Follow Your GutGI Complications in

Cardiothoracic PatientsHeather Z. Morgan, MPAS, PA-C

Chief Surgical ICU PA

Saint Vincent Hospital

Worcester, MA

An Approach to Acute GI Complications in Cardiothoracic Surgery Patients

A Review of Updated Evidence-Based Information

Learning Objectives

• To define some major GI complications that occur in cardiothoracic Patients

• To understand the pathophysiologic mechanisms of specific GI complications

• To identify and prognosticate those patients who are at risk of GI complications in cardiothoracic surgery patients

• To outline an approach to diagnosing GI complications

• To offer treatment solutions and clinical management pearls unique to the cardiovascular surgery population

Disclosures

• I have no conflicts of interest

Why GI Complications?

• GI complications after cardiac surgeries pose a significant healthcare burden.

• Associated with higher morbidity and prolonged intensive care unit and hospital LOS.

• Identifying these predictive factors and other associated complications may help in prevention and early diagnosis

• Thus, improving patient outcomes in this vulnerable population and increasing healthcare value

Mechanism of GI Complications

• Visceral hypo-perfusion during the perioperative period is the main recognized factor.

• Sympathetic vasoconstriction, hypo-perfusion, and hypoxia of the splanchnic bed.

• This may occur during cardiopulmonary bypass-due to regional redistribution of blood flow away from gut mucosa

• May also result in low cardiac output or hypotension during the post operative period

• Inadequate tissue perfusion contributes to mucosal hypoxia with a reduction in absorptive and barrier functions.

What Occurs due to Inadequate Perfusion

• Stress ulceration

• Mucosal atrophy

• Bacterial overgrowth from stress ulcer prophylaxis

• Increased permeability

Due to Poor perfusion

All of these changes lead to:

• Bacterial translocation

• Sepsis

• Multi-system organ failure

GI Complications in Cardiac Surgery Patients

Ann Surg.

2007;246:323–9.

NYHA, New York

Heart

Association.

GI Complications in Cardiothoracic Patients

• Post Operative Ileus

• Upper GI Bleed

• Lower GI Bleed

• Mesenteric Ischemia

• Acute Pancreatitis

Post Operative Ileus

• It is one of the most common GI complications after cardiac surgery

• Although, frequently benign and self-limiting, it can also represent a more severe intra-abdominal process.

Post Operative Ileus

Due to:

• Drugs

• Vagal injury

• Congestion of the hepatic/splanchnic bed

• Inflammatory process (i.e. Cholecystits/Pancreatitis)

• RPH

• C.diff colitis

• Mesenteric ischemia

Post Operative Ileus-Evaluation

• Physical exam Including abdominal and rectal exam

• Monitor I/O’s Closely

• KUB

• CT Scan of Abdomen/Pelvis-with PO/IV Contrast

• C.diff titers

• Labs-*lactate

Treatment

• Make pt NPO

• NGT for decompression

• Stopping or minimizing all agents that impair gut motility (Opiates)

• Promotility agents-reglan,erythromycin

• Neostigmine 2mg IV for pseudo-obstruction

• Bowel regimen

• TPN

• If worsens after these treatments-Gen Sx/GI Consult for colonoscopy or surgery

UGIB vs LGIB

• UGI=Above the Ligament of Treitz—Symptoms: Melena, hematemesis, Coffee-Ground Emesis

• LGI=Below the Ligament of Treitz—Symptoms: BRBPR, Hematochezia

Upper GI Bleed Pathology

• Major Causes:

• PUD, Esophagogastric varices, Gastric or duodenal ulcers, arteriovenous malformation, tumor, esophageal (Mallory-Weiss) tear

• History:

• Liver disease, ETOH, Coagulopathy, NSAID, antiplatelet, Anticoagulant, H/O Abdominal surgeries

UGI Bleeds in TAVR

• Risk of UGIB following TAVR was found to be 2.0%

• The risk of UGIB in patients receiving triple antithrombotic therapy was found to be 10-fold greater than patients not receiving triple antithrombotic therapy (11.8% vs 1.0%).

• Endoscopy findings demonstrated five high-risk esophageal lesions including erosive esophageal ulcers, visible vessels at the GE junction, erosions at distal esophagus, and an actively bleeding esophageal ring that had been intubated through by the transesophageal echocardiography (TEE) probe.

UGIB Etiology

• One of the most common GI complications, which is encountered on and off pump surgery with an incidence of 0.5-1%

• Results from stress ulceration from duodenal ulcers and less commonly from gastric ulcers and esophagogastritis

• Mechanism of cause is usually decreased blood flow, mucosal ischemia, and a hypoperfusion/reperfusion injury that maybe exacerbated by increased gastric acidity.

