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Practical Approach To Acute Gastrointestinal Bleeding PowerPoint Presentation

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This medical PowerPoint presentation is about acute gastrointestinal (GI) bleeding, a medical emergency that requires prompt evaluation and management. The presentation gives a practical approach to the diagnosis and treatment of acute GI bleeding.

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Slide 1-

Practical Approach to Acute Gastrointestinal Bleeding Christopher S. Huang MD Assistant Professor of Medicine Boston University School of Medicine Section of Gastroenterology Boston Medical Center
Slide 2-

Learning Objectives UGIB Nonvariceal (PUD) and variceal Resuscitation, risk assessment, pre-endoscopy management Role of endoscopy Post-endoscopy management LGIB Risk assessment Role and timing of colonoscopy Non-endoscopic diagnostic and treatment options
Slide 3-

Definitions Upper GI bleed – arising from the esophagus, stomach, or proximal duodenum Mid-intestinal bleed – arising from distal duodenum to ileocecal valve Lower intestinal bleed – arising from colon/rectum
Slide 4-

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)
Slide 5-

Case Vignette – CC: 68 yo male presents with a chief complaint of a large amount of “bleeding from the rectum”
Slide 6-

Case Vignette - HPI Describes bleeding as large volume, very dark maroon colored stool Has occurred 4 times over past 3 hours He felt light headed and nearly passed out upon trying to get up to go the bathroom
Slide 7-

Case Vignette - HPI Denies abdominal pain, nausea, vomiting, antecedent retching No history of heartburn, dysphagia, weight loss No history of diarrhea or constipation/hard stools No prior history of GIB Screening colonoscopy 10 years ago – no polyps, (+) diverticulosis
Slide 8-

Case Vignette – PMHx, Meds Hepatitis C CAD – h/o MI PVD AAA – s/p elective repair 3 years ago HTN Hypercholesterolemia Lumbago Medications: Aspirin Clopidogrel Atorvastatin Atenolol Lisinopril
Slide 9-

Case Vignette – Physical Exam Physical examination: BP 105/70, Pulse 100, (+) orthostatic changes Alert and mentating, but anxious appearing Anicteric Mid line scar, benign abdomen, nontender liver edge palpable in epigastrium, no splenomegaly Rectal examination – no masses, dark maroon blood
Slide 10-

Case Vignette - Labs Labs Hct 21% (Baseline 33%) Plt 110K BUN 34, Cr 1.0 Alb 3.5 INR 1.6 ALT 51, AST 76
Slide 11-

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 re: need for/timing of endoscopy
Slide 12-

Differential Diagnosis – Upper GIB Peptic ulcer disease Gastroesophageal varices Erosive esophagitis/gastritis/duodenitis Mallory Weiss tear Vascular ectasia Neoplasm Dieulafoy’s lesion Aortoenteric fistula Hemobilia, hemosuccus pancreaticus Rare, but cannot afford to miss Most common
Slide 13-

Differential Diagnosis – Lower GIB Diverticulosis Angioectasias Hemorrhoids Colitis (IBD, Infectious, Ischemic) Neoplasm Post-polypectomy bleed (up to 2 weeks after procedure) Dieulafoy’s lesion Most common diagnosis
Slide 14-

History and Physical 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, orthostatics 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
Slide 15-

History and Physical 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, orthostatics 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
Slide 16-

Always get objective description of stool Take Home Point # 1 Avoid noninformative terms such as “grossly guaiac positive”
Slide 17-

If you need a card to tell you whether there’s blood in the stool, it’s NOT an acute GIB Take Home Point #2
Slide 18-

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
Slide 19-

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
Slide 20-

Take Home Point #3 Upper GI bleed must still be considered in patients with severe hematochezia, even if NG aspirate negative
Slide 21-

Initial Assessment Always remember to assess A,B,C’s Assess degree of hypovolemic shock
Slide 22-

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
Slide 23-

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
Slide 24-

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
Slide 25-

Restrictive Strategy Superior NEJM 2013;368;11-21 Benefit seen primarily in Child A/B cirrhotics
Slide 26-

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 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
Slide 27-

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 Am J Gastroenterol 2004;99:619
Slide 28-

Early Intensive Resuscitation Reduces UGIB Mortality Am J Gastroenterol 2004;99:619 (groups are essentially the same) Intervention: Faster correction of hemodynamics, Hct and coags. Time to endoscopy similar
Slide 29-

