EM-CCM Conference: February 2014

EM-CCM Conference: February 2014 (Sorry posting this a little late!)

Presented by Dr. Freedman

Summary by Dr. Youn

 

CASE: 84M with CAD (recent NSTEMI) on ASA and Clopidogrel, CHF, HTN, DM p/w 4 episodes of BRBPR with dizziness and SOB.   Pt was hypotensive, tachycardic with pale conjunctiva and gross red blood on rectal examination.  GI, Surgery, and Critical Care Medicine were consulted.  Labs were notable for H/H of 7/22 and Troponin 2.94.  The patient’s primary problem list included GI bleed (lower vs. brisk upper), shock/hypotension, Type 2 MI, and platelet dysfunction.

 

DISCUSSION:

 

LGIB DEFINITION: any bleeding distal to Ligament of Treitz

ETIOLOGY:

  • Diverticulosis: 17-40%
  • AV Malformation: 2-30%
  • Colitis: 9-21%
  • Neoplasm: 11-14%
  • Anorectal: 4-10%
  • Brisk UGIB: 0-11%
  • Small Bowel: 2-9%

RISK STRATIFICATION: no scoring system, but characteristics with increased risk of severe LGIB

  • HR > 100
  • SBP < 115
  • Syncope
  • Nontender abdomen
  • Bleeding noted during initial 4 hours of course
  • History of aspirin use
  • Two or more comorbidities
  • Strate LL, Orav E, Syngal S. Early Predictors of Severity in Acute Lower Intestinal Tract Bleeding. Arch Intern Med. 2003;163(7):838-843.

GOALS OF LGIB MANAGEMENT:

  • Resuscitation
    • ABCs
    • Vascular access
    • Blood products
    • Hemodynamic monitoring
  • Identification/Localization of bleeding source
    • NG lavage (NG = NasoGastric to some, NG = No Good to others)
    • Endoscopy
    • Angiogram/IR
    • CT Angiography
    • Bleeding scan
  • Appropriate intervention
    • Endoscopy
    • Surgery
    • IR embolization/vasopressin infusion

 

EBM#1: ANTI-PLATELET REVERSAL

  • No RCTs, numerous retrospective, observational studies: No difference in outcomes
  • Desmopression (DDAVP): No outcome data
  • Nearly 2-fold increase in risk of UGIB with use of low-dose aspirin; further increased risk of UGIB with use of low-dose aspirin along with clopidogrel, oral anticoagulants, NSAIDs, or high-dose corticosteroids (Circulation. 2011; 123:1108-1115)

 

EBM#2: EMERGENT ENDOSCOPY/COLONOSCOPY

  • Green et al. Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial.  Am J Gastroenterol 2005; 100:2395–2402.
    • Prospective, randomized
    • N = 100
    • Purge and colonoscopy within 8 hours vs. elective colonoscopy
    • Urgent colonoscopy identified definite source of LGIB more than standard care algorithm
    • No difference in outcome measures: mortality, hospital stay, ICU stay, transfusion requirements, early rebleeding, late rebleeding, surgery
  • Laine L, Shah A. Randomized trial of urgent vs. elective colonoscopy in patients hospitalized with lower GI bleeding.  Am J Gastroenterol 2010; 105: 2636–2641.
    • Randomized, prospective study
    • N = 72 (after EGD)
    • All received EGD within 6 hours.  If no upper bleeding source identified, randomized to colonoscopy within 12 hours or elective colonoscopy (36-60hours)
    • No difference in outcome measures: further bleeding, units of blood, hospital days, subsequent diagnostic or therapeutic interventions for bleeding, hospital charges

 

EBM#3: ANGIOGRAPHY – requires > 1cc/min bleeding

  • Localization: 40-80% in literature
  • Embolization: 80-100% success rate, with 14-29% rebleeding
  • Complication rate: up to 23%

 

EBM#4: SURGERY

  • Subtotal colectomy: bleeding source not identified, massive blood loss, hemodynamic instability (last resort?); high mortality 25-33%
  • Targeted resection: refractory bleeding after localization, 7% mortality if localized; avoid blind resection

 

EBM #5: CT ANGIOGRAPHY

  • Yoon W, Jeong Y Y, Shin S S. et al. Acute massive gastrointestinal bleeding: detection and localization with arterial phase multi-detector row helical CT. Radiology. 2006; 239(1):160–167.
    • Prospective, observational, non-randomized
    • All patients for IR underwent CTA prior to exam
    • Sens 90%, Spec 99%, 95% PPV, 99%NPV
  • CTA predicts those who will benefit from IR

 

RESIDENT/FACULTY DISCUSSION:

–       Do not hesitate to initiate massive transfusion protocol for unstable, bleeding patients upon initial evaluation and management

–       Is there a target Hgb in LGIB?  Can we apply the 2013 NEJM study (restrictive vs. liberal transfusion strategies in UGIB) to LGIB patients?

–       Consider Cordis catheter and Level 1 for fast (and warm), large volume resuscitation in hemodynamically unstable bleeding patients

–       Don’t fret if GI delays endoscopy, just make sure they see the patient

–       Ultimately, sick bleeders need ICU (MICU vs. SICU depends on your institution, administrative protocols)

–       Premarin (conjugated estrogens) for GIB?  Some case studies on use of conjugated estrogens in GI bleeding patients with CRF or ESRD, no randomized studies.

–       1g drop in hemoglobin ~200cc blood loss.  Therefore, if patient has significant bleed with drop in hemoglobin, guaiac status (positive or negative) is irrelevant.  There should be gross blood or melena on rectal exam.  If you’re finding only guaiac positive stool, then that’s not the source of the Hgb drop.  Do the rectal exam.  Leave the guaiac card behind.

–       Tranexamic acid (TXA): Cochrane review 2012 in UGIB

  • 7 double-blinded, randomized studies on TXA versus placebo, cimetidine, or lansoprazole
  • Primary outcome of all-cause mortality showed benefit of TXA compared with placebo, but no difference in subgroup analyses
  • No difference between TXA versus placebo in bleeding, surgery, or transfusion requirements
  • Overall, number of patients with any thrombotic event was not significantly increased in TXA group
  • No literature on TXA in LGIB
The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.
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Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital

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