Bleeding

GI Bleed check list

NSAID/aspirin use, abdominal pain, alcohol, liver disease, surgery? -> gastric bypass, colectomy, AAA repair, hx of GIB, prior scope, anticoag meds

Last meal

Echo, IVC, ascites, distended stomach

CBC, CMP, coag, fibrinogen, TEG, type and cross

IV access, 2 18G; consider A line and Cordis

PCC, VitK, cryo, platelets PRN; PRN reverse anticoagulant meds

Discontinue anticoag and antihypertensives

Pantoprazole 80mg IV x1, followed by 40mg IV pantoprazole q12

If cirrhotic: octreotide 50mcg bolus, 50mcg/hr; CTX 1g IV

If upper GIB: erythromycin 250mg prior to intubation/endoscopy; over 5-30 minutes, 20-90 minutes prior to endoscopy (avoid in qtc >450 or if gastric u/s reveals empty stomach

If uremic/antiplatelets: consider DDAVP 0.3mcg/kg

Transfuse PRN

#Upper GI Bleed

Symptoms of xxx

Most recent hemoglobin: ; baseline hemoglobin x

Blatchford score of xxx

-2 large bore IVs, type and cross 2 units, pantoprazole 80mg IV once, then pantoprazole 40mg IV BID thereafter

-GI consult for endoscopy

-Give erythromycin 3mg/kg IV over 20-30 minutes, 30-90 minutes prior to endoscopy to decrease need for 2nd look endoscopy

-avoid NSAIDS and anticoagulation

-hold antihypertensives

-Coags x 1

-Lactate x 1

-CBC Q6 until Hgb is stable

#Bleeding gastric varices

In patients with gastric varices, contrast-enhanced cross-sectional imaging should be performed to determine the best treatment

Typically, octreotide is administered to reduce portal pressures, and antibiotics are provided to reduce risk for infectious complications of gastrointestinal bleeding. These complications include bacteremia, which can increase morbidity and mortality from variceal bleeding. Treatment options for gastric varices along the greater curvature of the stomach depend on the anatomy of the abdominal vasculature

#unstable GI bleed 2/2 AVM

For active lower gastrointestinal bleeding with associated hemodynamic instability, CT angiography is the study of choice.

For active lower gastrointestinal bleeding, catheter angiography and possible embolization should be performed as soon as possible after positive results on CT angiography

#acute upper GI bleed

Upper endoscopy within 24 hours

Nonbleeding visible vessel within the ulcer base, high risk for rebleeding (Forrest classification … )

-PPI IV BID for 72 hours, PO BID for 2 weeks, and PO once daily for 6 weeks

-in cirrhotic, regardless of ascites, broad spectrum abx for 7 days is recommended

#hemorrhoids

Grade 1/2/3/4; anasol/prepH; surgery needed?

#upper GI bleed

NSAIDs should be discontinued in patients with NSAID-induced bleeding peptic ulcer disease; if treatment must be continued, a selective cyclooxygenase-2 inhibitor plus a once-daily proton pump inhibitor should be used.

Patients with peptic ulcer disease and low risk for rebleeding (clean-based ulcer, ulcers with pigmented spots) can start oral feeding within 24 hours of endoscopy, receive once-daily oral proton pump inhibitor therapy, and be discharged from the hospital.

Per the ACG-ACA Clinical Practice Guideline on Anticoagulants and Antiplatelets (AJG 2022), will continue aspirin in the setting of secondary prevention

#lower GI bleed

The duration of the anticoagulant effect of the direct oral anticoagulants (DOACs) is limited because of their short half-life; in most cases of gastrointestinal bleeding, simply holding the DOAC is sufficient

In hemodynamically stable patients without evidence of rapid lower gastrointestinal bleeding, colonoscopy is the first test of choice.

Although nuclear studies may be able to detect lower gastrointestinal bleeding, precise anatomic location is inferior to that provided by first-line diagnostic tests, such as colonoscopy, CT angiography, and conventional angiography

Per the ACG-ACA Clinical Practice Guideline on Anticoagulants and Antiplatelets (AJG 2022), will continue aspirin in the setting of secondary prevention

Management of warfarin in GI bleed:

In a patient with gastrointestinal bleeding, resuming anticoagulation within the first week after discontinuation minimizes risk for 90-day thrombosis, without increasing risk for 90-day recurrent gastrointestinal bleeding.

High bleed risk procedures (>2% in 30 days): polypectomy (>1cm), PEG/PEJ placement, ERCP with sphincterectomy, EMR/ESD, EUS-FNA, endoscopic hemostasis (excluding APC), radiofrequency ablation, POEM, treatment of varices, therapeutic balloon assisted enteroscopy, tumor ablation, cystogastrostomy, ampullary resection, pneumatic or bougie dilation, laser ablation and coagulation

Low/moderate risk bleeding procedures (<2% in 30days): EGD w/w/o bx, colonoscopy with/without biopsy, flex sig with/without bx, ercp with stent, eus w/o fna, push enteroscopy and diagnostic balloon assisted enteroscopy, enteral stent deployment, APC, balloon dilation of liminal stenoses, polypectomy <1cm, ercp without sphincterectomy, marking, video capsule endoscopy