCl8 hemaLochezla w/ masslve upper Cl8

Nasogastr|c Lavage
8lood/coee-ground -> hlgh rlsk leslon
May be negauve lf bleedlng has sLopped or arlses beyond closed pylorus
8lllous uld and no blood -> hlghly unllkely Lo be uCl8

Shou|d th|s panent undergo upper GI endoscopy?
?es- lf pauenL ls suspecLed of havlng uCl8

Cood dlagnosuc Lool: hlghly sensluve and speclc for locaung and ldenufylng
bleedlng leslons ln Lhe upper Cl LracL

Cood Lherapeuuc Lool: endoscopy can achleve acuLe hemosLasls and prevenL
recurrenL bleedlng

Cood prognosuc Lool: endoscopy can rlsk sLraufy: rlsk of rebleed, whlch
guldes Lrlage declslons.

8lsks: asplrauon, perforauon, lncreased bleedlng and rlsks assoclaLed wlLh
sedauon

Upper GI 8|eeds
What are the most common causes of
UGI8?
Cause % of all GI
Bleeds
Duodenal ulcer 30-37%
Gastric ulcer 19-24%
Portal hypertensive gastropathy
5-10%
Esophageal varices
5-10%
Gastritis or duodenitis 5-10%
Esophagitis or esophageal ulcer 5-10%
Mallory-Weiss tear 3-7%
Gastrointestinal malignancy 1-4%
Dieulafoy's Lesion
Artery at gastric fundus
1%

Gastric antral vascular ectasia 0.5 to 2%
Aorto-enteric fistula
<1%
re-endoscopy treatment of panents suspected of
UGI8
Lv|dence supports the emp|r|c use of:
roLon pump lnhlblLor (l)
lv lnfuslon (omeprazole) pre-LCu ylelds shorLer LCS, less rebleedlng,
more clean-based ulcers, less need for LCu LreaLmenL.
A neuLral gasLrlc pP ls crlucal for Lhe sLablllLy of cloLs over bleedlng
arLerles.
osL-LCu LreaLmenL can be Lallored based on ndlngs

Lv|dence DCLS NC1 support the emp|r|c use of:
P2-blocker Lherapy (no change ln raLe of rebleeds)



n Lngl ! Med 2007, 336:1631
Lau. NEJM. 2007
P. ylorl lnfecuon

nSAlu use

SLress/Crlucal lllness

CasLrlc Acld
Causes of epnc U|cer D|sease
epnc U|cer D|sease- Lndoscop|c 1reatment
1nL S1ANDAkD: ln[ecuon Lherapy
Sallne, alcohol or eplnephrlne (1:10,000)
1hermal coagulauon
PemosLauc cllps
llbrln sealanL
Argon plasma coagulauon

Is comb|nanon therapy beuer than monotherapy?
17 randomlzed sLudles lnvolvlng 173 pauenLs
Lplnephrlne alone -> 19 rebleed raLe
Lplnephrlne + 2nd meLhod -> 10
MorLallLy decreased from 3 Lo 2.3
Cochrane Review. 2006
epnc U|cer D|sease- Med|ca| 1reatment
roton ump Inh|b|tors reduce r|sk of reb|eed
Lau eL al, nL!M 2000
8C1 - omeprazole vs placebo ln pauenLs endoscoplcally LreaLed hlgh
rlsk ulcers
240 pauenLs, endpolnL rebleed wlLhln 30 days
7 rebleed raLe ln LreaLed pLs vs 23
30 day morLallLy - 4 vs. 10 (p=0.13)
Cochrane 8evlew 2004
24 8C1s, 4373 pauenLs
8ebleed on l 11 vs. 17 conLrol
need for surgery 6 vs. 9
no dlerence ln all cause morLallLy
Among pauenLs wlLh hlgh rlsk ulcers (acuve bleed or vlslble vessel)
morLallLy reduced by 47
noL dependenL on rouLe of l, conLrol Lherapy, lnlual endoscoplc
Lherapy
Peptic Ulcer Disease- Medical Treatment


