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Practical approach to Non variceal bleed
This document provides an overview of the practical approach to managing non-variceal upper gastrointestinal bleeding. It discusses initial considerations including risk stratification, definitions, differential diagnosis, history and physical exam findings. It then covers resuscitation including fluid management and transfusion thresholds. The role of endoscopy is explained, including optimal timing and findings requiring endoscopic therapy. Risk scores for predicting outcomes and need for intervention are presented. Management strategies before and after endoscopy are outlined.
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Introduction to non-variceal upper gastrointestinal bleeding (UGIB) and learning objectives related to its management.
Definitions of UGI and lower intestinal bleeding, factors to consider in diagnosis and risk stratification.
List of non-variceal UGI bleeding causes with incidence rates, focusing on peptic ulcers and erosions.
The significance of stool color, patient history, and physical examination findings in assessing UGI bleeding.
Assessment of hypovolemia indicators along with predictors to differentiate between upper and lower GI sources.
Initial shock assessment, IV resuscitation with crystalloids, and pre-endoscopy fluid management.
Comparative study on restrictive vs. liberal transfusion strategies and outcomes relating to UGIB mortality.
Use of Rockall, AIMS65, and Blatchford scores to predict mortality and guide best practices pre-endoscopy.Pharmacotherapy and pre-endoscopic measures including PPI administration and their impact on UGI bleed management.
Guidelines for early endoscopic intervention, including the significance of endoscopic stigmata and treatment options.
Management strategies post-endoscopy with emphasis on guidelines for resuming treatment protocols.
Various endoscopic devices and techniques, including mechanical and thermal therapies for bleeding control.
Key takeaways emphasizing the importance of timely resuscitation and supportive care in managing UGIB.
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Practical approach to Non variceal bleed
- 1. Practical Approach toNon Variceal UGI bleed Presenter : Dr.Abhinav Kumar
- 2. Learning Objectives • UGIB –Nonvariceal (PUD) – Resuscitation, risk assessment, pre-endoscopy management – Role of endoscopy – Post-endoscopy management
- 3. Definitions • Upper GIbleed – arising from the esophagus, stomach, or proximal duodenum • Lower intestinal bleed – arising from colon/rectum
- 4. Initial Considerations • Differentialdiagnosis? – What is most likely source? – What diagnosis can you least afford to miss? • How sick is this patient? (risk stratification) – Determines disposition – Guides resuscitation – Guides decision : need for/timing of endoscopy
- 5. Acute Upper GastrointestinalBleed Non Variceal Bleed 1. Peptic ulcer 2. Gastroduodenal erosions 3. Oesophagitis 4. Mallory-Weiss tear 5. Vascular Malformations 6. Portal hypertensive Gastro duodenopathy 7. UGI malignancy 35 -50% 5 - 15% 5 - 15% 15% 5% 5% 1% Gut 2002;51(Suppl IV):iv1–iv6
- 6. Incidence of UGIBleed in India
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- 10. Stool color andorigin/pace of bleeding • Guaiac positive stool – Occult blood in stool – Does not provide any localizing information – Indicates slow pace, usually low volume bleeding • Melena – Very dark, tarry, pungent stool – Usually suggestive of UGI origin (but can be small intestinal, proximal colon origin if slow pace) • Hematochezia – Spectrum: bright red blood, dark red, maroon – Usually suggestive of colonic origin (but can be UGI origin if brisk pace/large volume)
- 11. History & PhysicalExamination History • Localizing symptoms • History of prior GIB • NSAID/aspirin use • Liver disease/cirrhosis • Vascular disease • Aortic valvular disease, chronic renal failure • AAA repair • Radiation exposure • Family history of GIB Physical Examination • Vital signs, orthostatic • Abdominal tenderness • Skin, oral examination • Stigmata of liver disease • Rectal examination – Objective description of stool/blood – Assess for mass, hemorrhoids – No need for guaiac test
