Management of Upper GI Bleeding

Report
AN APPROACH TO GI BLEEDING IN THE
CARDIAC SURGERY PATIENT
Ryan O’Gowan, MBA, PA-C
FAPACVS
FCCM
St. Vincent Hospital, Worcester, MA
DISCLOSURES

I have no financial relationships with any drug
or device manufacturers to disclose.
OBJECTIVES

At the conclusion of this lecture the participant
should be able to:
Describe the pathology and pathophysiology of the
patient with upper and lower GI bleeding.
 Outline the approach to diagnosing and treating GI
bleeding, as well as clinical management.
 Describe pitfalls or circumstances unique to the
cardiac surgery population, as well as the
literature pertaining to this population.

PATIENT SCENARIO 1

A 68 year old cardiac surgery patient who is POD
#3 presents with intractable nausea and vomiting
on the telemetry unit. The patient develops
pronounced hematemesis.

Vital signs: HR 120, AF. SBP 88/60 laying flat;
78/58 sitting upright. Urine output 60cc in the last
4 hours. He is unable to stand secondary to
dizziness. Respiratory rate 35, O2 Sat 89% 6LNC.
PERSPECTIVES ON MANAGEMENT
PATIENT SCENARIO 1
Of note, the patient is an AVR with mechanical
valve, has begun anticoagulation with
coumadin, and has been on Amiodarone for AF.
 Pre-op, the patient had an uncomplicated UTI
treated with Levofloxacin.
 What is your next step in managing this
patient?

APPROACH TO GI BLEEDING-SHOCK
American College of Surgeons Committee on Trauma- ATLS Course Guidebook
NEXT STEPS IN MANAGEMENT

Remember CAB:
Circulation: IV Access, Crystalloid vs. Colloid
Resuscitation, Central line & pressors if
appropriate.
 Airway: Level of consciousness, airway
assessment.
 Breathing: Use of accessory muscles,
respiratory rate.

LOCALIZING THE SITE OF BLEEDING

Not all bleeding is
created alike:

Above the Ligament of
Treitz Hematemesis
 Melena

Below the Ligament of
Treitz Hematochezia
INITIAL MANAGEMENT
NGT/OGT: caution in patients with known
varices. +/- ice water lavage with 250cc.
 Consider Sengstaken-Blakemore tube in
patients with Variceal bleeding.
 Laboratory Studies; CBC, Coags, Lactate q6-8h.
Consider Serial ABGs (as base deficit may
signify degree of bleeding).
 Fluid Resuscitation with blood/factor
transfusions.

INITIAL MANAGEMENT
CALCULATING THE EXTENT OF BLEEDING
Blood Loss Determination:


1.) Estimate Normal Blood Volume: 66ml/kg (♂) or 60ml/kg
(♀)
2.) Estimate % loss of Blood Volume:
Class 1: < 15%
 Class 2: 15-30%
 Class 3: 30-40%
 Class 4: >40%


3.) Calculate the Volume Deficit (VD):


VD= Blood Volume (BV) x Percent Loss.
4.) Determine the Resuscitation Volume:

VD x 1.5 for Colloids or VD x 4 for Crystalloids.
The ICU Book, 3rd Edition. Marino, et. Al.
PHARMACOLOGIC ADJUNCTS

IV Proton Pump Inhibitors:
 IV
Omeprazole 20mg q12h.
 Omeprazole infusion 8mg/hr.

Somatotatins:
 Octreotide:
Bolus of 25-50mcg followed by infusion of
25-50mcg/hr x 48 hours. (indicated for variceal bleeding
or as an adjunct when endoscopy is not immediately
available)
PHARMACOLOGIC ADJUNCTS-SPECIAL
CIRCUMSTANCES

Empiric Antibiotic therapy:
 Indicated
for cirrhotic patients, as bacterial translocation
may occur secondary to immunocompromise.

Tranexamic Acid:
 Recent
studies did not show benefit of Tranexamic Acid
for GI bleeding over placebo.
DIFFERENTIAL DIAGNOSIS OF UGI BLEEDING
Barret’s esophagus
 Esophageal cancer
 Esophagitis
 Gastric Cancer
 Gastric Ulcer
 Gastrinoma
 Mallory Weiss Tears
 Variceal Disease

PATIENT SCENARIO 1-CONTINUED

Initial labs showed a drop in the HCT to 19.9 with an
INR of 3.9. Lactate was 3.1. ABG was 7.19/32/82/18
with a base deficit of -4.

