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“Approach to Lower GI Bleeding”

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“Approach to Lower GI Bleeding” GASTROINTESTINAL EMERGENCIES Ganesh R. Veerappan, MD, FACG AGAF Akron Digestive Disease Consultants, Inc. July 12th, 2019 Outline . Acute abdominal pain . Acute upper GI bleeding - Non-variceal upper GI bleeding - Variceal upper GI bleeding . Acute lower GI bleeding . Food Impaction Acute Abdominal Pain . Abdominal pain of less than 24 hours . History and physical exam are most important in making a diagnosis . Labs and radiographic studies to confirm diagnosis . When diagnosis is obscure, and patient is stable serial exams . When diagnosis is obscure, and patient is unstable surgical exploration Acute Abdominal Pain History . Chronology – onset, duration, progression . Location . Intensity and character . Aggravating and relieving factors – food, BM’s, medicine . Associated symptoms and ROS . Past medical history . Family and social history Acute Abdominal Pain Physical Exam . Vital signs . Systemic exam . Abdominal exam . Genital, rectal, pelvic exam Acute Abdominal Pain – Diagnostics . Labs - CMP, CBC/diff, Amylase/Lipase, Lactate - β-hCG in women of reproductive age - PT/INR in liver disease . Radiology . Plain abdominal series . U/S . CT scan Acute Abdominal Pain Special Circumstances (1) Elderly – History and physical exam may be unreliable – Labs may be normal even with severe intra- abdominal process – Biliary tract disease, malignancy, obstruction, complicated PUD, incarcerated hernia Pregnancy – Appendicitis, cholecystitis, pyelonephritis, adnexal problems, ovarian torsion, ovarian cyst , ectopic pregnancy Acute Abdominal Pain Special Circumstances (2) Immunocompromised host – Organ transplant, chemotherapy, chronic immune suppression, immunodeficiency syndromes – General population disease vs. unique disease (neutropenic enterocolitis, pneumatosis intestinalis, graft-vs.-host disease, CMV, fungal infections, lymphoma, Kaposi’s, etc.) The ICU patient – History and physical exam not ideal – Greater role of imaging (i.e., CT scan) – Overlooked trauma injuries, post-op complications, ileus/obstruction, acalculous cholecystitis, stress ulcer, ischemia Acute Abdominal Pain – Common Causes (1) CONDITION ONSET SITE CHARACTER TYPE RADIATION INTENSITY Appendicitis Gradual Periumbil- Diffuse Ache None + icalRLQ localized Cholecystitis Rapid RUQ Localized Constricting Scapula ++ Pancreatitis Rapid Epigastric, Localized Boring Midback ++ to +++ back Diverticulitis Gradual LLQ Localized Ache None + to ++ Perforated Sudden Epigastric Localized Burning None +++ peptic ulcer diffuse Small bowel Gradual Periumbil- Diffuse Crampy None ++ obstruction ical Gastro- Gradual Periumbil- Diffuse Spasmodic None + to ++ enteritis ical + = Mild, ++ = Moderate, +++ = Severe Acute Abdominal Pain – Common Causes (2) CONDITION ONSET SITE CHARACTER TYPE RADIATION INTENSITY Mesenteric Sudden Periumbil- Diffuse Agonizing None +++ ischemia ical Ruptured Sudden Abdominal, Diffuse Tearing Back, flank +++ AAA back, flank Pelvic Gradual RLQ, LLQ, Localized Ache Upper thigh ++ inflammatory or pelvic disease Ruptured Sudden RLQ, LLQ, Localized Light- None ++ ectopic or pelvic headed pregnancy + = Mild, ++ = Moderate, +++ = Severe Acute Appendicitis . Younger patients (teens, 20s) . Pain, anorexia, nausea, fever . Vague peri-umbilical pain migrates to RLQ . Mild leukocytosis . CT aids in diagnosis . Antibiotics and surgical resection Acute Cholecystitis . Persistent dull ache, RUQ, radiates to back or scapula . Pain resolves in biliary colic but persists with cholecystitis . Nausea, vomiting, low-grade fever . + Murphy’s sign . Mildly elevated WBC’s, LFT’s . Diagnosed with RUQ US . Cholecystectomy treatment Acute Cholangitis . Charcot’s triad - fever, RUQ pain, jaundice (  TB) . Reynold’s pentad - above + MS changes and hypotension . A medical emergency; may lead to biliary sepsis/septic shock, with high mortality . US to look for stones and CBD dilation; MRCP . IV ABX – (i.e., Zosyn, etc.) . RX: biliary decompression – ERCP – within 12 hours if stable; emergent if not stable . Cholecystectomy prior to discharge from hospital Acute Pancreatitis . Most commonly due to gallstones and ETOH . Boring abd pain radiate straight through back . Fever, anorexia, nausea, vomiting . Amylase and lipase > 2-3X NL values . Not all enzyme elevations are pancreatitis! . CT abdomen but not necessary to confirm dx . Hypoactive BS’s, mild leukocytosis . NPO/IVFs/Analgesics Acute Diverticulitis . Older population . Sigmoid colon most common site . Fever, LLQ tenderness, palpable mass . Leukocytosis . CT used to make dx and R/O perforation . IV/PO antibiotics . Outpatient colonoscopy Perforated Peptic Ulcer . Epigastric, sudden, sharp severe pain . Tachypnea, tachycardia . Hypotension, rigid abdomen . X-ray: free air 75% of the time . Immediate surgery Small Bowel Obstruction . 