- 12. Specific causes ofupper GI bleeding may be suggested by the patient's symptoms • Peptic ulcer: Epigastric or right upper quadrant pain • Esophageal ulcer: Odynophagia, gastro esophageal reflux, dysphagia • Mallory-Weiss tear: Emesis, retching, or coughing prior to hematemesis • Variceal hemorrhage or portal hypertensive gastropathy: Jaundice, weakness, fatigue, anorexia, abdominal distention • Malignancy: Dysphagia, early satiety, involuntary weight loss, cachexia
- 13. History & PhysicalExamination History • Localizing symptoms • History of prior GIB • NSAID/aspirin use • Liver disease/cirrhosis • Vascular disease • Aortic valvular disease, chronic renal failure • AAA repair • Radiation exposure • Family history of GIB Physical Examination • Vital signs, orthostatic • Abdominal tenderness • Skin, oral examination • Stigmata of liver disease • Rectal examination – Objective description of stool/blood – Assess for mass, hemorrhoids – No need for guaiac test
- 14. Signs of Hypovolemia •Mild to moderate hypovolemia: Resting tachycardia. • Blood volume loss of at least 15 percent: Orthostatic hypotension (a decrease in the systolic blood pressure of more than 20 mmHg and/or an increase in heart rate of 20 beats per minute when moving from recumbency to standing). • Blood volume loss of at least 40 percent: Supine hypotension.
- 15. Narrowing the DDx:Upper or Lower Source? • Predictors of UGI source: – Age <50 – Melenic stool – BUN/Creatinine ratio • If ratio ≥ 30, think upper GIB J Clin Gastroenterol 1990;12:500 Am J Gastroenterol 1997;92:1796 Am J Emerg Med 2006;24:280
- 16. • Most usefulsituation: patients with severe hematochezia, and unsure if UGIB vs. LGIB – Positive aspirate (blood/coffee grounds) indicates UGIB • Can provide prognostic info: – Red blood per NGT – predictive of high risk endoscopic lesion – Coffee grounds – less severe/inactive bleeding • Negative aspirate – not as helpful; 15-20% of patients with UGIB have negative NG aspirate Ann Emerg Med 2004;43:525 Arch Intern Med 1990;150:1381 Gastrointest Endosc 2004;59:172 Utility of NG Tube
- 17. Take Home Point#1 Upper GI bleed must still be considered in patients with severe hematochezia, even if NG aspirate negative
- 18. Laboratory data • completeblood count • serum chemistries • liver tests • coagulation studies • serial electrocardiograms • cardiac enzymes
- 19. • initial hemoglobin(acute UGI)patient's baseline because the patient is losing whole blood. • hemoglobin will decline as the blood is diluted by the influx of extravascular fluid into the vascular space and by fluid administered during resuscitation. • Overhydration can lead to a falsely low hemoglobin value.
- 20. ACUTE VS CHRONIC •Acute bleeding normocytic red blood cells • Chronic bleeding Microcytic red blood cells or iron deficiency anemia
- 21. Initial Assessment • Alwaysremember to assess A,B,C’s • Assess degree of hypovolemic shock Class I Class II Class III Class IV Blood loss (mL) 750 750-1500 1500-2000 >2000 Blood volume loss (%) < 15% 15-30% 30-40% >40% Heart rate <100 >100 >120 >140 SBP No change Orthostatic change Reduced Very low, supine Urine output (mL/hr) >30 20-30 10-20 <10 Mental status Alert Anxious Aggressive/dro wsy Confused/unco nscious
- 22. Resuscitation • IV access:large bore peripheral IVs best (alt: cordis catheter) • Use crystalloids first • Anticipate need for blood transfusion • Threshold should be based on underlying condition, hemodynamic status, markers of tissue hypoxia • Should be administered if Hgb ≤ 7 g/dL • 1 U PRBC should raise Hgb by 1 (HCT by 3%) • Remember that initial Hct can be misleading (Hct remains the same with loss of whole blood, until re-equilibration occurs) • Correct coagulopathy
- 23. Resuscitation • IV access:large bore peripheral IVs best (alt: cordis catheter) • Use crystalloids first • Anticipate need for blood transfusion • Threshold should be based on underlying condition, hemodynamic status, markers of tissue hypoxia • Should be administered if Hgb ≤ 7 g/dL • 1 U PRBC should raise Hgb by 1 (HCT by 3%) • Remember that initial Hct can be misleading (Hct remains the same with loss of whole blood, until re-equilibration occurs) • Correct coagulopathy 40% 40% 20% bleed Time IVFs
- 24. Fluid resuscitation • Stabilizationis essential prior to endoscopy to minimize treatment-associated complications. • Active bleeding should receive intravenous fluids (eg, 500 mL of normal saline or lactated Ringer's solution over 30 minutes) • Patients at risk of fluid overload may require intensive monitoring with a pulmonary artery catheter.
