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Gastrointestinal hemorrhage in

the ICU
Doctor Chad
Pulmonary & Critical Care Medicine

Objectives
Initial approach to the patient with GIB
Evaluation and treatment of UGIB
Review pharmacologic and transfusion thresholds in
GIB
Evaluation and treatment of LGIB
Stress Ulcer Prophylaxis in the ICU
Board Review
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Initial Approach to Adults with GIB


Case
TA 45

yo M with a PMHx of ETOH abuse presents with BRBPR


for 5 days.

Blood

streaked stools on and off - seemed like more red in the


toilet bowl so came in

Takes

no medications except baby aspirin daily

VS

98F 100/55 101 99% 18

PE

only significant for mild tachycardia

WBC 11 Hg 10.0 Plts 208 - no previous CBC

What is the DDx for his GIB

Causes of acute UGIB and LGIB


Causes of AUGIB

Ulcers (esophageal, gastric,


duodenal)

Dieulafoys lesions

Varices (esophageal, gastric)

Aortoesophageal fistula

Causes of ALGIB
Diverticulosis

Ischemic colitis
Arterial-venous
malformations
Vascular ectasias
Hemorrhoids
Rectal varices
Inflammatory Bowel
Disease
Infectious diarrhea
5

Ligament of Treitz

Causes of UGIB

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 1%

Artery at gastric fundus 1%

Gastric antral vascular ectasia 0.5 to 2%

Aorto-enteric fistula <1%

JAMA. 2012 Mar;307(10):1072-9

Incidence of Adults with GIB


Annual incidence of hospitalization for acute upper GI
bleeding (AUGIB) is 1/1,000 people in North America.
AGIB mortality is 7% to 10%
Mortality risk higher in elderly patients and patients with
multiple comorbid conditions
ICU pts that develop clinically significant bleeding have
mortality as high as 48% compared with 9% in ICU
patients without bleeding.
JAMA. 2012 Mar;307(10):1072-9

Factors suggestive of UGIB


Study looking at LR predictive of UGIB (proximal to
ligament of Treitz)
Patient

reported history of Melena [5.1-5.0]

Melena
Blood

on exam [25]

or coffee grounds on nasogastric lavage [LR 9.6]

BUN/Cr

> 30 [7.5]

JAMA. 2012 Mar;307(10):1072-9

PMHx suggesting specific GIB causes


Portal hypertensive gastropathy in a patient with a hx
liver disease or alcohol abuse Varices
AAA or Aortic graft Aorto-enteric fistula
Older age - Angiodysplasia
NSAIDs - PUD
Smoking hx - Malignancy
Enteric Anastomotic Surgery - Marginal Ulcers (at site)

JAMA. 2012 Mar;307(10):1072-912

Importance of Medication History


Predispose to Ulcers: NSAIDS, ASA
Medication induced esophagitis: Tetracyclines,
Clindamycin, Bisphosphonates, KCL, Quinidine
Black Stool: Bismuth and Iron
Promote Bleeding: Antiplatelets, anticoagulant

JAMA. 2012 Mar;307(10):1072-9

Clinically significant bleeding


1. Increase in resting heart rate > 20 beats per min
2. Spontaneous decrease of > 20 mmHg in systolic BP
3. Decrease in BP with change in position from supine to
sitting up > 10 mm Hg
4. Decrease in hemoglobin level of more than 2 g/dL
from baseline
5. Failure of hemoglobin to rise with blood transfusion

High risk recurrent bleeding

Age > 65 years


Comorbid conditions
Low initial hemoglobin
Melena
Fresh blood on rectal exam
Hematemesis
Bloody NG aspirate
Transfusion requirement

Triage: ICU vs Floor


Indications for ICU admission:
Hemodynamic instability - stages of shock
Decrease in Hct of >6
Transfusion of >2 units pRBCs in <12hrs
Active bleeding
Severe comorbidities

JAMA. 2012 Mar;307(10):1072-9

Stages of Hypovolemic Shock

Elizabeth D Agabegi; Agabegi, Steven S. (2008). Step-Up to Medicine (Step-Up Series). Hagerstwon, MD: Lippincott Williams & Wilkins. ISBN 0-7817-7153-6.

When to Intubate?
AMS - unable to protect airway
Severe bleeding prior to endoscopy

JAMA. 2012 Mar;307(10):1072-9

General Management of Rapid GIB


ABCs
NPO
IV access: 2 large (16g) bore piv > CVC
Aggressive hemodynamic resuscitation reduces mortality - IVF
Reverse coagulopathy
Serial blood count monitoring
Transfusion of blood products when appropriate*
Consultation with gastroenterology, general surgery, and/or
interventional radiology

Am J Gastroenterol. 2004 Apr. 99(4):619-22.

