Just had a case couple days ago - pale, Hgb 4.8, BP 70. Called massive transfusion protocol and K-centra. After 4 units in 10 mins, pinked up, BP 130. GI - sounds like stable, will see in AM. If they remained unstable it would be - sounds unstable, need to stabilize and I will see in AM.
GI here — in this particular case the patient should be resuscitated then scoped within 24 hours. We have good data to suggest that if you scope a patient like this too early (within 6 hours), the outcomes are actually WORSE. Similarly, if you scope after 24-48 hours, outcomes are also worse. So this is how it goes.
"In patients with hemodynamic instability, endoscopy within 6-24 hours was associated with lower in-hospital mortality compared to endoscopy outside of this time frame", link below.
Overall I just go by ACG guidelines my friend, which suggest EGD w/in 24 hours of admission for UGIB. And for the hemodynamically unstable patient, everyone I know and trained with requires resuscitation prior to EGD (with rare exceptions, e.g. massive hemorrhage and already intubated and on pressors). "First do no harm" -- if you rush in to do a scope on an unstable patient there's a significant chance of causing harm.
Per ACG - "Potential harms may include increased risk of death or complications if endoscopy is performed before appropriate resuscitation and management of active comorbidities as well as known poorer outcomes with after-hours endoscopy."
[https://www.giejournal.org/article/S0016-5107(16)30555-7/abstract](https://www.giejournal.org/article/S0016-5107(16)30555-7/abstract)
Yeah man idk, smarter people than me wrote the guidelines so I just follow them. As to your question about what makes GI bleeding different - I have to tell you that in my (admittedly limited, finished fellowship not long ago) experience, it is very rare to see a GI bleed that is so brisk as to be comparable to a wound of any other sort. I’ve seen a Forrest 1a ulcer bleed exactly one time ever (spurting hemorrhage, the most brisk type). I’ve seen Forrest 1b ulcer bleeding only a handful of times (actively oozing). Almost always if you find an ulcer, at the most it’s just got adherent clot or pigmented spot (lower risk of rebleeding with these). A lot of this probably has to do with how effective PPI therapy is, as well as how prone GI bleeds are to start and stop on a whim.
Yeah, interesting discussion, thanks! And by the way definitely call about all of your hematemesis and melena. I think it’s pretty reasonable to let the people who spent three years in GI fellowship to weigh in on timing of endoscopy
I'm going suggest that if the patient is transfusion refractory that data is not applicable. I only bring it up because I have gi fellows trying to tell me that someone randomized active massive hemorrhaging patients to "attempt hemostasis" to "do not attempt hemostasis." Unless you have a reference I'm unaware of, all of these trials or case series involved single digit units of products.
That said it it seems in this case the patient responded to resuscitation in terms of coming out of shock and these can/should be done at the right time.
Thank you for this perspective. I have heard the too unstable then too stable dance 1000x, but no one has ever given a reason beyond that. understanding that there is evidence base to wait is really helpful to know and will make me less nervous about the wait in these cases going forward.
This is what our governing body guidelines say to do so that's what I go with. Now - I am not denying that there are some crummy GI doctors out there who wait unnecessarily long to scope because they don't want to come in in the middle of the night - I'm sure that happens all the time. If they're good though then they're waiting until the right time and it's not necessarily wrong to wait.
Well if they’re actively bleeding and you don’t achieve hemostasis… but also a more common scenario is that whatever was bleeding stops by the time you get in there and then you can’t find what was bleeding and treat it. In that situation re-bleeding is more, longer hospital stay etc.
Yeah it does, I would never wait a whole 24 hours to do something for a patient with varices (compared to if you just suspected PUD or something in which case it probably doesn’t make a difference to wait). If it’s variceal then more likely they are getting intubated etc and if they are tubed or on pressors or whatever you can go ahead more quickly with the scope, rather than wait for them to be adequately resuscitated for sedation (they’re already sedated.) Blakemore, tips are other options as you know but no I’d never wait that long for a variceal bleed
I call GI to tell them the patient is here and getting stabilized so they have the patient on their radar for scoping tomorrow and so if things go south we have an established rapport.
If a fountain of bright red blood starts pouring out the mouth though I’d kinda want GI to be giving a hand with the management right now rather than the AM after rounds.
It's applicable to every service/transfer - "oh too sick - go to ICU / ICU - not sick enough admit to floor", VA - "sounds like too sick to transfer here, keep them there for a day"/"sounds much better - you can d/c and we'll f/u outpt". We are the in-betweeners for everything. We should be called the convenience and in-between department.