The patient was intubated, was given 3 units RBCs
and 2 units FFP. An arterial line was placed, and the
patient was started on pressors. GI/General Surgery
were consulted and the patient was started on IV
pantoprazole and Octreotide.
DIAGNOSTIC EVALUATION

Endoscopy: Approach is determined by if
bleeding is upper vs. lower.
UGI can be therapeutic and diagnosticElectrocautery
 Banding of varices
 Injection of bleeding vessels with Epinephrine


CTA has an evolving role in diagnosing GI
Bleeding, and may have increased utility in
detecting small bowel bleeding sites.
(World J Gastroenterol. 2010 August 21; 16(31): 3957–3963.)
UGI-ELECTROCAUTERY
UGI-VARICEAL BANDING
PATIENT SCENARIO 1-CONTINUED
UGI Endoscopy identified a small bleeding
ulceration which was cauterized.
 The patient continued to be transfused with
RBCs and FFP. He failed to respond
appropriately, as his HCT came up to 23.8,
after a total of 4 Units.
 The SBP went up to 180 systolic with an
episode of ventilator asynchrony, and 300cc of
bright red blood was suctioned out his OGT.

DIAGNOSTIC EVALUATION

Angiography and angioembolization:
 Surpassing


Greater Utility, may also be useful in evaluating Mesenteric
Ischemia if abdominal pain with elevated lactate.
Tagged RBC Scan


Tagged RBC scan-
Requires a large volume of active blood loss to be read as
positive.
Always weigh the utility of various studies, as
some may be both diagnostic and therapeutic.
POSITIVE TAGGED RBC SCAN
POSITIVE ANGIOGRAPHIC STUDY
PATIENT SCENARIO 1-CONTINUED
The patient underwent angioembolization, of a
bleeding branch of the gastro-duodenal artery,
which was localized secondarily after his
varices were banded.
 He was stabilized, had his Warfarin restarted,
and was later referred to a specialized center
for a TIPS procedure to definitively control his
portal hypertension and varices.

PATIENT SCENARIO 2
A 67 year old female S/P bare metal stenting
presents with recurrent angina. She has been
loaded with Plavix 300mg and has developed
hematochezia. She has an IABP in place and is
pre-op for CABG.
 HCT is 24.7, INR is 1.2, PLT 94,000. PRU
(P2Y12 assay) shows 80% inhibition.

IDENTIFICATION OF LOWER GI BLEEDING
Physical Exam is the first step.
 External hemorrhoids are often overlooked.
 LLQ pain may be indicative of diverticulitis,
another common cause.

DIFFERENTIAL DIAGNOSIS- LGI BLEEDING
External Hemorrhoids
 Colonic polyps
 Diverticulitis
 Colitis (Ischemic, Ulcerative, Crohn’s)
 Infectious Diarrhea (E.Coli H7:0157, Shiga
toxin, Salmonella)
 Anal Fissures
 Neoplasm/Radiation Proctitis

PATIENT SCENARIO 2-CONTINUED
The patient is stabilized, receives OPCAB x 3,
and remains with IABP in place post op.
 On POD 2, her HCT falls to 21.3 and PLT to
55,000. She develops abdominal pain and is
presently NPO. Lactate is 4.1, Creatinine is 1.7.
 What is your next priority?

COLONOSCOPY- ISCHEMIC SIGMOID COLITIS
RESUSCITATION
Patient’s with reduced Ejection Fractions who
are not intubated may require more restrictive
transfusion strategies.
 The TRICC trial excluded patients with ACS and
maintains a transfusion target HCT of 30.
 Reduced splanchnic flow to the kidneys and
mesentery warrant increased suspicion of renal
failure and mesenteric ischemia.

PATIENT SCENARIO 2-CONTINUED
The patient is given 3 units PRBCs and 6 units
Platelets- LGI bleeding continues.
 CXR reveals IABP with the tip migrated just
above the renal arteries; it is repositioned and
the tip is now at 4th ICS.
 Judicious fluid resuscitation is an important
element of care as the patients EF is 30%; she
receives 20mg IV Lasix between the 2nd and 3rd
unit of RBCs.

LGI ALGORITHM
PHARMACOLOGIC ADJUNCTS
Nexium and Octreotide have been validated,
but mainly in UGI bleeding, they are class B/C
in LGI bleeding.
 If patients are receiving anticoagulants,
Risk/Benefit must be carefully weighed before
using their respective antidotes.
 Sucralfate enemas have been shown to reduce
rebleeding in patients with radiation proctitis.

PATIENT SCENARIO 2-CONTINUED
The patient is stabilized from a cardiac
perspective, but continues to pass bloody
stools.
 Lactate remains elevated at 3.4, and HCT does
not respond appropriately to an additional 3
units RBCs- it remains low at 22.1.
 What are additional strategies that can be
employed prior to GI surgery?

IMA ANGIOGRAPHY
SUPERSELECTIVE ANGIOEMBOLIZATION
PATIENT SCENARIO 2-CONTINUED
The patient is taken to IR for superselective
angioembolization.
 Bleeding is stabilized temporarily, but the
patient rebleeds.
 She receives another 2 units RBCs (total in last
24 hours is 8 units).