UGIB Risk Factors

• Advanced Age

• h/o Gastritis/PUD

• Anti-thrombotic drugs-NSAIDS, Anti-platelet, anti-coagulants (especially when used in combination)

• h/o H. Pylori

• Acquired von-Willibrand disease (common in HOCM, AS, MR, LVAD)

• Diabetes Mellitus

• Cardiovascular disease

SUP-Stress Ulcer Prophylaxis

• Any Patient with any history of Ulcer disease or gastritis should receive a H-2 Blocker or PPI

• Any patient requiring prolonged ventilatory support, Septic, or who has a coagulopathy

• Utilizing a PPI (?Protonix vs. Prilosec)

*especially while pt’s are on Dual/Triple-Antiplatelet therapy.

Sucralfate

Utilizing it in patients who have:

• Marginal cardiac output

• Visceral hypoperfusion

• Some degree of coagulopathy

• Intubated

Sucralfate

Even in low risk patients, little downside to utilizing Sucralfate

• 1Gram q6h orally or via gastric tube

• Does not decrease gastric pH

• May reduce incidence of nosocomial pneumonia

• Suggest utilizing in all intubated pts.

*It Is Inexpensive and Harmless

PPI Prophylaxis

• More effective than H-2 blockers in decreasing incidence of hemorrhagic gastritis and active ulcer formation

• However the risk involved with inappropriately utilizing H2/PPIs can cause nosocomial pneumonia and increase risk of Cdiff

• Try and use PPIs with ASA or Clopidogrel as this does decrease the incidence of GIB or ulceration

UGI Diagnostic Components

• Endoscopy in upper GI bleed is diagnostic and can be therapeutic.

During EGD:

• Variceal banding

• Electrocautery

• Epinephrine injection into bleeding vessel

Pharmacologic Treatment of UGI Bleed

Acid Suppression

• PPI:

Protonix 80mg IV bolus, then 8mg/hour infusion vs Protonix 40mg IV q12

Somatostatin analogues:

Suspected variceal bleeding/cirrhosis

Octreotide 50mcg IV bolus, then 50mcg/hour infusion

Lower GI Bleeds

• Melena is the passage of black, tarry, foul-smelling stools as a result of degradation of blood to hematin. The source of melena is most often from the upper GI tract. However, it may also be from the small intestine or the right colon.

• Hematochezia is the passage of bright red blood per rectum, with or without stool. Occult bleeding is bleeding not apparent to the patient and is usually detected with stool guaiac testing

LGIB Etiology

• Mesenteric ischemia or ischemic colitis

• Colitis (ie C.diff)

• Colonic lesions-polyps, tumors, diverticular disease-these may become an issue when precipitated by anticoagulants

• Heyde’s syndrome-Intestinal angiodysplasia-a/w AS, acquired von Willebrand’s disease

• AV malformation

Diagnostic Tools for LGIB

• Radionuclide scanning

• Mesenteric angiography

• Colonoscopy

• Capsule endoscopy

• Small bowel enteroscopy

Treatment of LGIB

• Correction of coagulopathy and elimination of precipitating causes

• Antibiotics for C.diff (Vanco 125mg PO Q6H/Flagyl 500mgIV Q8H)

• Mesenteric angiography with infusion of vasopressin (0.2-0.4u/min)

• Selective embolotherapy with injection of gelfoam or autologous clot into mesenteric arterial branch• Less morbidity and mortality compared to surgery.

• A safe and effective treatment for uncontrollable LGIB post CT sx.

Treatment of LGIB

• Octreotide 50ug over 30 minutes or Somatostatin 50ug bolus followed by an infusion

Both of these medications decrease splanchnic blood flow can help treat GI angiodysplasia

Initial Management of Any GI Bleeding

• Airway protection-airway monitoring with endotrachial intubation-if indicated

• Hemodynamic stabilization-large bore IV access vs Central venous catheter, IV fluid resusitation, PRBC transfusion, FFP/Platelets, epogen considered

• Nasogastric tube placement-careful with h/o esophageal varices

• Administer IV PPI

• Clinical and laboratory monitoring-eerial Labs,serial PE and VS

• Consult GI Stat

• Endoscopic exam and therapy

Severe GI Bleeding

Massive Transfusion

• 10 or More PRBC in under 24 Hours

• Replacement of 50% of Total Blood Volume within 3 Hours

• Blood Loss >150ml/min

• Most Recent Retrospective Study Showed that 1:1:1

• PRBC:FFP:Platelets

Cautious Resuscitation

• Cardiac patients with low EF require a strategically restrictive transfusion process.

• Those patients who may not be intubated have a higher risk of fluid overload and acute pulmonary edema

• Continue to allow for blood transfusion with a dose of Lasix between units.

• Watch for TRALI, Volume Overload, Difficulty Ventilating.