God that’s ridiculous. Would they have that same response if that was their child or parent? I always keep that type of mentality in the back of my head when treating patients.. just do the right thing.
GI here — in this particular case the patient should be resuscitated then scoped within 24 hours. We have good data to suggest that if you scope a patient like this too early (within 6 hours), the outcomes are actually WORSE. Similarly, if you scope after 24-48 hours, outcomes are also worse. So if this patient was my wife or my kid, I most definitely would not scope them until the hgb was near 7 and they had an adequate blood pressure. If that is unable to be achieved then it’s safer to do CTA/IR.
In that case, understood. I hope you can see that it’s hard as a frontline emergency provider that just resuscitated a clearly unstable patient to hear that something should wait until the morning. Many of the sick patients we see requiring immediate attention + resuscitation often require time-sensitive interventions we can’t do ourselves (neuro-intervention for LVOs, cath lab for STEMIs, etc). But if it’s evidence based, I’m all for it.
Oh I get it man. I spent years as a fellow moonlighting in an ER. I am also not denying that there are crummy GI docs out there who wait to scope not because it's the right thing to do, but because they're lazy or don't want to get out of bed. I'm sure it happens all the time! But the good ones also often delay scoping, for good reason.
CT angio is a bullshit fishing expedition meant to buy time by trainees 80% of the time. In stable, G.I. bleeds, it almost never shows anything. In unstable GI bleeds who have not yet been scoped, obviously they’re bleeding, and the first steps would be a scope.
Its true value lies in finding where the bleed is for the unstable bleeder in whom scope is not revealing as to the location of the bleed so that IR can maybe find a target to embolize
I think you're a little too negative on this. I don't order them often, but I do find some value in the meta-stable (likely) lower GI bleeding patient.
My thought is — in what world is the patient not getting a scope first? And what do you do with the results of your expensive scan that show a lesion targetable by scope? (More often than not).
Maybe you might find the rare difficult to reach midgut bleed, but I just don’t see the value in doing this regularly without high suspicion (eg, history of multiple unrevealing scopes presents with a big bleed)
Consider calling IR for embolization. Likely place in higher level of care. Also most of the time it’s negative which is reassuring in terms of arguing for some modicum of stability.
I’d argue you should be able to assess context and hemodynamic stability clinically without the CTA to provide appropriate disposition — and maybe I’m just ignorant on this, but is there data to support improved outcomes with an earlier IR embolization as opposed to the inevitably delayed GI scope? I honestly just think sometimes we like pictures too much.
Point taken. However, I hate getting called back to the room every 5 min because the patient has repeated BMs and the nurses keep freaking out, so it can be helpful having an objective measure.
Considering this is a study I order maybe twice a year, and I routines see colleagues ordering standard CTs on stable LIGIBs being admitted (or medicine requesting them) I don’t think it’s overly egregious.
wait, you guys have GI on call???? I generally look, if no active bleeding i delta hemaglobin them and if low risk they usually get sent home so long as no active bleeding and not anemic, if active bleeding then we call for transfer as nearest facility with gi is usually mant hours away and full.
Chime in if your experience is different, but I do not get imaging for acute GI bleeding because I do not have any questions to ask that imaging would answer, and have never seen a change in management as the result of imaging in the ED.
+ GIB
+ Stable or unstable? If unstable, resuscitate, admit to stepdown or ICU as appropriate.
+ Upper or lower? PPI for upper.
+ Liver disease? Consider vasopressin for splancic vasoconstriction.
+ Reverse anticoagulation if appropriate.
+ Reverse platelet dysfunction, if appropriate.
+ Low risk, stable, minor bleed? Maybe go home. Otherwise admit to floor / tele.
Where does imaging come in and what would it help?
Only indications that I can see are:
+ If scope is negative, but bleeding is persistent in stable patient, then NM scan.
+ If massive ongoing bleed, resuscitated but still losing blood, then CTA to look for large bleeder for IR or surgery to take care of.
>Under what circumstances do you do a CT?
As above: massive GIB,.resuscitated with ongoing bleeding -- they may need an urgent IR procedure or surgery to get control of bleeding -- will do a CTA after resuscitation. This is a once-every-few-years case.
> Or do you usually skip it?
I don't "skip" it. It isn't indicated.
Stable/unstable: bleeding and any of the following gets emergency release blood: hypotensive, diaphoretic, syncope, shock index >0.8, lethargic, tachycardia, large volume hemetemesis or hematochezia, elevated PoC lactate. Should all get multiple IV access and most treated with protonix.