What |s the ro|e of Somatostann]Cctreonde?
8educes splanchnlc blood ow
Cne meLa-analysls showed reducuon ln conunued bleedlng or
rebleedlng rlsk of 47
usually reserved for cases where endoscopy ls delayed,
unsuccessful, unavallable


epnc U|cer D|sease- Med|ca| 1reatment
Shou|d n. y|or| be erad|cated?
?es
ulcer recurrence raLes 6 vs. 60 ln Lhose LreaLed for P. ylorl
1reaL wlLh Lrlple Lherapy: l, Amox and ClarlLhromycln resulLs ln 80
eradlcauon raLe
epnc U|cer D|sease- rognosncanon
What |s the prognosnc s|gn|hcance of the u|cers appearance
on LGD?
8lsk of rebleedlng based on endoscoplc ndlngs
Acuvely bleedlng 90
vlslble vessel 30
AdherenL cloL 23-30
Clean base 2-3
?oung, healLhy wlLhouL cllnlcal slgns of severe bleed and wlLh clean ulcer on
endoscopy can generally be dlscharged home

now shou|d you manage reb|eeds?
MosL uCl8s resolve sponLaneously or can be conLrolled wlLh 1
sL

endoscoplc procedure.
Second auempL aL endoscopy ls reasonable ln mosL pauenLs
CLhers progress Lo:
surgery for oversew or parual gasLrecLomy
Anglography for locallzauon and embollzauon
lnLra-arLerlal vasopressln
Gastroesophagea| Var|ces
Gastroesophagea| Var|ces
resenL ln 40-60 of pauenLs wlLh clrrhosls
MosL common ln dlsLal 2-3 cm of esophagus
up Lo 30 of lnlual bleedlng eplsodes are faLal
8lsk of rebleedlng ls up Lo 70

Med|ca| Management
rophy|acnc annb|oncs shou|d be g|ven
Plgh raLe of u1ls, S8, 8esp lnfecuons, bacLeremla ln Lhls populauon
Cochrane 8evlew 2002
8 Lrlals, 864 pauenLs
MorLallLy reduced 27 vs conLrols
8acLerlal lnfecuons reduced 60
noroxacln, clprooxacln, or cerlaxone are preferred agenLs
Med|ca| Management of Var|cea| 8|eed|ng
Vasopress|n- rare|y used anymore
lnduces mesenLerlc vasoconsLrlcuon --> decreased ouulow Lo
porLal sysLem
Can cause cerebral, myocardlal, bowel and llmb lschemla due Lo
sysLemlc vasoconsLrlcuon
Somatostann]Cctreonde
uecreases porLal lnow Lhrough lnhlbluon of splanchnlc
vasodllauon
SysLemlc vasoconsLrlcuon noL an lssue
Lmcacy of Somatostann ana|ogues vs. Vasopress|n
SubsLanually beuer lnlual conLrol of bleedlng (nn1=4)
SubsLanually lower rlsk of lschemlc compllcauons.
CcLreoude ls Lhe pharmacologlc agenL of cholce
Lndoscop|c 1reatment of Var|cea|
8|eed|ng
Sc|erotherapy]band ||ganon are dehn|nve treatments for
var|ces, used |n con[uncnon w|th octreonde.
ScleroLherapy
ln[ecuon of sclerosanL lnLo varlx"Lhrombosls/brosls
Compllcauons: sLrlcLure, bleedlng, perforauon, medlasunlus
asplrauon
varlceal band llgauon
lacemenL of small elasuc bands around varlces ln dlsLal
esophagus
few slde eecLs
Cllnlcal Lrlals of scleroLherapy vs band llgauon
Slmllar raLes of achlevlng hemosLasls and prevenuon of early
rebleedlng
8and llgauon sllghLly beuer ln prevenung laLe rebleedlng
Management of kefractory Var|cea|
8|eeds
10 of varlcleal bleeds are refracLory Lo lnlual medlcal/
endoscoplc managemenL

Cpuons:
repeaL endoscopy,
balloon Lamponade,
porLo-sysLemlc shunL

AASLu Culdellnes suggesL Lo repeaL LCu rsL

8a||oon-tamponade
A lasL dlLch, Lemporlzlng measure Lo
achleve lnlual conLrol of bleedlng
auenLs musL be lnLubaLed
SengsLaken-8lakemore Lube: gasLrlc
and esophageal balloons, gasLrlc
sucuon porL
MlnnesoLa Lube: same as S8 Lube
wlLh exLra esophageal sucuon porL.
Plgh rlsk of rebleed when deaLed
Lsophageal rupLure ls a dreaded
compllcauons

