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Khalid Khan MBChBUniversity of Arizona
Disclosures
None
Objectives
Triage, resuscitation and initial management of gastrointestinal bleeding Medical therapy for non‐variceal gastrointestinal Medical therapy for non‐variceal gastrointestinal bleedingMedical therapy for variceal hemorrhage
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Incidence of GI HemorrhageAdult Pediatric
1‐2% hospital admits common ICU admissions
GI hemorrhage uncommon
h h10% mortalityGreater ‐ recurrent bleeders
Majority stop sponateously
PICU inpatients rather than admits
0.4% life threatening
Data on Pediatric GI Hemorrhage
PrevalencePICU data
Crit Care Med 1992; 20:35
Community/ ER: developing nations Indian J Pediatr 1994; 61:651
ManagementCases reports and seriesKhan K, et al. Gastrointest Endosc 2003;57:110‐12
Pediatric GI hemorrhage
Children and adultsCommunity/
ER
ICU/ inpatient
Newborn and infants
ER
Nursery
NICU
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Management of Pediatric GI Hemorrhage
None necessaryMedical managementEndoscopic therapyEndoscopic therapyInterventional radiologySurgery
Methods to Stop GI Hemorrhage
None necessary e.g., Mallory‐Weiss Tear (>90% stop)Medical managementEndoscopic therapyEndoscopic therapyInterventional radiologySurgery
Methods to Stop GI Hemorrhage
None necessary e.g., Nose bleedMedical managementEndoscopic therapyEndoscopic therapyInterventional radiologySurgery
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Methods to Stop GI Hemorrhage
None necessary e.g., maternal blood, food coloringMedical managementEndoscopic therapyEndoscopic therapyInterventional radiologySurgery
Methods to Stop GI Hemorrhage
None necessaryMedical managementEndoscopic therapy: next presentationEndoscopic therapy: next presentationInterventional radiology: e.g., coiling, TIPSSurgery: e.g., gastrectomy, Meckels, intussuception
Site of GI hemorrhageUpper (proximal to the ligament of Treitz)
Esophageal
LowerSmall bowelColon
StomachDoudenumPancreatobiliary
Anus
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Upper GI Upper GI
Gastritis
Varices Ulcer
GastritisMallory‐Weiss tear
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Upper GI hemorrhageIs it upper?
Majority of all GI hemorrhage is upperHematemesis diagnosticMelenaMelena
Acid‐hemoglobin to hematinIntestinal bacteria, digestive enzymes
Nasogastric tubeHematochezia
Patients with very rapid UGI source
GI Bleed‐ from the ER
Endotracheal intubation?Intravenous access and fluid resuscitationStat labs: Hct/CBC, coags, type/cross match
History: age, liver disease, bleeding disorder, risk of peptic ulcer, NSAIDSExam: morphology, bruising, jaundice, splenomegaly
Hematemesis/ melena/ NGT blood hematochezia
Upper vs. Lower GI bleed
Acute upper GI hemorrhage‐ from the ER
Secure airwayResuscitation
Uncontrolled massive
hemorrhage
Medical management
History suggestive of
portal hypertension
EndoscopyHemorrhage controlled
Negative: consider lower GI bleed
Positive:disease specific
treatment
Medicalmanagement
Melena , consider meckels
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Acute upper GI hemorrhage‐ inpatient/ICU
Endotracheal intubation?Hematemesis/ melena/ hematocheziaNGT blood
Risk factors: coagulation, effective anti‐acid prophylaxis, risk for gastric ulceration, underlying lying disease e.g., GVHD
Endoscopy/
Uncontrolled massive
hemorrhage
Endoscopy/ colonoscopy/
flexible sigmoidoscopy Hemorrhage
controlled
Negative Consider lower GI bleed
PositiveDisease specific treatment
Medical management of UGI bleeding
Acid suppression (Peptic ulcer):No good data on benefit in childrenIV Omeprazole prior to EGD reduced signs of active bleeding need for therapy: N Engl J Med 2007 356 1631bleeding, need for therapy: N Engl J Med 2007; 356:1631
High dose IV PPI (Not H2 RA) reduce rate of rebleeding with/without endoscopic therapy: BMJ 2005; 330:568
Oral BID high dose equivalent to IV PPI (pH >6)Untreated visible vessel or clot
Peptic ulcerAdherent clot Visible vessel
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Medical management of UGI bleeding
Somatostatin and Octreotide (peptic ulcer bleeding):reduce splanchnic blood flowinhibit gastric acid
i i ffgastric cytoprotective effectsReduced risk of rebleeding: Ann Intern Med 1997; 127:1062
Adjunctive therapy before endoscopyUnsuccessful endoscopy, contraindicated, or unavailable
Medical management of peptic ulcer
D/C NSAIDsAnti‐ulcer medication
d f lEradication of H. pyloriFollow up EGD for gastric ulcer in 6 weeks: adults
Other sources of UGI hemorrhage
Mucosal lesions (specific medical treatment)Gastritis, ischemia, stress ulcerationEosinophilic esophagitisPTLD, GVHD,
Mallory‐WeissNo role for medical treatment
Dieulafoy’s No role for medical treatment
