Management of Gastrointestinal Bleeding in 2015

WITH SPECIAL FOCUS ON GI BLEEDING IN PATIENTS WITH LEFT VENTRICULAR ASSIST DEVICES (LVAD)

Gastrointestinal Bleeding is a Common Medical Condition

250K-500K hospital admissions per year UGI bleeding incidence is 100/100,000 adults

Incidence increases 20-30 fold from the third to ninth decade of life

LGI bleeding incidence 20/100,000 adults Overwhelmingly disease of the elderly

GI bleeding stops spontaneously in 80%

Costs

Average hospital costs exceed $5000 per admission

Most of this for hospital bed and ICU stays rather than physician fees, blood products, diagnostic tests and medications

Goal is to reduce hospital admission and LOS in order to reduce costs

Morbidity Data

Majority will receive blood transfusions 2-10% require urgent surgery to arrest the

bleeding Average LOS 4-7 days Mortality rates for UGI bleeding 2-15% Mortality for patients who develop bleeding

after admission to hospital for another reason is 20-30%

Causes of acute upper gastrointestinal bleeding

CommonGastric ulcerDuodenal ulcerEsophageal varicesMallory-Weiss tear

Less commonGastric erosive/gastropathyEsophagitisCameron lesionsDieulafoy lesionTelangiectasiasPortal hypertensive gastropathyGastric antral vascular ectasia (watermelon stomach)Gastric varicesNeoplasms

RareDuodenitis, esophageal ulcer, aortoenteric fistula, Crohn's disease, hemobilia, pancreatic disease

Causes of acute lower gastrointestinal bleedingCommonColonic diverticulaAngioectasiaLess commonColonic neoplasms (including post polypectomy bleeding)Inflammatory bowel diseaseColitisIschemicRadiationUnspecified (infectious or non specific)HemorrhoidsSmall bowel sourceUpper gastrointestinal source

RareDieulatory lesion, Colonic ulcerations, Rectal varices

Facts about UGI bleeding

Hematemesis occurs 25% of the time Melena alone occurs 25% of the time--require

50cc -100cc of blood to have melena Hematochezia occurs only 15% in a massive

UGI bleed Elevated BUN out of proportion to the creatinine

is a good marker for an UGI bleed NGT may miss an active bleeding duodenal

ulcer bleed

Facts about Lower GI bleeding

Frank red blood indicates a brisk LGI bleed

Melena can mean a right sided bleed

Most lower GI bleeding is self limited

Lower GI bleeding is mostly painless

Diverticulosis is the main cause for significant LGI bleeding

Assessment of Patient with Acute GI Bleeding

Assess hemodynamics and resuscitate Keep Hgb >= 7 gm/dL Assess level of risk

Timing of endoscopy

Timing of discharge

Level of care

Possible discharge from ED based on certain criteria: BUN <18.2 mg/dL

Hgb > 13 mg/dL (M)/ 12 mg/dL (F)

SBP > 110 mm Hg and HR < 100

absence of melena, syncope, cardiac failure, and liver disease

<1% of need for intervention

Glascow-Blatchford Bleeding Score

Endoscopic Clipping

Endoscopic Banding

Argon Plasma Coagulator

Watermelon Stomach (GAVE- gastric antral vascular ectasia)

Treatment of GAVE

Bleeding Ulcer

Bleeding Colonic Diverticulum

CT Angiography

Angiography

Congestive Heart Failure and Ventricular Assist Devices

500, 000 new cases a year Interagency Registry For Mechanical Circulatory

Support (INTERMACS)--1400+ LVAD were placed between 2006 and 2009. That number is rising

At Medstar Washington Hospital Center we placed over 70 devices in 2014 and we are projecting more in 2015

It is clear LVAD are becoming a mainstay for advanced heart failure

Major Causes of Mortality after VAD Placement

Cardiac Failure 22% Infection 16% CNS 14% Multi-organ failure 10% Respiratory failure 5% GI bleed 1%

Mechanisms for GI bleeding in LVAD patients

Use of antiplatelet therapy and anticoagulation Acquired Von Willebrand Syndrome

fragmentation of high-molecular-weight multimers of vWF by the shear forces of the HVAD

chronic low pulse pressure intestinal hypoperfusion from reduced pulse pressure leads to

regional hypoxia, vascular dilation, and subsequent

angiodysplasia Similar situation seen in Aortic Stenosis

Gastrointestinal Bleeding in Recipients of the HeartWare Ventricular Assist SystemDaniel J. Goldstein, MD,* Keith D. Aaronson, MD, et al., JACC: Heart Failure, Vol 3, No 4, April 15, 2015:303-313

Looked at 382 patients enrolled over 30 center b/w 2008-2012

Average age was 53 yrs old, predominantly male (70%)

Majority were 96% NYHA Heart Failure

15% of the patients had GI bleeding (59 of the 382)

Clinical characteristics—high BMI, diabetic, ischemic etiology of HF, elevated creatinine

Most GI bleeds occurred after 30 days of implantation

Mean INR at presentation was 2.2

34% of the bleeding patients had 2 or more GI bleeding events

At 1 year, 84 % had no further bleeding

The most common lesion was an AVM Second was an ulcer Most common lesion site was the small bowel then

stomach LVAD support was longer in patients with GI bleed No deaths related to GI bleeding Incidence of GI bleeding was 16% or .27 GIB/yr Survival doesn’t seem to be affected by GI bleeding