- 25. Transfusion Strategy • Randomizedtrial: – 921 subjects with severe acute UGIB – Restrictive (tx when Hgb<7; target 7-9) vs. Liberal (tx when Hgb<9; target 9-11) – Primary outcome: all cause mortality rate within 45 days NEJM 2013;368;11-21
- 26. Restrictive Strategy Superior RestrictiveLiberal P value Mortality rate 5% 9% 0.02 Rate of further bleeding 10% 16% 0.01 Overall complication rate 40% 48% 0.02 NEJM 2013;368;11-21 Benefit seen primarily in Child A/B cirrhotics
- 27. Resuscitation • IV access:large bore peripheral IVs best (alt: cordis catheter) • Use crystalloids first • Anticipate need for blood transfusion • Threshold should be based on underlying condition, hemodynamic status, markers of tissue hypoxia • Should be administered if Hgb ≤ 7 g/dL • 1 U PRBC should raise Hgb by 1 (HCT by 3%) • Remember that initial Hct can be misleading (Hct remains the same with loss of whole blood, until re-equilibration occurs) • Correct coagulopathy Weigh risks and benefits of reversing anticoagulation Assess degree of coagulopathy Vitamin K – slow acting, long- lived FFP – fast acting, short lived - Give 1 U FFP for every 4 U PRBCs
- 28. Resuscitation • Early intensiveresuscitation reduces mortality – Consecutive series of patients with hemodynamically significant UGIB – First 36 subjects = Observation Group (no intervention) – Second 36 subjects = Intensive Resuscitation Group (intense guidance provided) – goal was to decrease time to correction of hemodynamics, Hct and coagulopathy Am J Gastroenterol 2004;99:619
- 29. Early Intensive Resuscitation ReducesUGIB Mortality Am J Gastroenterol 2004;99:619 (groups are essentially the same) Intervention: Faster correction of hemodynamics, Hct and coags. Time to endoscopy similar
- 30. • Observation group – 5MI – 4 deaths • Intense group – 2 MI – 1 death (sepsis) Early Intensive Resuscitation Reduces UGIB Mortality Am J Gastroenterol 2004;99:619
- 31. Causes of Mortalityin Patients with Peptic Ulcer Bleeding • Patients rarely bleed to death • Prospective cohort study >10,000 cases of peptic ulcer bleed • Mortality rate 6.2% • 80% of deaths not related to bleeding Am J Gastroenterol 2010;105:84
- 32. Causes of Mortalityin Patients with Peptic Ulcer Bleeding • Most common causes of non-bleeding mortality: – Terminal malignancy (34%) – Multiorgan failure (24%) – Pulmonary disease (24%) – Cardiac disease (14%) Am J Gastroenterol 2010;105:84
- 33. Take Home Point#2 Early resuscitation and supportive measures are critical to reduce mortality from UGIB
- 34. • Identify patientsat high risk for adverse outcomes • Helps determine disposition (ICU vs. floor vs. outpatient) • May help guide appropriate timing of endoscopy Risk Stratification
- 35. Rockall Scoring System •Validated predictor of mortality in patients with UGIB • 2 components: clinical + endoscopic Variable 0 1 2 3 Age <60 60-79 ≥ 80 Shock No SBP ≥ 100 P<100 Tachy- SBP ≥ 100 P>100 Hypotension- SBP <100 Comorbidity No major Cardiac failure, CAD, other major Renal failure, liver failure, malignancy Gut 1996;38:316
- 36. Clinical Rockall Score– Mortality Rates 0% 10% 20% 30% 40% 50% 60% 0 1 2 3 4 5 6 7
- 37. AIMS65 • Simple riskscore that predicts in-hospital mortality, cost in patients with acute UGIB lbumin <3.0 NR > 1.5 ental status altered ystolic BP <90 + years old Gastrointest Endosc 2011;74:1215
- 38.