Observation group 5 MI 4 deaths Intense group 2 MI 1 death (sepsis) Early Intensive Resuscitation Reduces UGIB Mortality Am J Gastroenterol 2004;99:619
Slide 30-

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 Am J Gastroenterol 2010;105:84
Slide 31-

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%) Am J Gastroenterol 2010;105:84
Slide 32-

Take Home Point #4 Early resuscitation and supportive measures are critical to reduce mortality from UGIB
Slide 33-

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
Slide 34-

Rockall Scoring System Validated predictor of mortality in patients with UGIB 2 components: clinical + endoscopic Gut 1996;38:316
Slide 35-

Clinical Rockall Score – Mortality Rates
Slide 36-

AIMS65 Simple risk score that predicts in-hospital mortality, LOS, cost in patients with acute UGIB Albumin <3.0 INR > 1.5 Mental status altered Systolic BP <90 65+ years old Gastrointest Endosc 2011;74:1215
Slide 37-

AIMS65 Gastrointest Endosc 2011;74:1215
Slide 38-

Blatchford Score Predicts need for endoscopic therapy Based on readily available clinical and lab data Can use UpToDate calculator Lancet 2000;356:1318
Slide 39-

Blatchford Score Gastrointest Endosc 2010;71:1134
Slide 40-

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
Slide 41-

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
Slide 42-

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
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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 J Clin Gastroenterol 1996;22:267 Gastrointest Endosc 1999;49:145 Ann Intern Med 2010;152:101 Endoscopy - Nonvariceal UGIB
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When is Endoscopic Therapy Required? ~80% bleeds spontaneously resolve Endoscopic stigmata of recent hemorrhage major
Slide 45-

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
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Major Stigmata - NBVV
Slide 47-

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
Slide 48-

Minor Stigmata Flat pigmented spot Clean base Low rebleeding risk – no endoscopic therapy needed
Slide 49-

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
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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
Slide 51-

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%) Nonvariceal UGIB –Post-endoscopy management Ann Intern Med 2010;152:1
Slide 52-

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%) Nonvariceal UGIB –Post-endoscopy management Ann Intern Med 2010;152:1 Not dying is more important than not rebleeding
Slide 53-

Variceal Bleeding Occurs in 1/3 of patients with cirrhosis 1/3 initial bleeding episodes are fatal Among survivors, 1/3 will rebleed within 6 weeks Only 1/3 will survive 1 year or more
Slide 54-

Predictors of large esophageal varices Severity of liver disease (Child Pugh) Platelet count < 88K Palpable spleen Platelet count/spleen diameter (mm) ratio <909 Gut 2003;52:1200 J Clin Gastroenterol 2010;44:146 J Gastroenterol Hepatol 2007;22:1909 Arch Intern Med 2001;161:2564 Am J Gastroenterol 1999;94:3103
Slide 55-

VARICEAL Bleed Vasoconstrictor therapy Antibiotics Resuscitation ICU level care Endoscopy ALternative/Rescue therapies Beta blockade
Slide 56-

Vasoconstrictor therapy Goal: Reduce splanchnic blood flow Terlipressin – only agent shown to improve control of bleeding and survival in RCTs and meta-analysis Not available in US Vasopressin + nitroglycerine – too many adverse effects Somatostatin – not available in US Octreotide (somatostatin analogue) Decreases splanchnic blood flow (variably) Efficacy is controversial; no proven mortality benefit Standard dose: 50 mcg bolus, then 50 mcg/hr drip for 3-5 days Gastroenterology 2001;120:946 Cochrane Database Syst Rev 2008;16:CD000193 N Engl J Med 1995;333:555 Am J Gastroenterol 2009;104:617
Slide 57-

Antibiotics Bacterial infection occurs in up to 66% of patients with cirrhosis and variceal bleed Negative impact on hemostasis (endogenous heparinoids) Prophylactic antibiotics reduces incidence of bacterial infection, significantly reduces early rebleeding Ceftriaxone 1 g IV QD x 5-7 days Alt: Norfloxacin 400 mg po BID Hepatology 2004;39:746 J Korean Med Sci 2006;21:883 Hepatogastroenterology 2004;51:541
Slide 58-

