Thread by @anjefus

Let's do a new tutorial

GI-Bleeding for non-endoscopists

#MedTwitter #GITwitter #livertwitter #ICU #FOAMed
@stevenbollipo @drkeithsiau @ebtapper @jaumebosch9 @GI_Pearls @DrHarryThomas (these are endoscopists)

First rule, stay cool

There are three different GI-bleeding locations:
upper (until suspensory muscle of duodenum)
middle
lower (starting from the coecum)

Frequency:
upper>middle>lower

So, first gastroscopy before coloscopy
(exception: it is really clear like fifth times diverticle bleedings --> why did the patient receive no surgery?)

One important differentiation:
upper GI-Bleeding
bleeding of varices vs. "usual" upper GI-Bleeding

First step is not the endoscopy!

But Basic management:
Anamnesis and physical examination:
Tumor? Cirrhosis? Medication(!)? History of bleeding?

What does the patient want? Palliative situation?

More basics:
Vitals, laboratory (Hb? coagulation parameters? Ca?, lactate).

More Basics

Stabilize the patient:
Give Volume
Get transfusion maybe (aim a Hb of 7mg/dl, but in heavy bleedings, aim higher, he'll hit the 7 or lower).
Beyond Basics: Intubation if GCP<9 or if he can puke the blood in the beam)

Stabilize the coagulation:
First with, guess it, basics:
Keep him warm >34°
ph>7.2
give Ca if ionized Ca<0.9 (Factor IV!)
Think about FFP (250 ml increase Quick about 6%)
and PPSB: 1 IE/kg increases Quick about 1%
Fibrinogen 2-4(-8g)
Individual concept

Hint:
If a patient bleeds again and again, diffuse, you don't find anything. Check Factor XIII. Decrease of it can be the cause. Substitute.

Don't let him do this:

But give parenteral nutrition to cirrhosis patients (they loose muscles fast).

Vomiting red blood and black stool --> upper GI-bleeding
bloody stool --> lower GI Bleeding
BUT: Blood is like laxative --> bloody stool can be upper GI-bleeding, too.

Upper GI-Bleeding:
Forrest I a (Spurting hemorrhage)
Forrest I b (Oozing hemorrhage)
Forrest II a (Non bleeding Visible vessel)
Forrest II b (Adherent clot)
Forrest II c (Flat pigmented haematin (coffee ground base) on ulcer base)

and

Forrest III (Lesions without signs of recent hemorrhage or fibrin-covered clean ulcer base)

Forrest I b --> highest risk of rebreeding!

Now, you have done something. Actually a lot.
Call the endoscopist and make a concept.

While you are doing this give a PPI:
8-10 mg/h Pantozol
3x40 mg Bolus or continously 240mg/24 h

Before gastroscopy give erythrmycin 250 mg i. v. (30-120 min before). I suggest 30min, because it will take longer anyway.

Special case: Varices bleeding:
If you think, the patient has it:
-still give PPI, stop when varices bleeding is proven
- give antibiotics! Ceftriaxon 2 g (over 5-7 day, if patient is stabile, give it p. o. e.g. (amonicillin/clavulan acid)
-give something vasoactive!

Vasactive would be:
Terlipressin: 2 mg i. v. every 4 hours
Somatostatin: 250 mikrogramm bolus, then 250 mikrogramm/hour
Octreotid: 50 mikrogramm bolus, then 50 mikrogramm/hour

I do it so: Somatostatin: 3 mg in 36 ml NaCl; Bolus 3ml
dann 3 ml/h continously

Avoid PPIs in Cirrhosis patients:
Some people like to give them, when ligatures are very down. Then: prefer esomeprazole, only for a short time

If you (or the endoscopist) cannot stop the bleeding from varices:
TIPS ----> emergency!

After varices bleeding:
secondary prophylaxis with non-selective beta-blocker
Propanolol or better Carvedilol (e.g. 12,5mg 1-0-0 or 6,25 mg 1-0-1)

If you don't find the bleeding source up go
down
down
down
down

If there is no source neither

Options:
Capsule endoscopy
double ballon enteroscopy
spiral endoscopy
Angio-CT (you only see something there, if there is active bleeding)

No tranexam acid: not less rebleedings but more thrombosis

This is from:

Dieulafoy Lesions:
If possible: Doppler endoscopic probe (DEP)–guided therapy
Rebleeding within 30 days occurred in 11% of those treated with DEP-guided endoscopic therapy compared with 33% of those receiving visually-guided hemostasis.

Source:
(NEJM JW Gastroenterol Oct 2020 and Clin Gastroenterol Hepatol 2020 Aug 20; [e-pub])

I am from Germany.
NICE guidelines say: First Angio-CT, then, radiological intervention or colposcopy. I don't think that helps a lot, because there have to be enough bleeding to see something in angio ct (what do you think @drkeithsiau ?)

Anamnesis and examination --> patient's will --> stabilization --> gastroscopy --> colposcopy --> rethinking (middle GI bleeding? Angio-CT)

Thank you for your attention.
Feel free to comment, ask, discuss, insult, retweet or ignore.

How could I forget? @DeMadaria

Vasactive would be:
Terlipressin: 2 mg i. v. every 4 hours
Somatostatin: 250 mikrogramm bolus, then 250 mikrogramm/hour
Octreotid: 50 mikrogramm bolus, then 50 mikrogramm/hour

I do it so: Somatostatin: 3 mg in 36 ml NaCl; Bolus 3ml
dann 3 ml/h continously

Avoid PPIs in Cirrhosis patients:
Some people like to give them, when ligatures are very down. Then: prefer esomeprazole, only for a short time

If you (or the endoscopist) cannot stop the bleeding from varices:
TIPS ----> emergency!

After varices bleeding:
secondary prophylaxis with non-selective beta-blocker
Propanolol or better Carvedilol (e.g. 12,5mg 1-0-0 or 6,25 mg 1-0-1)

If you don't find the bleeding source up go
down
down
down
down

If there is no source neither

Options:
Capsule endoscopy
double ballon enteroscopy
spiral endoscopy
Angio-CT (you only see something there, if there is active bleeding)

No tranexam acid: not less rebleedings but more thrombosis

No tranexam acid: not less rebleedings but more thrombosis

Source:

Dieulafoy Lesions:
If possible: Doppler endoscopic probe (DEP)–guided therapy
Rebleeding within 30 days occurred in 11% of those treated with DEP-guided endoscopic therapy compared with 33% of those receiving visually-guided hemostasis.

Source:
(NEJM JW Gastroenterol Oct 2020 and Clin Gastroenterol Hepatol 2020 Aug 20; [e-pub])

I am from Germany.
NICE guidelines say: First Angio-CT, then, radiological intervention or colposcopy. I don't think that helps a lot, because there have to be enough bleeding to see something in angio ct (what do you think
@drkeithsiau ?)

By the way. How could I forget?
@DeMadaria

Thank you very much for your attention.
Feel free to comment, ask, discuss, insult, retweet or ignore.

I am sorry. I messed a little up. This is the complete thread. Insult, please.