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[Dr. Handy] Hi, welcome to Harrison's Podclass where we discuss important concepts in internal medicine. I'm Cathy Handy. [Dr. Wiener] And I'm Charlie Wiener and we're coming to you from the Johns Hopkins School of Medicine. [Dr. Wiener] Today's episode is a 64-year-old with GI bleed. Okay Cathy, so today's case is a 64-year-old man with known cirrhosis, who's admitted to the ICU with a large upper GI bleed and altered mental status. He's confused and unable to provide any history.
His initial hemoglobin is 6.9 g/dL and his vital signs are notable for a heart rate of 115 and a blood pressure of 90 over 55. So you want to start there? [Dr. Handy] Well, this patient clearly belongs in the ICU with a hemodynamically significant GI bleed. We don't know his baseline hemoglobin but we should assume that this is a drop. He needs immediate volume resuscitation and blood transfusion because his hemoglobin is already below seven.
Sometimes we will use a higher threshold of hemoglobin in patients with coronary artery disease but we don't have that history, so we'll use a threshold of seven. Based on his mental status, he may require intubation for airway protection. [Dr. Wiener] Any suspicions of cause? [Dr. Handy] Well, common things being common, first I would think of peptic ulcer disease since that's the most common cause of GI bleeding in the United States.
In this case, the only history we have is a history of cirrhosis, so while peptic ulcer disease is a possibility I'd also be concerned about a variceal bleed. [Dr. Wiener] And how would the risk of a variceal bleed change your approach? [Dr. Handy] Well just for some background, over the last decade, it's become common practice to screen known cirrhotics with endoscopy to look for esophageal varices.
Such screening studies have shown that approximately one third of patients with histologically confirmed cirrhosis also have varices and it's anticipated that roughly one third of patients with varices will develop bleeding. Now variceal bleeds can be very severe and they would require endoscopic interventions. Remember also that most patients with cirrhosis have a coagulopathy based on their thrombocytopenia and prolonged INR.
As soon as he's stabilized, he should have an upper endoscopy because that will likely be diagnostic and possibly therapeutic as well. [Dr. Wiener] Okay, well, you're obviously on the right lines because here's what the question's asking. The question says, in addition to fluid resuscitation including transfusion of packed red blood cells, all of the following are appropriate therapies at this time except?
A. endoscopic sclerotherapy; B. endoscopic variceal ligation; C. octreotide; D. propranolol; or E. transjugular intrahepatic portosystemic shunt, or TIPS. [Dr. Handy] So these answers assume that the bleeding is due to esophageal varices because all of these are sort of related to varices.
In that context, we need to think about the therapies for right now, the approach to patients with a variceal bleed is first to treat the acute bleed which can be life-threatening, and then it's to prevent further bleeding. The medical management of acute variceal hemorrhage includes the use of vasoconstricting agents, usually somatostatin or octreotide.
Balloon tamponade with a Sengstaken-Blakemore tube or Minnesota tube can be used in patients who cannot receive endoscopy therapy immediately or who need stabilization prior to endoscopic therapy. Endoscopic intervention is used as first-line treatment to control bleeding acutely. Some endoscopists will use variceal injection therapy which is sclerotherapy as initial therapy particularly when bleeding is vigorous.
Variceal band ligation is used to control acute bleeding in over 90% of cases and should be repeated until obliteration of all varices is accomplished. When esophageal varices extend into the proximal stomach, band legation is less successful. In these situations when bleeding continues from gastric varices, consideration for transjugular intrahepatic portosystemic shunt, which we call TIPS, should then be made.
This offers an alternative to surgery for acute decompression of portal hypertension. [Dr. Wiener] So TIPS is also used for patients with refractory ascites or frequent bleeds as you mentioned, right? [Dr. Handy] Yeah in the properly selected patients, TIPS will reduce chronic portal hypertension but since you're diverting portal blood to the systemic circulation, you run a risk of worsening hepatic encephalopathy.
Encephalopathy can occur in as many as 20% of patients after TIPS and is particularly problematic in elderly patients and in patients with pre-existing encephalopathy. TIPS should really only be reserved for individuals who fail endoscopic or medical management, or who are poor surgical risks. And it can sometimes be used as a bridge to transplantation.
[Dr. Wiener] Okay, so you've mentioned the two endoscopic treatments, you've mentioned octreotide as a portal vasoconstrictor and you've mentioned TIPS as a last ditch treatment. So I guess that means propranolol is not indicated in this case, right? The answer's D?
[Dr. Handy] Right, beta blockers, like propranolol or sometimes nadolol is also used, those have been shown to decrease the risk of recurrent variceal bleeding and reduce mortality from subsequent bleeds, but they should not be used in the setting of an acutely bleeding patient. This patient here is hypotensive, so giving a beta blocker would not be helpful and potentially make things worse. [Dr. Wiener] Okay, now this is actually a two part question.
It goes on to ask, in the patient above, all of the following could be used as prophylaxis for further variceal bleeding except? And the answers are, A. initiation of a non-selective beta blocker, such as propranolol, which you've all ready mentioned; B. initiation of daily subcutaneous octreotide injections; C. liver transplantation; D. repeated variceal ligation; if the initial bleed was controlled with endoscopic variceal ligation; or once again, TIPS.
[Dr. Handy] Well, we've all ready mentioned a number of these. So propranolol, repeated variceal ligation and TIPS can all be used chronically to prevent further variceal bleeds, and liver transplantation in selected patients is essentially curative because you're fixing the underlying problem of cirrhosis. [Dr. Wiener] So the answer is B, we use octreotide acutely but not chronically?
[Dr. Handy] Right, as in this patient during the acute variceal bleed, a continuous infusion of octreotide may promote splanchnic vasoconstriction and can be used to manage acute variceal bleeding. However, a subcutaneous octreotide is not used as prophylactic treatment. [Dr. Wiener] Okay, so the teaching points in this case are that in patients with known history of cirrhosis who present with an acute upper GI bleed, it should be treated initially as if it is likely a serial variceal bleed.
Urgent endoscopy may be diagnostic and therapeutic. In addition to supportive therapy, there are a variety of acute treatments which may be used to control the acute bleeding and after stabilization additional treatments may prevent subsequent episodes of bleeding. [Dr. Handy] To read more, you can check out Harrison's chapter on gastrointestinal bleeding and the chapter on cirrhosis and its complications. [outro music] [Mr. Shanahan] This is Jim Shanahan, publisher at McGraw Hill.
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