70% of cases in adults due to adhesions . Sudden, crampy, peri-umbilical abd pain . Nausea and vomiting temporary relief . Distended abdomen & hyperactive bowel sounds . X-ray – dilated loops of bowels & fluid levels . RX- conservative (NPO, NG) vs. surgery Acute Mesenteric Ischemia • Decreased perfusion in gastrointestinal vasculature leading to ischemia and high mortality • 4 major categories 1) embolic arterial occlusion (50%) 2) thrombotic arterial occlusion (15%) 3) nonocclusive mesenteric ischemia (20%) 4) venous thrombosis (15%) • RFs include older age, CAD, PVD, arrhythmias • Acute onset crampy periumbilical “pain out of proportion” to exam, nausea, vomiting, fear of food • ↑ WBC’s; acidosis late finding • CT with angiography best initial test Acute Aortic Aneurysm (AAA) . Rupture or dissection of AAA . Acute, sudden onset, severe tearing mid- abdominal pain . Lightheadedness, diaphoresis, nausea . 75%: Classic triad: hypotension, pulsatile mass, and abdominal pain . Emergency surgery Extra-abdominal Causes of Acute Abdominal Pain CARDIAC THORACIC INFECTIONS Myocardial ischemia/infarction Pneumonitis Herpes zoster Myocarditis Pleurodynia Osteomyelitis Endocarditis Pneumothorax Typhoid fever Congestive heart failure Empyema Esophagitis HEMATOLOGIC METABOLIC Esophageal spasm Sickle cell anemia Uremia Esophageal rupture Hemolytic anemia Diabetes mellitus Henoch-Schönlein Porphyria MISCELLANEOUS Acute leukemia Acute adrenal insufficiency Muscular Hyperlipidemia Narcotic withdrawal Hyperparathyroidism Familial Mediterranean fever NEUROLOGIC Psychiatric disorders Radiculitis Heat stroke Abdominal epilepsy Tabes dorsalis GI Bleeding GI Bleeding Upper GI Bleeding . Bleeding proximal to the ligament of Trietz Lower GI Bleeding . Bleeding distal to the ligament of Trietz GI Bleeding Hematemesis . Vomiting of fresh red blood or old blood (“coffee grounds”) Melena . Black, tarry, foul-smelling stools . Degradation of blood to hematin by bacteria . DDX: bismuth (Pepto-Bismol), iron Hematochezia . Passage of bright red or maroon blood per rectum . May or may not be mixed with stool GI Bleeding Obscure GI bleeding . No bleeding source found on initial EGD and colonoscopy Obscure-overt GI bleeding . Frank bleeding is noted (hematemesis, melena, hematochezia) Obscure-occult GI bleeding . No frank bleeding, but iron deficiency anemia and/or hemoccult (+) stool GI Bleeding Vital Signs VITAL BLOOD BLEED SIGNS LOSS (%) SEVERITY Shock (Resting 20-25 Massive hypotension) Postural (Orthostatic 10-20 Moderate tachycardia/ hypotension) Normal < 10 Minor Upper GI Bleeding - Causes Common - Gastric ulcer - Duodenal ulcer - Esophageal varices - Mallory-Weiss tear Less frequent - Dieulafoy’s lesions - Vascular ectasia - Portal hypertensive gastropathy - Gastric varices - Gastric antral vascular ectasia - Esophagitis - Gastric erosions - Neoplasia Rare - Esophageal ulcer - Pancreatic source - Erosive duodenitis - Crohn’s disease - Aortoenteric fistula - Hemobilia Causes of Upper GI bleeding Active ulcer bleeding Esophageal Varices Duodenal ulcer Portal Hypertensive Mallory Weiss Tear GAVE Gastropathy Non-Variceal UGI Bleeding: Predictors of Recurrent Bleeding Clinical factors Endoscopic factors - Age > 65 - Active bleeding - Shock (SBP < 100 mm Hg) - Visible vessel - Health Status (ASA Class) - Clot - Co-morbid illness - Ulcer size > 2 cm - Abnormal mental status - Ulcer location: lesser curvature - Ongoing bleeding , superior or posterior walls - Transfusion requirement Bleeding presentation Lab factors - Melena - Hgb < 10 g/dL - Hematemesis - Coagulopathy - Red blood on rectal exam - Blood in gastric aspirate or stomach Variceal Upper GI Bleeding – Risks for Recurrent Bleeding Early Rebleeding Late Rebleeding (<6 weeks) (>6 weeks) - Age >60 years - Severity of liver failure - Severity of initial bleed - Red signs on varicies - Ascites - Ascites - Renal failure - Hepatoma - Active bleeding on - Active alcoholism endoscopy - Red signs on varicies GI Bleeding – Initial Approach - Assess hemodynamics with vital signs - RESUSCITATION!! - Place 2 large bore IV’s and begin normal saline infusion - Type/cross blood; transfuse blood once available - LABS - NO ROLE FOR GASTROCCULT!! - CBC, CMP, PT/INR - Consider troponin/CPK’s in elderly, massive bleed, or patient with cardiac HX - Hgb may not reflect degree of blood loss for 72 hrs - Elevated BUN – suggests UGIB - Role of NG tube? GI Bleeding – Initial Treatment -Non-variceal upper GI bleeding - PO/IV Protonix -Variceal upper GIB - Octreotide IV infusion 50mcg bolus and 50 mcg/hr drip - Cirrhotic pt with acites + GIB -- IV ABX (Cipro) -All GI bleeds consult gastroenterologist for endoscopy Upper GI Bleeding: An Algorithm Acute Lower GI Bleeding Causes Common Diverticulosis
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