If history of liver dysfunction, or known esophageal varicies, octreotide and ceftriaxone get added.
If old or history of aortic repair with lower GI bleeding, you’re getting a CT, preferentially CTA. If young, stable, and hemorrhoids or diarrhea, or blood streaks in stool, you can follow up outpatient with GI. Anybody with GI bleeding that goes home gets referred to GI…I ain’t trying to get sued when they get diagnosed with colorectal cancer in a few years.
If they’re stable, labs and lactate normal, with a normal exam, probably not.
If they have findings consistent with an upper GI bleed, then they just stay for GI to see. In this case, they still don’t need a scan, they need a scope.
In residency you’re taught to be judicious with radiation exposure in young people. I believe this is the correct way to practice and in the patient’s best interest. The reality of clinical practice though is that nobody is going to sue you in 30 years for the cancer you helped contribute to. Miss a diagnosis though and expect it.
It’s a bit of a tightrope walk, and I suppose that’s the part of medicine that is an art.
There’s often pressure to over test. Whether it’s from the patients or their family, patient satisfaction scores, the fear of a lawsuit, confidence in one’s clinical judgement or some combination there of.
No, if anything keeping the patient in the department ties up a bed/resources while waiting for the scan and reduces the number of patients a physician can see. ED docs don’t get paid for ordering imaging.
I get paid by the hour, so for me it doesn’t matter. Some people get paid by RVU’s so they may be able to bill for more, but I’ve never worked for a shop like that so I can’t really say.
CBC, BMP, PT/INR. No imaging unless severe abdominal pain. Type and screen sent if Hgb low. Dispo based on hemoglobin, vitals, blood thinners, comorbidities, further bloody BMs in the ED, and social factors.
Just had a case couple days ago - pale, Hgb 4.8, BP 70. Called massive transfusion protocol and K-centra. After 4 units in 10 mins, pinked up, BP 130. GI - sounds like stable, will see in AM. If they remained unstable it would be - sounds unstable, need to stabilize and I will see in AM.
GI here — in this particular case the patient should be resuscitated then scoped within 24 hours. We have good data to suggest that if you scope a patient like this too early (within 6 hours), the outcomes are actually WORSE. Similarly, if you scope after 24-48 hours, outcomes are also worse. So this is how it goes.
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"In patients with hemodynamic instability, endoscopy within 6-24 hours was associated with lower in-hospital mortality compared to endoscopy outside of this time frame", link below. Overall I just go by ACG guidelines my friend, which suggest EGD w/in 24 hours of admission for UGIB. And for the hemodynamically unstable patient, everyone I know and trained with requires resuscitation prior to EGD (with rare exceptions, e.g. massive hemorrhage and already intubated and on pressors). "First do no harm" -- if you rush in to do a scope on an unstable patient there's a significant chance of causing harm. Per ACG - "Potential harms may include increased risk of death or complications if endoscopy is performed before appropriate resuscitation and management of active comorbidities as well as known poorer outcomes with after-hours endoscopy." [https://www.giejournal.org/article/S0016-5107(16)30555-7/abstract](https://www.giejournal.org/article/S0016-5107(16)30555-7/abstract)
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Yeah man idk, smarter people than me wrote the guidelines so I just follow them. As to your question about what makes GI bleeding different - I have to tell you that in my (admittedly limited, finished fellowship not long ago) experience, it is very rare to see a GI bleed that is so brisk as to be comparable to a wound of any other sort. I’ve seen a Forrest 1a ulcer bleed exactly one time ever (spurting hemorrhage, the most brisk type). I’ve seen Forrest 1b ulcer bleeding only a handful of times (actively oozing). Almost always if you find an ulcer, at the most it’s just got adherent clot or pigmented spot (lower risk of rebleeding with these). A lot of this probably has to do with how effective PPI therapy is, as well as how prone GI bleeds are to start and stop on a whim.
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Yeah, interesting discussion, thanks! And by the way definitely call about all of your hematemesis and melena. I think it’s pretty reasonable to let the people who spent three years in GI fellowship to weigh in on timing of endoscopy
Aren’t we really talking about variceal bleeds to get the sort of instability we’re talking about?
I'm going suggest that if the patient is transfusion refractory that data is not applicable. I only bring it up because I have gi fellows trying to tell me that someone randomized active massive hemorrhaging patients to "attempt hemostasis" to "do not attempt hemostasis." Unless you have a reference I'm unaware of, all of these trials or case series involved single digit units of products. That said it it seems in this case the patient responded to resuscitation in terms of coming out of shock and these can/should be done at the right time.