Resuscitation Promptly but with caution Goal = maintain hemodynamic stability, Hgb ~7-8, CVP 4-8 mmHg Avoid excessively rapid overexpansion of volume; may increase portal pressure, greater bleeding
Slide 59-

Endoscopy Should be performed as soon as possible after resuscitation (within 12 hours) Endotracheal intubation frequently needed Band ligation is preferred method Layer, L. & Jaganmohan, S. & Raju, GS & DuPont, AW (Oct 28 2009). Esophagus - Band Ligation of Actively Bleeding Gastroesophageal Varices. The DAVE Project. Retrieved Aug, 2, 2010, from http://daveproject.org/viewfilms.cfm?film_id=715
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ALternative/Rescue therapies TIPS – Transjugular Intrahepatic Portosystemic Shunt Early placement of shunt (within 24-72hrs) associated with improved survival among high-risk patients Preferred treatment for gastric variceal bleeding (rule out splenic vein thrombosis first) Fan, C. (Apr 25 2006). Vascular Interventions in the Abdomen: New Devices and Applications. The DAVE Project. Retrieved Aug, 2, 2010, from http://daveproject.org/viewfilms.cfm?film_id=497 Hepatology 2004;40:793 Hepatology 2008;48:Suppl:373A N Engl J Med. 2010 Jun 24;362:2370
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TIPS+embolization of gastric varices
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ALternative/Rescue therapies Sengstaken-Blakemore Tube Very effective for immediate, temporary control High complication rate – aspiration, migration, necrosis + perforation of esophagus Use as bridge to TIPS within 24 hours Airway protection strongly recommended
Slide 63-

ALternative/Rescue therapies Specially designed covered metal stent Tamponades distal esophageal varices Removable; does not require airway protection Very limited data Self-Expanding Metal Stent Gastrointest Endosc 2010;71:71
Slide 64-

Beta blockade Reduces risk for recurrent variceal hemorrhage Use nonselective beta blocker (e.g. Nadolol – splanchnic vasoconstriction, decrease cardiac output) and titrate up to maximum tolerated dose, HR 50-60 Start as inpatient, once acute bleeding has resolved and patient shows hemodynamic stability
Slide 65-

Lower GI Bleed Bleeding arising from the colorectum In patients with severe hematochezia, first consider possibility of UGIB 10-15% of patients with presumed LGIB are found to have upper GIB
Slide 66-

Lower GI Bleed Differential Diagnosis - Diverticulosis (# 1 cause) - Angioectasias - Hemorrhoids - Colitis (IBD, Infectious, Ischemic) - Neoplasm - Post-polypectomy - Dieulafoy’s lesion Large volume, painless Smaller volume, pain, diarrhea
Slide 67-

LGIB – Risk Stratification Predictors of severe* LGIB: HR>100 SBP<115 Syncope nontender abdominal examination bleeding during first 4 hours of evaluation aspirin use >2 active comorbid conditions 0 factors: ~6% risk 1-3 factors: ~40% >3 factors: ~80% Arch Intern Med 2003;163:838 Am J Gastroenterol 2005;100:1821 * Defined as continued bleeding within first 24 hours (transfusion of 2+ Units, decline in HCT of 20+%) and/or recurrent bleeding after 24 hours of stability
Slide 68-

LGIB – Risk Factors for Mortality Age Intestinal ischemia Comorbid illnesses Secondary bleeding (developed during admission for a separate problem) Coagulopathy Hypovolemia Transfusion requirement Male gender Clinical Gastro Hepatol 2008;6:1004
Slide 69-

Role of Colonoscopy Like UGIB, ~80% of LGIBs will resolve spontaneously; of these, ~30% will rebleed Lack of standardized approach Traditional approach: elective colonoscopy after resolution of bleeding, bowel prep – low therapeutic benefit Angiography for massive bleeding, hemodynamically unstable patient Urgent colonoscopy approach Similar to UGIB – identify stigmata of hemorrhage, perform therapy
Slide 70-

Urgent Colonoscopy Within 6-12 hours of presentation Requires rapid “purge” prep with 5-6 L Golytely administered 1L every 30-45 minutes Colonoscopy performed within 1 hour after clearance of stool, blood and clots Need for bowel prep and risks of procedural sedation may be prohibitive in unstable patient
Slide 71-

