Stabilization How Common is GI Bleed Why do we care about them 300000 hospitalizations annually in the US UGIB mortality rate 6 10 Massive LGIB mortality rate 4 10 Mortality increases in the elderly patients with hepatic and renal dysfunction CAD and malignancies peop ID: 927357
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Slide1
What is the most important first step in managing a GI bleed?
Stabilization!
How Common is GI Bleed? Why do we care about them?
300,000 hospitalizations annually in the U.S. UGIB mortality rate 6 -10 % Massive LGIB mortality rate 4 -10% Mortality increases in the elderly, patients with hepatic and renal dysfunction, CAD and malignancies (people usually die from another complication, NOT exsanguination).How do they usually present? UGIB - hematemesis, coffee ground emesis, melena, nausea with epigastric pain, hypotension, hematochezia, AMS (in cirrhosis)LGIB – Same but typically more hematochezia. (Melena comes prior to the ligament of What are the main causes? UGIB - PUD 40-79%, Gastritis/duodenitis 5-30%, Esophageal varices 6-21%, Mallory-Weiss tear 3-15%, Esophagitis 2-8%, Gastric cancer 2-3%, Dieulafoy’s lesion <1%, AVM <1%, Portal gastropathy <1%LGIB – Large Bowel – diverticuli 17-40%, AVM 2-30%, colitis (ischemia, infectious, IBD, radiation) 9-21%, colonic neoplasms/post-polypectomy bleeding 11-14%, anorectal causes (hemorrhoids and rectal varicies) 4-10%, colonic tuberculosisLGIB – Small Bowel – angiodysplasia, jejunoileal diverticula, Meckel’s diverticulum, Neoplasms/lymphomas, enteritis, Crohn’s disease, aortoduodenal fistula in patient with synthetic vascular graftGI Bleed “fake outs?”Epistaxis, charcoal, iron, bismuth, beetsWhat are the fundamental principles of treating GI Bleeds? Stabilize, risk stratify, predict the cause and then focus on management details
GI Bleed (1)
Updated 1/18 Stromberg
C.L.I.P.S.
Slide2Why do we use ceftriaxone in patients with Cirrhosis and UGIBs?
Antibiotic prophylaxis may reduce mortality and bacterial infection in cirrhotic inpatients with UGIBs
Initial management? (Stabilize)
Vitals (hypotension = 20-25% blood loss; othostatic tachycardia = 10-20%)IV Access – Isotonic FluidsNPO, stop anticoagulants. Labs – CBC, BUN, coags, T&S or cross if needed, stool guaiac, ROTEM?Blood products consider if bleeding rapidly or Hb less than 7 & 9 (in CAD) Risk StratifyMICU? Yes if hypotensive, active bleeding, or respiratory distress.Blatchford score for UGIBs can be helpful. Upper VS Lower Bleed? NG Lavage? NOT good at ruling out UGIB. Has no mortality benefit or change in LOSIn one study, 11% of hematochezia was from an UGIB. What diseases do you want to identify that will change your management?In patients with cirrhosis, we add octreotide and ceftriaxone.UGIB management and their evidence? PPI – reduces rebleeding rate, LOS and transfusion. Good evidence.
Octreotide – In esophageal varices: may reduce initial hemostasis failure and number of transfusions. May not reduce mortality.
Ceftriaxone - Bacterial infections exist in 20% of patients admitted with UGIB and 50% develop an infection during hospitalization. Good evidence
Consult GI – EGD, Tagged RBC scan? Angiography? TIPS procedure?
LGIB
Mgt
Rule out an upper GI bleed!
GI, tagged RBC scan? angiography? Push
enteroscopy
? Barium UGI series? Capsule endoscopy?How do I order a transfusionAdult General Transfusion OrdersetBB Prepare and cross match, BB Transfuse RBCs
GI Bleed(2)
C.L.I.P.S.