Episode 38: GI bleeding with Elliot Tapper

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Back with returning guest Dr. Elliot Tapper (@ebtapper), gastroenterologist, transplant hepatologist, and director of the cirrhosis program at the University of Michigan in Ann Arbor, to talk about critical GI bleeding.

Takeaway lessons

1. Consider the Glasgow-Blatchford score to stratify risk and need for admission, GI consultation, etc.
2. Octreotide (or terlipressin) is indicated in every cirrhotic with GI bleeding, i.e. patients with confirmed or probable varices.
3. Proton pump inhibitors are appropriate for bleeding ulcers. Note they are not needed in variceal bleeding, and are not needed if octreotide is also being given; octreotide reduces gastric pH just as much as a PPI.
4. Bleeding cirrhotics should receive antibiotics. They have a high risk for inpatient infections, whether from bacterial translocation, instrumentation, etc.
5. By and large, twice-daily PPIs are as good as PPI drips. The latter is mostly an evidence-free Hail Mary addition.
6. As a general rule, colonoscopy for lower GI bleeding rarely needs to be done urgently; at most, early colonoscopy (within 24-48 hours) may reduce length of stay, but the yield of finding intervenable findings (particularly in unprepped bowel) is extremely low.
7. In very unstable patients, it is not very common that you would need to place a gastric tube and perform lavage to prove an upper GI bleeding source; just do the EGD. In less obvious cases it can be quite useful, though. Don’t be misled by trace amounts of bleeding, which can occur (due to stress) even in lower GI bleeds.
8. NG/OG placement in the setting of varices is safe, unless there’s been recent banding performed.
9. Early CTA is a good approach for severe lower GI bleeding. It is basically never the first line approach for presumed upper GI sources, however; IR embolization is less effective here (due to the redundant blood supplies), and endoscopy will help localize the bleeding source for any needed embolization anyway.
10. “Early” EGD usually means within 12 hours and is appropriate for active bleeds that are not catastrophic.
11. Although massive bleeding can result from varices, with good medical treatment it is actually rare. In most cases judicious transfusion can be used to avoid overly increasing venous pressures.
12. For truly rapid upper GI bleeds, intubate early (to prevent aspiration and facilitate EGD), ensure adequate IV access, and perform emergent EGD; endoscopy remains the first line treatment. Even when visualization is difficult it provides useful information by localizing the bleeding region. Normal (Hgb >7) transfusion targets are not relevant in active exsanguination. A PPI drip is reasonable but is not particularly high yield at this point.
13. Balloon tamponade (Minnesota or Blakemore tubes) has its own risks, and few clinicians are expert at their placement. Overall it is rarely needed unless endoscopy is not immediately available, such as if a patient needs transfer to another institution.
14. EGD can lead to rescue surgery if it visualizes bowel perforation, and to IR if a bleeding vessel is found that can’t be addressed endoscopically.
15. Repeat endoscopy during the same hospitalization is rarely needed. For ulcers, it is common to re-scope in about 8 weeks to make sure it has healed and is not cancerous.

References

The Glasgow-Blatchford Bleeding Score (GBS) to stratify risk.