Practical approach to Non variceal bleed

Practical Approach to Non
Variceal UGI bleed
Presenter : Dr.Abhinav Kumar

Learning Objectives
• UGIB
– Nonvariceal (PUD)
– Resuscitation, risk assessment, pre-endoscopy
management
– Role of endoscopy
– Post-endoscopy management

Definitions
• Upper GI bleed – arising
from the esophagus,
stomach, or proximal
duodenum
• Lower intestinal bleed –
arising from colon/rectum

Initial Considerations
• Differential diagnosis?
– 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

Acute Upper Gastrointestinal Bleed
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

Incidence of UGI Bleed in India

Stool color and origin/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)

History & Physical Examination
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

Specific causes of upper 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

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.

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

• Most useful situation: 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

Take Home Point #1
Upper GI bleed must still be
considered in patients with severe
hematochezia, even if NG aspirate
negative

Laboratory data
• complete blood count
• serum chemistries
• liver tests
• coagulation studies
• serial electrocardiograms
• cardiac enzymes

• 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.

ACUTE VS CHRONIC
• Acute bleeding  normocytic red blood cells
• Chronic bleeding  Microcytic red blood cells
or iron deficiency anemia

Initial Assessment
• Always remember 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

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

Resuscitation
cordis catheter)
occurs)
40%
40% 20%
bleed Time
IVFs

Fluid resuscitation
• Stabilization is 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.

Transfusion Strategy
• Randomized trial:
– 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

Restrictive Strategy Superior
Restrictive Liberal 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

Resuscitation
cordis catheter)
occurs)
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

Resuscitation
• Early intensive resuscitation 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

Early Intensive Resuscitation
Reduces UGIB Mortality
(groups are essentially the same)
Intervention: Faster correction of
hemodynamics, Hct and coags.
Time to endoscopy similar

• Observation
group
– 5 MI
– 4 deaths
• Intense group
– 2 MI
– 1 death (sepsis)
Early Intensive Resuscitation
Reduces UGIB Mortality

Causes of Mortality in 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

Causes of Mortality in Patients
with Peptic Ulcer Bleeding
• Most common causes of non-bleeding
mortality:
– Terminal malignancy (34%)
– Multiorgan failure (24%)
– Pulmonary disease (24%)
– Cardiac disease (14%)

Take Home Point #2
Early resuscitation and supportive
measures are critical to reduce
mortality from UGIB

• Identify patients at high risk for adverse outcomes
• Helps determine disposition (ICU vs. floor vs. outpatient)
• May help guide appropriate timing of endoscopy
Risk Stratification

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

Clinical Rockall Score – Mortality Rates
0%
10%
20%
30%
40%
50%
60%
0 1 2 3 4 5 6 7

AIMS65
• Simple risk score 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

AIMS65

Blatchford Score
• Predicts need for
endoscopic therapy
• Based on readily
available clinical
and lab data
• Can use UpToDate
calculator
Lancet 2000;356:1318

Blatchford Score

Blatchford Score
• Most useful 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

• For Non-Variceal UGIB
– 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

Pre-endoscopy PPI
• Reduces the 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

Pre-endoscopy Prokinetics
• Improve gastric 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).

Antibiotics for patients with cirrhosis
• up to 20% Bacterial infections
• overall reduction in infectious complications and possibly
decreased mortality
• reduce the risk of recurrent bleeding  esophageal varices

NO ROLE
• Somatostatin and its analogs
• Tranexamic acid

• 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
Ann Intern Med 2010;152:101
Endoscopy - Nonvariceal UGIB

When is Endoscopic Therapy
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

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

Adherent Clot
• Role of endoscopic therapy
of ulcers with adherent clot
is controversial
• Clot removal usually
attempted
• Underlying lesion can then
be assessed, treated if
necessary

Minor Stigmata
Flat pigmented spot Clean base
Low rebleeding risk – no endoscopic therapy
needed

Stigmata of Recent Hemorrhage
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

PPI infusion or scheduled 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

Factors associated with Rebleeding
• 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)

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

Nonvariceal UGIB –
Post-endoscopy management
• 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

• 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%)

• 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%)
Not dying is more important
than not rebleeding

Endoscopic Hemostatic Devices
Injection therapy
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

Injection Therapy
• Most commonly used
• Needles used for sclerotherapy are suitable for injection
• Mechanism of action:
Vascular tamponade
Vasoconstriction
Cytochemical reaction

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

BEYOND INJECTION THERAPY –
WHY?

Injection alone Dual therapy 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

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

Seibert et al, Endoscopy , 2003 : 35 : 189

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

Endoloop
• Detachable loop made of nylon
• Indications
– Post polypectomy bleed
– Esophageal/ gastric variceal bleed
– Closing fistulous tract
– Submucosal tumours

• 10 patients with 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

GIE, 2008, Volume 67, No. 3 : 556 - 560

Arezzo et al, Endoscopy, 2011; 32: 18 - 19

Ana Catrina et al, CGH, 2011 : 104- 106
Gastocutaneous Fistula after Percutaneous
Endoscopic Gastrostomy

Indications
Similar to Loop but useful for smaller lesions
– Post polypectomy bleed
– AV malformation
– Mallory-Weiss tear
– Dieulafoy lesion
– Blue rubber bleb nevus syndrome
– Diverticular bleed

Principle of thermal devices
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

Procedure
1. Applying probe pressure to tamponed bleeding
2. Electrical energy is converted to thermal energy and
coagulate tissue

Argon Plasma Coagulator
Causes hemostasis by
conducting a high-
frequency electrical
current through a beam
of ionized argon gas
causing superficial tissue
damage and coagulation

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

Practical approach to Non variceal bleed

Practical approach to Non variceal bleed

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