Mesenteric Ischemia

• Mesenteric ischemia is rare, 0.2-0.4%, however extremely lethal and has a mortality rate of >87%

• It is usually noted in elderly cardiac surgery patients who have known atherosclerotic disease

• It is associated with dehydration

Mesenteric Ischemia-Etiology

• The type that is most associated with cardiac surgery is:

non-occlusive mesenteric ischemia

• This is due to splanchnic hypo-perfusion from a low cardiac output state

• It can occur on and off pump surgery, however more likely to occur due to a long pump run

• Causes of atherosclerotic embolism-due to use of IABP, and mesenteric thrombosis-due to HIT, are less common

Presentation of Mesenteric Ischemia

• Abdominal Pain-”out of proportion” to physical findings.

• Can be precipitated by post operative ileus

• Diagnosis can be difficult to illicit from a critically ill patient who is on the mechanical ventilator and is on sedatives.

Mesenteric Ischemia

• Pt presenting with signs and symptoms of sepsis should be approached with great concern:

• Hemodynamic instability, ie. increased use of vasopressors

• Respiratory acidosis/failure-without known source, this can occur while on the ventilator, can present as an ARDS type picture, or increase requirement of oxygen

• Signs of GI Bleeding(UGI/LGI) and diarrhea

• Occurs 5-10 days postoperatively

Diagnosis

• Check KUB

• Serial abdominal exams-absent BS, non-resolving ileus

• CT Abdomen/Pelvis with PO/IV contrast

• Mesenteric CT

• Mesenteric arteriography

• Elevated lactate

Mesenteric Ischemia

Treatment

• It is essential for early diagnosis and treatment*

• As the mortality rate can exceed >65%

• Emergency Ex Lap• Likely abdomen should remain open and be readied for a second look to

decrease the chance for abdominal compartment syndrome.

• SMA/IMA stent if due to stenosis

Pancreatitis

• Less than 0.5% of patients who undergo cardiac surgery

• High mortality rate

• 25% of patients died of pancreatic necrosis

• Associated with multi-system organ failure

Etiology

• Associated with patients who have a history of alcoholism

• Associated with low cardiac output state and hypo-perfusion

• Prolonged CPB can cause an insult to the pancreas to incur a persistent low output state

• That then incurs increase use of vasopressors that can lead to necrotizing pancreatitis

Pancreatitis

• Atypical presentation of:

• Fever

• Elevated WBC

• Ileus

• Distended abdomen

• Abdominal pain

• Hemodynamic instability

Ranson Criteria-For Severity of Acute Pancreatitis

Diagnosis

• Association of abdominal pain and hyper-amylasemia

• However patients with fulminant pancreatitis do not present with an elevated amylase

• Abdominal ultrasound

• Abdominal CT-show pancreatic phlegmon or abscess

Treatment

Approaching each patient with nonspecific symptoms:

• Place an NGT, NPO, IVF resuscitation, pain management

• Start prophylactic antibiotics

• Ex lap for debridement and drainage-as a last ditch, life saving effort.- associated with Highest Mortality Rate.

Pearls of Approach

• Obtain a good history to be informed of potential GIC risk

• Exam and diagnostic data should focus on signs and symptoms of potential GIC-serial exams can be key.

• Prevent with pharmacologic recommendations

• Early diagnosis and treatment can aid in improvement of morbidity and mortality rates.

• “Critical care is a mindset; not a location” - Manny Rivers

Case Study

• 57 year old male undergoes emergency CABG.

• PMH: HTN, Asthma, MI (12 yrs ago), IDDM-type 1, DM Neuropathy and retinopathy

• Postop the pt has a complicated course of prolonged intubation, HD instability requiring pressor support, and ARF requiring Hemodialysis.

• HD was completed after a week with return of renal function.

• Trach Placed after 14 days

• POD # 27 pt develops enormous amouts of BPBPR

Case Study

• An urgent GI Consult was placed

• Pt had an emergent UGI study done without any identifiable bleeding source

• Once the pt was relatively stable, a flexible sigmoidoscopy was done with the ability to access up to 40cm, Fresh blood was identified, but no source of bleeding.

• Serial CBC returns @ 6.1/20.1

Case Study

• Pt received 5 units of PRBCs and then 1 unit of FFP, 1-6 pack of platelets.

• Pt became HD stable.

• Consult to IR placed, pt had a mesenteric angiography-accessed via right femoral artery.

• Found Contrast extravastation at ileal loop

• Selective catheterization achieved with 3 coils with cessation of bleeding.

• Pt d/c to STR 1 week later- f/u outpatient Colonoscopy-nl

Thank you for your time and attention!

References

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• Krawiec F, Maitland A, et al. Duodenal ulcers are a major cause of gastrointestinal Bleeding after cardiac surgery. J Thoac Cardiovasc Surg 2017;154:181-188.

References

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