- 39. Blatchford Score • Predictsneed for endoscopic therapy • Based on readily available clinical and lab data • Can use UpToDate calculator Lancet 2000;356:1318
- 40. Blatchford Score Gastrointest Endosc2010;71:1134
- 41. Blatchford Score • Mostuseful for safely discriminating low risk UGIB patients who will likely NOT require endoscopic hemostasis • “Fast track Blatchford” – patient at low risk if: BUN < 18 mg/dL Hgb > 13 (men), 12 (women) SBP >100 HR < 100
- 42. • For Non-VaricealUGIB – IV PPI: 80 mg bolus, 8 mg/hr drip – Rationale: suppress acid, facilitate clot formation and stabilization – Duration: at least until EGD, then based on findings Pre-endoscopic Pharmacotherapy
- 43. Pre-endoscopy PPI • Reducesthe proportion of patients with high risk endoscopic stigmata (“downstages” lesion) • Decreases need for endoscopic therapy • Has not been shown to reduce rebleeding, surgery, or mortality rates N Engl J Med 2007;356:1631 Endoscopic treatment required: Omeprazole – 19% (23% of PUD) Placebo – 28% (37% of PUD) High risk Low risk
- 44. Pre-endoscopy Prokinetics • Improvegastric visualization at the time of endoscopy by clearing the stomach of blood, clots, and food residue • meta-analysis examined five trials with 316 patients the use of a prokinetic agent decreased the need for second-look endoscopy • empty stomach at the time of endoscopy compared with patients in the control group (69 versus 37 percent).
- 45. Antibiotics for patientswith cirrhosis • up to 20% Bacterial infections • overall reduction in infectious complications and possibly decreased mortality • reduce the risk of recurrent bleeding esophageal varices
- 46. NO ROLE • Somatostatinand its analogs • Tranexamic acid
- 47. • Early endoscopy(within 24 hours) is recommended for most patients with acute UGIB • Achieves prompt diagnosis, provides risk stratification and hemostasis therapy in high-risk patients • Higher risk clinical features (e.g., tachycardia, hypotension, bloody emesis or nasogastric aspirate in hospital) endoscopy within 12 h may be considered to potentially improve clinical outcomes J Clin Gastroenterol 1996;22:267 Gastrointest Endosc 1999;49:145 Ann Intern Med 2010;152:101 Endoscopy - Nonvariceal UGIB
- 48. When is EndoscopicTherapy Required? • ~80% bleeds spontaneously resolve • Endoscopic stigmata of recent hemorrhage Stigmata Continued/rebleeding rate Active bleeding 55-90% Nonbleeding visible vessel 40-50% Adherent clot Variable, depending on underlying lesion: 0-35% Flat pigmented spot 7-10% Clean base < 5% major
- 49. Major Stigmata –Active Spurting Kelsey, PB (Dec 04 2003). Duodenum - Ulcer, Arterial Spurting, Treated with Injection and Clip. The DAVE Project. Retrieved Aug, 1, 2010, from http://daveproject.org/viewfilms.cfm?film_id=39
- 50. Major Stigmata -NBVV
- 51. Adherent Clot • Roleof endoscopic therapy of ulcers with adherent clot is controversial • Clot removal usually attempted • Underlying lesion can then be assessed, treated if necessary
- 52. Minor Stigmata Flat pigmentedspot Clean base Low rebleeding risk – no endoscopic therapy needed
- 53. Stigmata of RecentHemorrhage Significance Endoscopic stigmata Forrest Prevalence Risks of rebleeding w/o therapy Acute Spurter Ia 18% ~ 100% Acute oozing Ib Non-bleeding visible vessel IIa 17% Up to 50% Non-bleeding adherent clot IIb 17% 30-35% Flat spot IIc 20% 5-8% Clean base III 42% < 3% Johnson et al. GIE 1990; Laine et al. NEJM 1994