EMERGENT SURGERY
She is taken to the OR for sigmoid colectomy
and colostomy and does well post op.
 Although angiograhic embolization did not stop
the bleeding, the surgeon was able to localize
the site more expeditiously and provide a more
definitive resection.

POST OPERATIVE COMPLICATIONS
In patients with primary re-anastamosis vs
colostomy, the suture line may dehisce.
 Sepsis/Intra-abdominal abscess may present ~
POD 5, if fecal spillage occurs intra-op
(peritonitis)
 Abdominal Compartment Syndrome
 Renal Failure
 Respiratory Failure

CARDIAC SURGERY LITERATURE REVIEW
Two of the biggest series on GI complications
in cardiac surgery come from the Texas Heart
Institute Journal in 2000 and 2003.
 The first is retrospective, the follow up paper is
prospective.

CARDIAC SURGERY LITERATURE REVIEW
N=4,463 patients; Retrospective Analysis. 113
GI Diagnoses in 86 patients. Prevalence 1.9%,
Mortality 30%.
 Risk Factors:









Age >70
Duration of CPB
Need for Blood transfusions
Reoperation
Triple Vessel CAD
PVD
NYHA Class IV CHF
Use of IABP/Inotropic Support post operatively
(Tex Heart Inst J 2000;27:93-9)
CARDIAC SURGERY LITERATURE REVIEW
N=11,058 patients; Prospective Analysis.
Prevalence 1.2%, Mortality 22.5%
 Complications:








UGI Hemorrhage (28.6%)
Gastroesophagitis (12.2%)
Intestinal Ischemia (11.5%)
Mixed Gastrointestinal complications (9.5%)
Pancreatitis (8.8%)
Cholecystitis (6.8%)
Perforated Peptic Ulcer (4.7%)
(Tex Heart Inst J 2003;30:280-5)
CARDIAC SURGERY LITERATURE REVIEW
The cohort from the second study included
CABG, Valve, Combination surgery, and Adult
Congenital patients.
 Multivariate Analysis showed six independent
predictors:

Prolonged mechanical ventilation
 Postoperative renal failure
 Preoperative renal failure
 Sepsis
 Sternal wound infection
 Valve surgery
(Tex Heart Inst J 2003;30:280-5)

GI LITERATURE REVIEW





Meta-analysis of 200 articles from 1966-2004. Evidence
Graded A, B, or C.
Incidence for LGI bleeds = 0.03% and for UGI bleeds ~1.5-3%.
For coffee ground emesis and heme (+), NG aspirate- UGI
should be performed when a concomitant LGI bleed is present.
For UGI bleeds, TC-99 scanning can detect bleeding rates of
0.1ml/min; however-active bleeding is required for an effective
test.
It may be prudent to electively intubate patients prior to UGI
endoscopy.
(Aliment Pharmacol Ther 2005;21:1281-1298)
GI LITERATURE REVIEW





For LGI bleeds, unless emergent, a bowel prep should take
place. Non-prepped bowels increase the risk of colonic
perforation of the endoscope.
It may be prudent to electively intubate patients prior to UGI
endoscopy.
For LGI bleeding, angiography may be therapeutic and
diagnostic, but requires bleeding rates of ~1ml/min.
Diverticular bleeds and angiodysplasia account for 50-80% of
bleeding when the SMA is the bowel source.
Vasopressin infusions may control 91% of these sources (Grade
B), but 50% rebleed upon cessation of the drip.
(Aliment Pharmacol Ther 2005;21:1281-1298)
GI LITERATURE REVIEW



Transcatheter embolization using alcohol or microcoils reduces
bleeding by 44-91%, however 7-40% with angiodysplasia
required emergency surgery for failure or rebleed.
When angiography is successful in localizing the site, limited
resection has a lower morbidity than surgery in historic controls
without angiographic localization (8.6% vs 37%-Grade B).
Surgery is required when: hemodynamic instability persists,
patients require >6 units RBCs, or severe bleeding recurs
(Grade B/C).
(Aliment Pharmacol Ther 2005;21:1281-1298)
SUMMARY POINTS






If in doubt, protect the airway.
Be vigilant for renal insufficiency and volume overload.
Be mindful in patients who don’t exhibit an appropriate
response to RBCs- trend HCTs q6h.
Patients on anticoagulants may pose special challenges.
Be wary of contrast nephropathy in patients who have had CTA
or Angiography.
Multidisciplinary care is key: engage GI and General Surgery
early on and create a clear plan with clear accountabilities.
THANK YOU FOR YOUR TIME AND ATTENTION.
I would like to extend a special thanks to Dr. Yuka-Marie Vinagre for your review.

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