Poiseuilles law
Poiseuilles law states that the rate of flow through a
tube is proportional to the fourth power of the radius of
the cannula and is inversely related to its length.

Transfusion Strategies for Acute Upper


Gastrointestinal Bleeding
A single center study in Barcelona, Spain RCT

Objective: Liberal blood transfusions Hg 9 g/dL vs. restrictive hemoglobin below 7g/dL.

Method: Randomized 921 patients with acute GI bleeding to undergo either a restrictive
blood transfusion strategy (to hemoglobin >7 g/dL) or a liberal strategy (to Hb > 9 g/dL).
The primary outcome was death at 45 days from any cause.

RESULTS
The average number of units transfused was 1.5 vs. 3.7.
At 45 days, 23 people (5%) restrictive blood transfusion group had died vs. 41 people
(9%) in the liberal blood transfusion group.

Those in the restrictive group had a 45% relative reduction, and a 4% absolute risk
reduction for death (5% vs. 9%, p=0.02).
People with mild to moderate cirrhosis with variceal bleeding were at clearly increased
risk of death by blood transfusion, while the risks or benefits of transfusion for people
with bleeding gastric ulcers or other non-variceal bleeds was uncertain.

N Engl J Med. 2013 Jan;368(1):11-21.

Transfusions
In low risk patients with self-limited bleeding and
absence of high-risk features, blood loss anemia
of hemoglobin 7 to 10 g/dL may be well tolerated
without need for pRBC transfusion
In patients with active GIB are not appropriate
candidates for conservative transfusion thresholds
and were excluded from studies assessing the
safety of such thresholds

N Engl J Med. 2013 Jan;368(1):11-21.

Acid Suppression
Use PPI as H2 blockers do not reduce ulcer
rebleeding
Infusion of high-dose omeprazole before index
endoscopy accelerated the resolution of signs of
bleeding in ulcers but does not reduce mortality or
transfusion requirements
High dose Oral and IV PPI equally effective

N Engl J Med 2007; 356:1631-1640

Omeprazole before Endoscopy in Patients with Gastrointestinal Bleeding

RCTs show superiority of high-dose PPIs in preventing


further bleeding after endoscopic hemostasis for peptic
ulcer bleeding

N Engl J Med 2007; 356:16311640

Management of AUGIB - NGT Lavage


NGT lavage? Controversial - no change in mortality but faster
time to endoscopy
If blood present, helpful (93% UGIB)
If clear lavage, not helpful
In one study 15.9% clear aspirate had UGIB on endoscopy
Color of aspirate affects mortality - red aspirate highest
mortality
Expert rec: Do NGT lavage if it will help with visualization for
endoscopy

Gastrointest Endosc. 2004 Oct. 60(4):497-504

Risk Stratification of AUGIB - Rockall Score

Lancet. 1996;347(9009):1138

Risk Stratification of AUGIB - Modified


Glasgow Blatchford Score

Lancet. 2000 Oct 14;356(9238):1318-21.

Risk of Ulcers Bleeding

Management of AUGIB - SURGERY


Primary surgical intervention should be considered
in patients with a perforated viscus

Perforated duodenal ulcer


Perforated gastric ulcer
Boerhaave syndrome

In patients who are poor operative candidates,


conservative treatment with nasogastric suction and
broad-spectrum antibiotics can be instituted

Gastrointest Endosc. 2004 Oct. 60(4):497-504

Management of AUGIB - Antibiotics in


cirrhotics
Cochrane Review:
Types of studies: RCTs comparing different types of antibiotic prophylaxis with no
intervention, placebo, or another antibiotic.
Results: Twelve trials (1241 patients) evaluated antibiotic prophylaxis vs. placebo or
no antibiotics.
Antibiotic prophylaxis compared with no intervention or placebo was associated
with:

Beneficial effects on mortality (RR 0.79, 95% CI 0.63 to 0.98)

Bacterial infections (RR 0.36, 95% CI 0.27 to 0.49)

Rebleeding (RR 0.53, 95% CI 0.38 to 0.74)

Days of hospitalization (MD -1.91, 95% CI -3.80 to -0.02)

Cochrane Database of Systematic Reviews 2010

Management of AUGIB - Other agents


A prokinetic agent eg erythromycin/reglan decreases
the need for second-look endoscopy - increases
visualization
Somatostatin and analogs eg octreotide may be
helpful - controversial - stronger role in variceal
bleed
Tranexamic acid (antifibrinolytic agent) role limited
as no benefit when PPI and Endoscopy used

Gastrointest Endosc. 2010;72(6):1138.