1rans[ugu|ar Intrahepanc ortosystem|c
Shunts (1IS)
1racL Lhrough hepauc parenchyma vla balloon dllauon
8-18 cumulauve rlsk of bleed aL one year
lncreased raLe of encephalopaLhy
unproven survlval beneL
8esL used as a brldge Lo LransplanLauon
Lower GI 8|eeds
Lower GI 8|eed
C||n|ca| resentanon
PemaLochezla mosL common
8lood from L colon brlghL red vs. dark/maroon blood from 8
colon
Powever, blood from cecum may presenL as melena
Lower GI 8|eed.Lno|ogy
ulveruculosls 30-30
MosL dlverucula are ln le colon, buL mosL bleedlng
dlverucula are on rlghL slde
Anglodysplasla 20-30
May be mosL common cause of LCl8 ln Lhose >60 yr
Collus, l8u, neoplasm, anorecLal dlsorders
D|agnosnc Lva|uanon
Shou|d you p|ace and NG tube?
PemaLochezla ls due Lo LCl8 ln only 89
nC Lube ls lndlcaLed ln pauenLs wlLh
hemaLochezla and hemodynamlc lnsLablllLy
What are the key d|agnosnc opnons?
Colonoscopy
8adlonucllde lmaglng
MesenLerlc anglography
Co|onoscopy
Locallze slLe, Lake speclmens, poLenually Lherapeuuc
Can LreaL dlverucula, anglodysplasla, hemorrholds,
posL-polypecLomy bleedlng
Can reach cecum ln 93
usually requlres bowel prep & sedauon
Larly colonoscopy resulLs ln shorLer hosplLal lengLh of
sLay
kad|onuc||de Imag|ng
More sensluve Lhan anglography, buL less speclc Lo
dlagnose locauon.
Can deLecL bleedlng as slow as 0.1 ml/mln
Locallzes bleedlng Lo area of abdomen, buL noL a
speclc slLe
May be used Lo help gulde anglography
8ule of Lhumb: lf radlonucllde lmaglng ls negauve so
wlll be anglography.
kad|onuc||de Imag|ng
Ang|ography
100 speclc buL sensluvlLy varles (30-30)
SMA ls source of mosL dlverucular and anglodysplasla
bleeds
Allows Lherapeuuc lnLervenuon wlLh vasopressln and
embollzauon
vasopressln sLops bleedlng ln 91, permlmng
semlelecuve surgery
kefractory b|eed|ng
Lxsangulnaung LCl8 ls a surglcal emergency.
ColecLomy can be llfe-savlng
Stress U|cer rophy|ax|s
Stress U|cers |n the ICU
Cause overL bleedlng ln 1.3 -13 of lCu pauenLs
>73 of pLs wlLh severe burns or head ln[ury have mucosal
eroslons [ 3days.
Maln lssue: lmpalred mucosal proLecuon from decreased
glycoproLeln mucous layer.

Cho|ces for Stress U|cer rophy|ax|s
roton ump Inh|b|tors
uecreases parleLal cell acld secreuon
8alses gasLrlc pP
n2 keceptor b|ockers
uecreases parleLal cell acld secreuon
8alses gasLrlc pP
Sucra|fate
CoaLs and proLecLs gasLrlc mucosa
no change ln gasLrlc pP
Who shou|d rece|ve stress u|cer prophy|ax|s?
ASn 1herapeunc Gu|de||nes on Stress U|cer rophy|ax|s
Ind|canons for prophy|ax|s:
Ls wlLh coagulopaLhy (plaLeleLs<30k, ln8>1.3)
Ls recelvlng Mv >2days
Ls wlLh ulcer dlsease or Cl8 wlLhln 1 yr
Ls wlLh 2 or more of Lhe followlng:
Sepsls, lCu admlsslon >1 wk, sLerold use
(some also advocaLe: severe burns, 18l)
Pow many pauenLs would you need Lo LreaL Lo prevenL 1 Cl
8leed?
Plgh rlsk: 30
Low rlsk: 900

Am J Health Syst Pharm. 1999
Wh|ch agent? Controvers|a|
I vs n2k8 vs Sucra|fate

Cutcome n2k8 Sucra|fate -va|ue
Cl 8leed 1.7 3.8 0.02
noso. nA 19 16 0.19
MorLallLy 23 23 0.79
lCu LCS 9d 9d 0.27
Cook DJ. NEJM. 1998
Cutcome ke|anve k|sk w I - va|ue
uCl8 0.36 (0.19-0.68) 0.002
MorLallLy 1.01 (0.83-1.24) 0.91
nosocomlal nA 1.06 (0.73-1.32) 0.76
C dlmclle lnfecuon noL reporLed n/a
Alhazzani W. Crit Care Med. 2013
8ouom ||ne
ls appears Lo be superlor Lo boLh P288s and
sucralfaLe ln prevenung Cl bleeds ln crlucally lll
pauenLs.

no clear slgnal regardlng raLes of nosocomlal nA or
morLallLy.