- 54. PPI infusion orscheduled 2nd endoscopy • After primary endoscopic hemostasis, PPI infusion achieved a similar rate of ulcer rebleeding as compared to scheduled second endoscopy • PPI infusion reduced patients’ discomfort and endoscopists’ workload from repeating endoscopy • Second endoscopy may have an advantage of shortening the hospital stay • Second endoscopy should be recommended if PPI infusion is not available
- 55. Factors associated withRebleeding • Hemodynamic instability (systolic blood pressure less than 100 mmHg, heart rate greater than 100 beats per minute) • Hemoglobin less than 10 g/L • Active bleeding at the time of endoscopy • Large ulcer size (greater than 1 to 3 cm in various studies) • Ulcer location (posterior duodenal bulb or high lesser gastric curvature)
- 56. Endoscopic Hemostasis Therapy •Epinephrine injection • Thermal electrocoagulation • Mechanical (hemoclips) • Combination therapy superior to monotherapy Kelsey, PB (Nov 08 2005). Stomach - Gastric Ulcer, Visible Vessel. The DAVE Project. Retrieved Aug, 1, 2010, from http://daveproject.org/viewfilms.cfm?film_id=306 Baron, TH (May 01 2007). Duodenum - Bleeding Ulcer Treated with Thermal Therapy, Perforation Closed with Hemoclips. The DAVE Project. Retrieved Aug, 1, 2010, from http://daveproject.org/viewfilms.cfm?film_id=620
- 57. Nonvariceal UGIB – Post-endoscopymanagement • Patients with low risk ulcers can be fed promptly, put on oral PPI therapy. • Patients with ulcers requiring endoscopic therapy should receive PPI gtt x 72 hours – Significantly reduces 30 day rebleeding rate vs placebo (6.7% vs. 22.5%) – Note: there may not be major advantage with high dose over non-high dose PPI therapy N Engl J Med 2000;343:310 Arch Intern Med 2010;170:751
- 58. • Determine H.pylori status in all ulcer patients • Discharge patients on PPI (once to twice daily), duration dictated by underlying etiology and need for NSAIDs/aspirin • In patients with cardiovascular disease on low dose aspirin: restart as soon as bleeding has resolved – RCT demonstrates increased risk of rebleeding (10% v 5%) but decreased 30 day mortality (1.3% v 13%) Nonvariceal UGIB – Post-endoscopy management Ann Intern Med 2010;152:1
- 59. • Determine H.pylori status in all ulcer patients • Discharge patients on PPI (once to twice daily), duration dictated by underlying etiology and need for NSAIDs/aspirin • In patients with cardiovascular disease on low dose aspirin: restart as soon as bleeding has resolved – RCT demonstrates increased risk of rebleeding (10% v 5%) but decreased 30 day mortality (1.3% v 13%) Nonvariceal UGIB – Post-endoscopy management Ann Intern Med 2010;152:1 Not dying is more important than not rebleeding
- 60. Endoscopic Hemostatic Devices Injectiontherapy Mechanical Devices Contact Thermal Devices Non Contact Thermal Devices 1. Adrenaline 2. Sclerosant 3. Combination 1. Band Ligators 2. Endoloops 3. Hemoclips 1. Heater probe 2. Monopolar electrocautery 3. Bipolar electrocautery Argon plasma coagulator
- 61. Injection Therapy • Mostcommonly used • Needles used for sclerotherapy are suitable for injection • Mechanism of action: Vascular tamponade Vasoconstriction Cytochemical reaction
- 62. Technique Kay et al,Journal of Pediatric Gastroenterology and Nutrition, 45(2):157-171, 2007. •Multiple injections are applied around a lesion and then directly at the bleeding point or visible vessel within the lesion •Precise identification of bleeding point is essential
- 63. BEYOND INJECTION THERAPY– WHY?