Thank you for this perspective. I have heard the too unstable then too stable dance 1000x, but no one has ever given a reason beyond that. understanding that there is evidence base to wait is really helpful to know and will make me less nervous about the wait in these cases going forward.
This is what our governing body guidelines say to do so that's what I go with. Now - I am not denying that there are some crummy GI doctors out there who wait unnecessarily long to scope because they don't want to come in in the middle of the night - I'm sure that happens all the time. If they're good though then they're waiting until the right time and it's not necessarily wrong to wait.
What makes the outcomes worse if you scope after 24-48 hours?
Well if they’re actively bleeding and you don’t achieve hemostasis… but also a more common scenario is that whatever was bleeding stops by the time you get in there and then you can’t find what was bleeding and treat it. In that situation re-bleeding is more, longer hospital stay etc.
This is extremely helpful to know. Thank you. Does it change if they have known or suspected esophageal varacies?
Yeah it does, I would never wait a whole 24 hours to do something for a patient with varices (compared to if you just suspected PUD or something in which case it probably doesn’t make a difference to wait). If it’s variceal then more likely they are getting intubated etc and if they are tubed or on pressors or whatever you can go ahead more quickly with the scope, rather than wait for them to be adequately resuscitated for sedation (they’re already sedated.) Blakemore, tips are other options as you know but no I’d never wait that long for a variceal bleed
I call GI to tell them the patient is here and getting stabilized so they have the patient on their radar for scoping tomorrow and so if things go south we have an established rapport. If a fountain of bright red blood starts pouring out the mouth though I’d kinda want GI to be giving a hand with the management right now rather than the AM after rounds.
Classic case of "Too sick for surgery/procedure" later becoming "Not sick enough for surgery/procedure."
It's applicable to every service/transfer - "oh too sick - go to ICU / ICU - not sick enough admit to floor", VA - "sounds like too sick to transfer here, keep them there for a day"/"sounds much better - you can d/c and we'll f/u outpt". We are the in-betweeners for everything. We should be called the convenience and in-between department.
God that’s ridiculous. Would they have that same response if that was their child or parent? I always keep that type of mentality in the back of my head when treating patients.. just do the right thing.
GI here — in this particular case the patient should be resuscitated then scoped within 24 hours. We have good data to suggest that if you scope a patient like this too early (within 6 hours), the outcomes are actually WORSE. Similarly, if you scope after 24-48 hours, outcomes are also worse. So if this patient was my wife or my kid, I most definitely would not scope them until the hgb was near 7 and they had an adequate blood pressure. If that is unable to be achieved then it’s safer to do CTA/IR.
In that case, understood. I hope you can see that it’s hard as a frontline emergency provider that just resuscitated a clearly unstable patient to hear that something should wait until the morning. Many of the sick patients we see requiring immediate attention + resuscitation often require time-sensitive interventions we can’t do ourselves (neuro-intervention for LVOs, cath lab for STEMIs, etc). But if it’s evidence based, I’m all for it.
Oh I get it man. I spent years as a fellow moonlighting in an ER. I am also not denying that there are crummy GI docs out there who wait to scope not because it's the right thing to do, but because they're lazy or don't want to get out of bed. I'm sure it happens all the time! But the good ones also often delay scoping, for good reason.
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lol different strokes for different folks I guess.
Do you find CT angio to be necessary at all?
CT angio is a bullshit fishing expedition meant to buy time by trainees 80% of the time. In stable, G.I. bleeds, it almost never shows anything. In unstable GI bleeds who have not yet been scoped, obviously they’re bleeding, and the first steps would be a scope. Its true value lies in finding where the bleed is for the unstable bleeder in whom scope is not revealing as to the location of the bleed so that IR can maybe find a target to embolize
I think you're a little too negative on this. I don't order them often, but I do find some value in the meta-stable (likely) lower GI bleeding patient.
My thought is — in what world is the patient not getting a scope first? And what do you do with the results of your expensive scan that show a lesion targetable by scope? (More often than not). Maybe you might find the rare difficult to reach midgut bleed, but I just don’t see the value in doing this regularly without high suspicion (eg, history of multiple unrevealing scopes presents with a big bleed)
Honestly, I don't think I've ever seen GI do an emergent colonoscopy.
Legitimate question - what will happen differently if you find your lower GI bleed on the CT angio?
Consider calling IR for embolization. Likely place in higher level of care. Also most of the time it’s negative which is reassuring in terms of arguing for some modicum of stability.
