GI Bleeding

Definition

• bleeding from the main pancreatic duct

• can be due to...

  • pseudoaneurysm in the peripancreatic arterial circulation

  • bleeding from small vessels within a pseudocyst or fluid collection that communicates with the pancreatic duct

Treatment

• cyanoacrylate injection

Acute Bleed

• aspirin should be resumed within 7 d of adequate hemostasis

  • there are no advantages to enteric coated or buffered aspirin in reducing risk of recurrent bleed

  • in those 70 y or older with history of GI bleed on chronic NSAIDs including ASA , PPI can reduce risk of recurrent bleed

Definition

• Glasgow-Blatchford score

  • 99% negative predictive value

  • best performance characteristics to exclude need for early endoscopy in those with low risk scores

• Rockall score

  • better for assessing mortality risk

• AIMS-65 score

  • albumin, INR, mental status, systolic blood pressure, older age

• Baylor bleeding score

Risk Factors

• Established independent risk factors for stress ulcers

  • use of mechanical ventilation for >48 hr is an independent risk factor for GI bleeding in the context of critical illness and warrants prophylaxis

  • coagulopathy, platelet < 50k or INR > 1.5

• Secondary risk factors for stress ulcers

  • high dose steroids, > 250 mg of hydrocortisone

  • sepsis

  • large surface area burns

  • acute renal or liver failure

• NSAID use

  • primarily due to COX mediated processes

    • decreasing prostaglandin synthesis

    • upregulate gastric acid production

    • reduce production of gastric mucous layer

    • reduce gastric blood flow

  • can also lead to direct epithelial injury

Treatment

• IV PPI BID

  • PPI prior to endoscopic therapy decreases the need for endoscopic intervention at the time of EGD

  • once adequate hemostasis has been achieved, switch PPI to oral

    • same efficacy and is less expensive than IV PPI

• Clipping, cautery, APC, injection therapies alone have not been shown to be superior to combination therapy

• Nasogastric lavage

  • in those with suspected large volume upper GI bleed, can be used to clear the gastric fundus of blood and improve diagnostic visualization

  • significant false negative rate, up to 15%, limits role as optimal discriminator between upper and lower GI bleed

  • has not been shown to reduce mortality in GI bleed

Treatment

• hemostatic powder (TC-325)

  • in the case of hemodynamically significant brisk bleed where transfer for IR intervention is suboptimal

  • endoscopic wide are treatment would be ideal in this case

  • approved for management of bleeding from GI tumors

  • no trials comparing effectiveness of APC, which has been used to control tumor bleeding

• focal therapy with epinephrine injection and bipolar cautery is unlikely to provided effective bleeding control

Treatment

• stigmata of recent hemorrhage helps to guide management

  • active bleeding (Forrest IA and IB) - highest risk of rebleeding

  • non-bleeding visible vessel (Forrest IIA)

    • combination therapy with epinephrine and hemostatic clips is significantly superior to epinepherine injection alone

    • but combination therapy is not superior to cautery or mechanical monotherapy

  • adherent clot (Forrest IIB)

  • flat pigmented spot (Forrest IIC)

  • clean-based ulcer (Forrest III) - lowest risk of rebleeding

• a large ulcer (>2.5 cm) is concerning for cancer

  • repeat EGD in 12 weeks following PPI therapy to confirm healing

  • non-healing is suspicious for malignancy