Endoscopic Therapy Srinivasan, R. & Luthra, G. & Raju, GS (Jul 17 2007). Colon - Endoscopic Hemostasis of Diverticular Bleed. The DAVE Project. Retrieved Aug, 3, 2010, from http://daveproject.org/viewfilms.cfm?film_id=63
Slide 72-

Urgent Colonoscopy Limited high quality evidence of benefit Establishes diagnosis earlier, shorter length of stay “Landmark” study supporting urgent colonoscopy for diverticular bleed published in 2000 2 consecutive prospective, non-randomized studies Group 1 (n=73): urgent colonoscopy, surgical therapy Group 2 (n=48): urgent colonoscopy, endoscopic therapy N Engl J Med 2000;342:78
Slide 73-

Urgent Colonoscopy Group 1: 17 pts with definite diverticular bleed 9 had recurrent/persistent bleeding 6 required emergency surgery Group 2: 10 pts with definite diverticular bleed All 10 patients treated endoscopically 0 had recurrent bleed, complications, further transfusions, or surgery N Engl J Med 2000;342:78
Slide 74-

Urgent Colonoscopy Two RCTs published to date Compared urgent colonoscopy (within 8 hours) vs. standard management Am J Gastroenterol 2005;100:2395 Standard Management Algorithm
Slide 75-

Urgent Colonoscopy – RCT#1 Am J Gastroenterol 2005;100:2395 Definite bleeding source identified more frequently (42% vs 22%) But no significant difference in important outcomes (but underpowered)
Slide 76-

Urgent Colonoscopy – RCT#2 85 patients with serious hematochezia (hemodynamically significant, Hgb drop > 1.5 g/dL, blood transfusion) EGD performed within 6 hours If EGD negative, randomized to urgent (<12 hr) or elective (36-60 hr) colonoscopy Primary endpoint= further bleeding Am J Gastroenterol 2010;105:2636
Slide 77-

EGD positive in 15% No evidence of improved clinical outcomes with urgent colonoscopy – but prespecified sample size not reached Urgent Colonoscopy – RCT#2 Am J Gastroenterol 2010;105:2636
Slide 78-

Urgent Colonoscopy In published series, endoscopic therapy is applied in 10-40% of patients undergoing colonoscopy for LGIB Taken together, evidence suggests that colonoscopy should be performed within 12-24 hours in stable patients However, it is unclear how faster timing affects major clinical outcomes
Slide 79-

Radiographic Studies Tagged RBC scan Noninvasive, highly sensitive (0.05-0.1 ml/min) Ability to localize bleeding source correctly only ~66% More accurate when positive within 2 hours (95-100%) Lacks therapeutic capability Coordinate with IR so that positive scan is followed closely by angiography
Slide 80-

Radiographic Studies Angiography Detects bleeding rates of 0.5-1 ml/min Therapeutic capability – embolization with microcoils, polyvinyl alcohol, gelfoam Complications: bowel infarction, renal failure, hematomas, thromboses, dissection Recommended test for patients with brisk bleeding who cannot be stabilized or prepped for colonoscopy (or have had colonoscopy with failure to localize/treat bleeding site)
Slide 81-

Radiographic Studies Multi-Detector CT (CT angio) Readily available, can be performed in ER within 10 minutes Can detect bleeding rate of 0.5 ml/min Can localize site of bleeding (must be active) and provide info on etiology Useful in the actively bleeding but hemodynamically stable patient Gastrointest Endosc 2010;72:402
Slide 82-

Role of Surgery Reserved for patients with life-threatening bleed who have failed other options General indications: hypotension/shock despite resuscitation, >6 U PRBCs transfused Preoperative localization of bleeding source important
Slide 83-

Algorithmic Evaluation of Patient with Hematochezia Hematochezia Assess activity of bleed NG lavage Prep for Colonoscopy Positive EGD Negative active inactive Risk for UGIB Hemodynamically stable? No risk for UGIB negative Treat lesion positive
Slide 84-

Algorithmic Evaluation of Patient with Hematochezia Active Lower GIB Hemodynamically stable? Angiography (+/- Tagged RBC scan) Or Surgery if life-threatening Consider “urgent colonoscopy” vs. traditional approach Yes No
Slide 85-

Take Home Points Always get objective description of stool color (best way – examine it yourself) Don’t order guaiac tests on inpatients Severe hematochezia can be from UGIB, even if NG lavage is negative
Slide 86-

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