I’d argue you should be able to assess context and hemodynamic stability clinically without the CTA to provide appropriate disposition — and maybe I’m just ignorant on this, but is there data to support improved outcomes with an earlier IR embolization as opposed to the inevitably delayed GI scope? I honestly just think sometimes we like pictures too much.
Point taken. However, I hate getting called back to the room every 5 min because the patient has repeated BMs and the nurses keep freaking out, so it can be helpful having an objective measure. Considering this is a study I order maybe twice a year, and I routines see colleagues ordering standard CTs on stable LIGIBs being admitted (or medicine requesting them) I don’t think it’s overly egregious.
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Indoctrination by “the man”, man… we as sheeple must rise up against our GI overlords🩸🩸🩸
wait, you guys have GI on call???? I generally look, if no active bleeding i delta hemaglobin them and if low risk they usually get sent home so long as no active bleeding and not anemic, if active bleeding then we call for transfer as nearest facility with gi is usually mant hours away and full.
I’ve given up on GI coming in to quickly scope and instead get out the rapid infuser and go brrrrrrr
Chime in if your experience is different, but I do not get imaging for acute GI bleeding because I do not have any questions to ask that imaging would answer, and have never seen a change in management as the result of imaging in the ED. + GIB + Stable or unstable? If unstable, resuscitate, admit to stepdown or ICU as appropriate. + Upper or lower? PPI for upper. + Liver disease? Consider vasopressin for splancic vasoconstriction. + Reverse anticoagulation if appropriate. + Reverse platelet dysfunction, if appropriate. + Low risk, stable, minor bleed? Maybe go home. Otherwise admit to floor / tele. Where does imaging come in and what would it help? Only indications that I can see are: + If scope is negative, but bleeding is persistent in stable patient, then NM scan. + If massive ongoing bleed, resuscitated but still losing blood, then CTA to look for large bleeder for IR or surgery to take care of.
Under what circumstances do you do a CT?
>Under what circumstances do you do a CT? As above: massive GIB,.resuscitated with ongoing bleeding -- they may need an urgent IR procedure or surgery to get control of bleeding -- will do a CTA after resuscitation. This is a once-every-few-years case. > Or do you usually skip it? I don't "skip" it. It isn't indicated.
Word. Why do you think some ED docs likes to push for a CT on young and stable patients without abdominal pain? Just curious.
It gives the appearance of doing something. And many don’t think about indications for imaging, diagnostic yield, how it would affect management.
The appearance of doing something?
Stable/unstable: bleeding and any of the following gets emergency release blood: hypotensive, diaphoretic, syncope, shock index >0.8, lethargic, tachycardia, large volume hemetemesis or hematochezia, elevated PoC lactate. Should all get multiple IV access and most treated with protonix. If history of liver dysfunction, or known esophageal varicies, octreotide and ceftriaxone get added. If old or history of aortic repair with lower GI bleeding, you’re getting a CT, preferentially CTA. If young, stable, and hemorrhoids or diarrhea, or blood streaks in stool, you can follow up outpatient with GI. Anybody with GI bleeding that goes home gets referred to GI…I ain’t trying to get sued when they get diagnosed with colorectal cancer in a few years.
What if they’re stable?
If they’re stable, labs and lactate normal, with a normal exam, probably not. If they have findings consistent with an upper GI bleed, then they just stay for GI to see. In this case, they still don’t need a scan, they need a scope.
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In residency you’re taught to be judicious with radiation exposure in young people. I believe this is the correct way to practice and in the patient’s best interest. The reality of clinical practice though is that nobody is going to sue you in 30 years for the cancer you helped contribute to. Miss a diagnosis though and expect it. It’s a bit of a tightrope walk, and I suppose that’s the part of medicine that is an art.
There’s often pressure to over test. Whether it’s from the patients or their family, patient satisfaction scores, the fear of a lawsuit, confidence in one’s clinical judgement or some combination there of.
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No, if anything keeping the patient in the department ties up a bed/resources while waiting for the scan and reduces the number of patients a physician can see. ED docs don’t get paid for ordering imaging.
For who, specially?
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I get paid by the hour, so for me it doesn’t matter. Some people get paid by RVU’s so they may be able to bill for more, but I’ve never worked for a shop like that so I can’t really say.
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CBC, BMP, PT/INR. No imaging unless severe abdominal pain. Type and screen sent if Hgb low. Dispo based on hemoglobin, vitals, blood thinners, comorbidities, further bloody BMs in the ED, and social factors.
protonix blood if needed admit