- 64. Injection alone Dualtherapy Odds ratio Failure 4.23 % 2.59 % 0.65 Rebleed 18.8 % 10.4 % 0.53 Emgergency Surgery 10.8% 7.1% 0.63 mortality 5% 2.5% 0.50 Vergara et al, Cochrane Review 2007
- 65.
- 66. Hemoclip – bleedingVessel
- 67. Indications for Hemoclip •Endoscopic marking of site • Bleeding ulcers • Bleeding arteries <2 mm in size • Post Polypectomy bleed • Diverticula in the colon • Closure of GI tract luminal perforations
- 68. Seibert et al,Endoscopy , 2003 : 35 : 189
- 69. Limitations for Hemoclip •Need for clear endoscopic view & identification of bleeding vessel • Difficult technique to target the lesion with retroversion • Difficult to treat larger lesions • Difficult to apply in deformed Duodenal cap • Difficult to use with Side Viewing endoscope
- 70.
- 71.
- 72. Endoloop • Detachable loopmade of nylon • Indications – Post polypectomy bleed – Esophageal/ gastric variceal bleed – Closing fistulous tract – Submucosal tumours
- 73. • 10 patientswith diagnosis of Lipoma, Leiomyoma, Carcinoid, Brunner’s Adenoma were included • Size 25mm – 55 mm • 9 patients required only 1 session • Retrieval in stool was possible in 60% • No procedure related complications GIE, 2008, Volume 67, No. 3 : 556 - 560
- 74. GIE, 2008, Volume67, No. 3 : 556 - 560
- 75. Arezzo et al,Endoscopy, 2011; 32: 18 - 19
- 76. Ana Catrina etal, CGH, 2011 : 104- 106 Gastocutaneous Fistula after Percutaneous Endoscopic Gastrostomy
- 77.
- 78. Indications Similar to Loopbut useful for smaller lesions – Post polypectomy bleed – AV malformation – Mallory-Weiss tear – Dieulafoy lesion – Blue rubber bleb nevus syndrome – Diverticular bleed
- 79.
- 80. Principle of thermaldevices 1.Thermal devitalization is defined as irreversible death of biologic tissue, which occurs if its temperature reaches 41.5°C. •Not a visible phenomenon 2.Thermal coagulation is defined as conversion of colloidal systems from solid state to a gel, which occurs at approximately 60°C. •Change in colour at the tissue 3.Thermal desiccation is defined as heat-induced dehydration of tissue, which occurs at the boiling temperature •Acts as a insulation layer 4.Thermal carbonization - Can cause smoke & interfere in vision 5.Thermal vaporization - Does not occur in the presence of inert gas
- 81. Procedure 1. Applying probepressure to tamponed bleeding 2. Electrical energy is converted to thermal energy and coagulate tissue
- 82.
- 83. Argon Plasma Coagulator Causeshemostasis by conducting a high- frequency electrical current through a beam of ionized argon gas causing superficial tissue damage and coagulation
- 84.
- 85. Take Home Points •All bleeding eventually stops (and majority of nonvariceal bleeds will stop spontaneously, with the patient alive) • Early resuscitation and supportive care are key to reducing morbidity and mortality from GIB