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Toronto Notes 2019 Small and Large Bowel
Treatment (in order of Increasing Potency)
• dietaryfibre
■ useful if mild or moderate constipation, but not if severe ■ aim for 30 g daily, increase dose slowly
• surface-acting(softenandlubricate) ■ docusate salts, mineral oils
• osmoticagents(effectivein2-3d)
■ lactulose, sorbitol, magnesium salts (e.g. magnesium hydroxide, i.e. milk of magnesia), lactitol
(β-galactosido-sorbitol), polyethylene glycol 3350
• cathartics/stimulants(effectivein24h)
■ senna, bisacodyl
• enemasandsuppositories(e.g.salineenema,phosphateenema,glycerinsuppository,bisacodyl
suppository)
• prokineticagents(prucalopride)
• linaclotide(secretagogue,increaseswatersecretionintotheintestinallumen)
Upper Gastrointestinal Bleeding
Definition
• bleedingproximaltotheligamentofTreitz,seeGastrointestinalTract,G2(75%ofGIbleeds)
■ ligament of Treitz: suspensory ligament where fourth portion of the duodenum transitions to
jejunum
Etiology
• abovetheGEjunction ■ epistaxis
■ esophageal varices (10-30%) ■ esophagitis
■ esophageal cancer
■ Mallory-Weiss tear (10%)
• stomach
■ gastric ulcer (20%) (see Peptic Ulcer Disease, G11)
■ erosive gastritis (e.g. from EtOH or post-surgery) (20%)
■ gastric cancer
■ gastric antral vascular ectasia (rare, associated with cirrhosis and CTD) ■ Dieulafoy’s lesion (very rare)
• duodenum
■ ulcer in bulb (25%)
■ aortoenteric fistula: usually only if previous aortic graft (see sidebar)
• coagulopathy(drugs,renaldisease,liverdisease) • vascularmalformation(Dieulafoy’slesion,AVM)
Clinical Features
• inorderofdecreasingseverityofthebleed:hematochezia(briskupperGIbleed)>hematemesis>coffee ground emesis > melena > occult blood in stool
Treatment
• stabilizepatient(1-2largeboreIVs,IVfluids,monitor)
• send blood for CBC, cross and type, platelets, PT, PTT, electrolytes, BUN, Cr, LFTs
• keep NPO
• considerNGtubetodetermineuppervs.lowerGIbleedinginsomecases
• IVPPI:decreaseriskofrebleedifendoscopicpredictorsofrebleedingseen(seeprognosissection)
■ given to stabilize clot, not to accelerate ulcer healing
■ if given before endoscopy, decreases need for endoscopic therapeutic intervention
• forvaricealbleeds,octreotide50μgloadingdosefollowedbyconstantinfusionof50μg/h
• considerIVerythromycin(ormetoclopramide)toaccelerategastricemptyingpriortogastroscopyto
remove clots from stomach
• endoscopy(OGD):establishbleedingsite+treatlesion
■ if bleeding peptic ulcer: most commonly used method of controlling bleeding is injection of epinephrine around bleeding point + thermal hemostasis (bipolar electrocoagulation or heater probe); less often thermal hemostasis may be used alone, but injection alone not recommended
■ endoclips
■ hemospray
Prognosis
• 80%stopspontaneously
• peptic ulcer bleeding: low mortality (2%) unless rebleeding occurs (25% of patients, 10% mortality)
• endoscopic predictors of rebleeding (Forrest classification): spurt or ooze, visible vessel, fibrin clot
• cansendhomeifclinicallystable,bleedisminor,nocomorbidities,endoscopyshowscleanulcerwith
no high risk predictors of rebleeding
• H2-antagonistsshouldnotbeusedsincetheyimpactminimallyonrebleedingratesandneedforsurgery • esophagealvariceshaveahighrebleedingrate(55%)andmortality(29%)
Gastroenterology G25
Always ask about NSAID/Aspirin® or anticoagulant therapy in GI bleed
Aortoenteric Fistula is a rare and lethal cause of GI bleed, most common in patients with a history of aortic graft surgery. Therefore, perform emergency endoscopy if suspected, emergency surgery if diagnosed Note: The window of opportunity is narrow. Suspect if history of aortic graft, abdominal pain associated with bleeding
Transfusion Strategies for Acute Upper Gastrointestinal Bleeding
NEJM2013;368:11-21
Study: Prospective, unblinded, RCT, follow-up up to 45 d. Populations: 921 patients with hematemesis, bloody nasogastric aspirate, melena, or both. Exclusion criteria included massive bleed, ACS, stroke/TIA or transfusion within previous 90 d; recent trauma/surgery; lower GI bleed.
Intervention: Patients randomized to restrictive (<70 g/L) or liberal (<90 g/L) transfusion.
Outcome: Mortality, further bleeding, adverse events. Results: Fewer patients in the restrictive group required transfusion (51% vs. 15%; p<0.001). The hazard ratio for death for restrictive compared to liberal transfusion was 0.55; 95% CI 0.33-0.92; p=0.02. Further bleeding occurred in 10% vs. 16% (p=0.01) of patients, while adverse effects occurred in 40% vs. 48% (p=0.02) of patients in the restrictive and liberal strategies, respectively. The restrictive strategy had a better survival rate in patients with bleeding associated with cirrhosis Child-Pugh class A or B (HR: 0.30; 95% CI 0.11-0.85), but not in cirrhosis Child-Pugh class C (HR: 1.04; 95% CI 0.45-2.37) or a peptic ulcer (HR: 0.70; 95% CI 0.26-1.25).
Conclusions: Transfusing patients with an acute upper GI bleed at hemoglobin of <70 g/L rather than 90 g/L is associated with fewer transfusions, better survival, and fewer adverse events.
Forrest Prognostic Classification of Bleeding Peptic Ulcers
Forrest Type of Lesion Class
I Arterial bleeding (oozing/spurting)
IIa Visible vessel
IIb Sentinel clot
IIc Hematin covered
flat spot
III No stigmata of
hemorrhage
Lancet 1974;2:394-397
Risk of Rebleed (%)
55-100
43 22 10
5