Management of AUGIB - Endoscopy


Hemostatic therapy indicated for high-risk
endoscopic stigmata
Cautery with bipolar probes or mechanical therapy
with hemostatic clips.
Injection of dilute epinephrine may precede either
modality.
Hemoclips superior to epinephine in prevention of
ulcer rebleeding

Clin Gastroenterol Hepatol. 2009;7(1):3347

Summary of Management of AUGIB

Summary of Management of AUGIB


Patients with high-risk stigmata for recurrent
bleeding (nonbleeding or actively bleeding vessel)
require post-EGD ICU monitoring for at least 24 h.
Most rebleeding episodes occur within 72 h of the
initial episode.
Early surgical consultation in patients with severe,
acute UGIB - possible aortoenteric fistula or high risk
of recurrent bleeding

Variceal bleed
Child A or B liver disease: Hepatic venous pressure
gradient < 20 octreotride for at least 48 hours after
onset of bleeding, and endoscopic therapy within 12
hours
Antibiotics - prophylaxis against spontaneous
bacterial peritonitis
Childs C: Emergent EGD

Variceal bleed Management


Balloon tamponade - Sengstaken-Blakemore tube
For patients with acute, severe hemorrhage with
rapid hemodynamic instability
Temporary stabilization until definitive treatment

Transjugular Intrahepatic Portosystemic


Shunt (TIPS)
Recent RCTs suggests that early decompression by
TIPS placement within 24 to 48 h in high-risk patients is
associated with reductions in treatment failure and in
mortality

N Engl J Med 2010; 362:23702379

Variceal bleed Management


Esophageal variceal hemorrhage
Band ligation is preferred
Sclerotherapy - if culprit varix cannot be localized
due to poor visibility/bands do not adhere

Causes of ALGIB

Management of ALGIB
Colonoscopy after prep
If unclear UGIB vs LGIB, do EGD first
If cannot find lesion on colonoscopy, radionuclide scanning
with technetium- 99m-labeled red cell scintigraphy - need
bleeding rate 0.1 to 0.5 mL/min

Sensitive not specific

Mesenteric angiography - detects bleeding > 0.5 mL/min.

100% specific, not sensitive

Positive angiogram is often followed by selective embolization of


the bleeding source

Stress Ulcer ppx in ICU patients


Mechanical ventilation of >48 h duration
Coagulopathy
Two or more of the following:

Sepsis
ICU admission of >1 week
Occult GIB >6 days

Steroid therapy

No difference between PPI and H2 blocker but H2


blocker preferred

Am J Health Syst Pharm. 1999;56(4):


347379.

References
Does this patient have a severe upper gastrointestinal bleed?
Srygley FD, Gerardo CJ, Tran T, Fisher DA. JAMA. 2012
Mar;307(10):1072-9.
Baradarian R, Ramdhaney S, Chapalamadugu R, Skoczylas L,
Wang K, Rivilis S, et al. Early intensive resuscitation of patients with
upper gastrointestinal bleeding decreases mortality. Am J
Gastroenterol. 2004 Apr. 99(4):619-22.

Blatchford O, Murray WR, Blatchford M. A risk score to predict


need for treatment for upper-gastrointestinal haemorrhage. Lancet.
2000 Oct 14;356(9238):1318-21.
Lau , J. Y., et al. (2007). "Omeprazole before Endoscopy in
Patients with Gastrointestinal Bleeding." New England Journal of
Medicine 356(16): 1631-1640.

Sarin N, Monga N, Adams PC. Time to endoscopy and outcomes


in upper gastrointestinal bleeding. Can J Gastroenterol. 2009 Jul.
23(7):489-93

Laine L, McQuaid KR. Endoscopic therapy for bleeding ulcers: an


evidence-based approach based on meta-analyses of randomized
controlled trials. Clin Gastroenterol Hepatol. 2009;7(1):3347.

Adler DG, Leighton JA, Davila RE, Hirota WK, Jacobson BC,
Qureshi WA, et al. ASGE guideline: The role of endoscopy in acute
non-variceal upper-GI hemorrhage. Gastrointest Endosc. 2004 Oct.
60(4):497-504

Garcia-Pagan JC, Caca K, Bureau C, Tseng PL, Huang YB. Early


use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J
Med. 2010;362(25):23702379

Rockall TA, Logan RF, Devlin HB, Northfield TC. Selection of


patients for early discharge or outpatient care after acute upper
gastrointestinal haemorrhage. National Audit of Acute Upper
Gastrointestinal Haemorrhage. Lancet. 1996 Apr
27;347(9009):1138-40. PubMed PMID: 8609747.

American Society of Health-System Pharmacists. ASHP


therapeutic guidelines on stress ulcer prophylaxis. Am J Health Syst
Pharm. 1999;56(4):
347379.

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