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Lower GI
LGI hemorrhageEvaluation
As for UGI hemorrhageIf unstable with hematochezia need EGD first
After stablized After stablized Rectal and anal examColonoscopy
Acute lower GI hemorrhageResuscitation
Rectal exam/ flexible sigmoidoscopy/ colonosocpy
Nasogastric tube/ EGD to r/o UGIH
Massive unexplained lower GI hemorrhage, consider EGD
Slow or intermittent blood loss
Angiography/ radionucleide study/ VCE/ enteroscopy/
Surgery Disease specific treatment
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Portal hypertensionyp
Variceal hemorrhageCirrhosis
25% mortality for each bleeding episode (less in children)
Over 2/3 will rebleed in 1 yearOver 2/3 will rebleed in 1 year
Acute upper GI hemorrhage due to portal hypertension
Admit to ICU, gastric lavage
Bl di h l i
Endoscopy
Bl di t i i t l t th
Medical management
Tamponade
Bleeding esophageal varicesBleeding gastric varices or portal gastropathy
Medical prophylaxis
Therapy endoscopic/radiological/ surgical
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Medical management of acute variceal hemorrhage
Transfusion of blood (avoid over transfusion)Correction of coagulopathyAntibiotics; Quinolones CeftrioxoneAntibiotics; Quinolones, Ceftrioxone
Improve survival: Hepatology 2004;39:746–753
Reduction of portal pressureNo role for factor VIIa, beta blockersAcid reduction: adjunct
Acute variceal hemorrhage: portal pressure
Vasopressin: most potent splanchnic vasoconstrictor, related multiple side effects; max 24 hours
Nitrates: improves side effects of vasopressin; Hepatology 1982;2:757–762
Terlipressin: fewer side effects, improved survival; Sem Liv Dis 1999;19:475–505
Somatostatin/ Octreotide: initial control of bleeding, 5‐day hemostasis, no differences in mortality or severe adverse events; Hepatology 2002;305:609–615
Prophylaxis: variceal rebleedingNo comparative pediatric dataGood Adult data
Medical prophylaxisSurgeryg yTIPSCombination treatment
Less dataPVT vs. cirrhosisSurgery
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Prophylaxis for Variceal hemorrhage
Primary prophylaxis
Normal esophagus
Varices, no hemorrhage
Recurrent varicealhemorrhage
Variceal hemorrhageSecondary prophylaxis
Gastric varices, portal gastropathy, gastric antral vascular ectasia
Prophylaxis for Variceal hemorrhage
Endoscopic
Medication
CirrhosisEnd stage liver disease
Surgery
Non‐cirrhotic portal hypertension
Portal vein thrombosis
TIPS
Prophylaxis:variceal rebleedingMedical
Non‐selective Beta Blockers: long acting Cirrhosis: Meta‐analysis. Lancet 1990;336:153 Non‐cirrhotic PH: BMJ 1989; 298:1363Portal gastropathy: Lancet 1991; 337:1431
Beta blocker + nitrates: Hepatology 1997; 26:34Negative: nitrates, spironolactone
EndoscopicCombination
Endoscopic + beta blocker: Ann Intern Med 2008; 149:109Endoscopic vs. combined medical: N Engl J Med 2001; 345:647
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Medical prophylaxis: pathophysiology
Variceal bleed recurs in over 2/3rd within a year (cirrhotics) and is associated with death if untreatredHighest risk first 6 weeksHVPGHVPG
Normal 6 mmhgVarices at 10 mmhgGI bleeding >12 mmhgNon‐selective Beta Blockers: increase mesenteric arteriolar tone, decrease cardiac outputNitrates: further reduce portal pressure
Medical prophylaxisClinical effect adults:
Aim for heart rate 55‐65 bpmReduce heart rate by 25%Reduce HVPG by 20%Reduce HVPG to < 12 mmhgReduce HVPG to < 12 mmhg
Considerations in children (infants)Most experience with propranolol?Portal pressure change rarely measuredHeart rate reduction: 25%Effectiveness?
Secondary prophylaxisAGA guidelines: Hepatology 2007; 46:922
Cirrhotics surviving a variceal hemorrhage should receive secondary prophylaxis with non‐selective beta‐blockers plus EVLEVL
Beta‐blocker should be adjusted to the maximal tolerated dose. EVL repeated 1–2 weeks until obliteration, surveillance EGD 1–3 months, then 6–12 monthly
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Summary Cascade for medical management
1. Assess ABC‐need for airway management2. Estimate severity of blood loss3. Establish IV access and resuscitate4. Identify source (upper versus lower, NGT, EGD)5. Consider:
1. Blood products and correct coagulopathyFor UGI hemorrhage1. IV vs. oral PPI2. IV Octreotide
Summary Medical cascade for portal hypertensive bleeding
1. Control airway, admit to PICU2. Resuscitate and tamponade if necessary3. Continue:
1. Blood products and correct coagulopathy2. IV vs. oral PPI3. IV Octreotide4. Antibiotics
Summary Secondary prophylaxis after variceal hemorrhage
1. Initiate non‐selective beta‐blocker2. Increase dose to reduce heart rate by 25%3. Monitor‐what?4. Combine with endoscopic therapy5. Add nitrate to beta‐blocker?6. Gastric acid reduction?
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