{"version":"1.0.0","segments":[{"startTime":0.342,"endTime":3.19,"body":"[intro music]"},{"startTime":3.19,"endTime":5.59,"body":"[Dr. Handy] Hi, welcome"},{"startTime":3.19,"endTime":5.59,"body":"to Harrison's Podclass"},{"startTime":5.59,"endTime":8.73,"body":"where we discuss important"},{"startTime":5.59,"endTime":8.73,"body":"concepts in internal medicine."},{"startTime":8.73,"endTime":9.86,"body":"I'm Cathy Handy."},{"startTime":9.86,"endTime":11.64,"body":"[Dr. Wiener] And I'm Charlie"},{"startTime":9.86,"endTime":11.64,"body":"Wiener and we're coming to you"},{"startTime":11.64,"endTime":13.74,"body":"from the Johns Hopkins School of Medicine."},{"startTime":15.96,"endTime":20.12,"body":"[Dr. Wiener] Today's episode"},{"startTime":15.96,"endTime":20.12,"body":"is a 64-year-old with GI bleed."},{"startTime":20.12,"endTime":23.52,"body":"Okay Cathy, so today's"},{"startTime":20.12,"endTime":23.52,"body":"case is a 64-year-old man"},{"startTime":23.52,"endTime":24.71,"body":"with known cirrhosis,"},{"startTime":24.71,"endTime":27.47,"body":"who's admitted to the ICU"},{"startTime":24.71,"endTime":27.47,"body":"with a large upper GI bleed"},{"startTime":27.47,"endTime":29.43,"body":"and altered mental status."},{"startTime":29.43,"endTime":32.33,"body":"He's confused and unable"},{"startTime":29.43,"endTime":32.33,"body":"to provide any history."},{"startTime":32.33,"endTime":35.58,"body":"His initial hemoglobin is 6.9 g/dL"},{"startTime":35.58,"endTime":37.36,"body":"and his vital signs are"},{"startTime":35.58,"endTime":37.36,"body":"notable for a heart rate"},{"startTime":37.36,"endTime":40.98,"body":"of 115 and a blood pressure of 90 over 55."},{"startTime":40.98,"endTime":42.45,"body":"So you want to start there?"},{"startTime":42.45,"endTime":44.82,"body":"[Dr. Handy] Well, this patient"},{"startTime":42.45,"endTime":44.82,"body":"clearly belongs in the ICU"},{"startTime":44.82,"endTime":47.87,"body":"with a hemodynamically"},{"startTime":44.82,"endTime":47.87,"body":"significant GI bleed."},{"startTime":47.87,"endTime":49.51,"body":"We don't know his baseline hemoglobin"},{"startTime":49.51,"endTime":51.76,"body":"but we should assume that this is a drop."},{"startTime":51.76,"endTime":53.96,"body":"He needs immediate volume resuscitation"},{"startTime":53.96,"endTime":55.29,"body":"and blood transfusion"},{"startTime":55.29,"endTime":57.78,"body":"because his hemoglobin"},{"startTime":55.29,"endTime":57.78,"body":"is already below seven."},{"startTime":57.78,"endTime":59.5,"body":"Sometimes we will use a higher threshold"},{"startTime":59.5,"endTime":62.06,"body":"of hemoglobin in patients"},{"startTime":59.5,"endTime":62.06,"body":"with coronary artery disease"},{"startTime":62.06,"endTime":63.36,"body":"but we don't have that history,"},{"startTime":63.36,"endTime":65.32,"body":"so we'll use a threshold of seven."},{"startTime":65.32,"endTime":66.55,"body":"Based on his mental status,"},{"startTime":66.55,"endTime":69.25,"body":"he may require intubation"},{"startTime":66.55,"endTime":69.25,"body":"for airway protection."},{"startTime":69.25,"endTime":70.81,"body":"[Dr. Wiener] Any suspicions of cause?"},{"startTime":70.81,"endTime":72.47,"body":"[Dr. Handy] Well, common"},{"startTime":70.81,"endTime":72.47,"body":"things being common,"},{"startTime":72.47,"endTime":74.55,"body":"first I would think of"},{"startTime":72.47,"endTime":74.55,"body":"peptic ulcer disease"},{"startTime":74.55,"endTime":76.1,"body":"since that's the most common cause"},{"startTime":76.1,"endTime":78.38,"body":"of GI bleeding in the United States."},{"startTime":78.38,"endTime":80.33,"body":"In this case, the only history we have"},{"startTime":80.33,"endTime":81.71,"body":"is a history of cirrhosis,"},{"startTime":81.71,"endTime":84.36,"body":"so while peptic ulcer"},{"startTime":81.71,"endTime":84.36,"body":"disease is a possibility"},{"startTime":84.36,"endTime":87.01,"body":"I'd also be concerned"},{"startTime":84.36,"endTime":87.01,"body":"about a variceal bleed."},{"startTime":87.01,"endTime":88.15,"body":"[Dr. Wiener] And how would the risk"},{"startTime":88.15,"endTime":90.17,"body":"of a variceal bleed change your approach?"},{"startTime":90.17,"endTime":91.461,"body":"[Dr. Handy] Well just for some background,"},{"startTime":91.461,"endTime":93.902,"body":"over the last decade,"},{"startTime":91.461,"endTime":93.902,"body":"it's become common practice"},{"startTime":93.902,"endTime":96.201,"body":"to screen known cirrhotics with endoscopy"},{"startTime":96.201,"endTime":98.37,"body":"to look for esophageal varices."},{"startTime":98.37,"endTime":99.85,"body":"Such screening studies have shown"},{"startTime":99.85,"endTime":101.67,"body":"that approximately one third of patients"},{"startTime":101.67,"endTime":105.01,"body":"with histologically confirmed"},{"startTime":101.67,"endTime":105.01,"body":"cirrhosis also have varices"},{"startTime":105.01,"endTime":107.02,"body":"and it's anticipated"},{"startTime":105.01,"endTime":107.02,"body":"that roughly one third"},{"startTime":107.02,"endTime":109.77,"body":"of patients with varices"},{"startTime":107.02,"endTime":109.77,"body":"will develop bleeding."},{"startTime":109.77,"endTime":112.0,"body":"Now variceal bleeds can be very severe"},{"startTime":112.0,"endTime":114.87,"body":"and they would require"},{"startTime":112.0,"endTime":114.87,"body":"endoscopic interventions."},{"startTime":114.87,"endTime":116.94,"body":"Remember also that most"},{"startTime":114.87,"endTime":116.94,"body":"patients with cirrhosis"},{"startTime":116.94,"endTime":119.75,"body":"have a coagulopathy based"},{"startTime":116.94,"endTime":119.75,"body":"on their thrombocytopenia"},{"startTime":119.75,"endTime":121.41,"body":"and prolonged INR."},{"startTime":121.41,"endTime":124.23,"body":"As soon as he's stabilized, he"},{"startTime":121.41,"endTime":124.23,"body":"should have an upper endoscopy"},{"startTime":124.23,"endTime":125.94,"body":"because that will likely be diagnostic"},{"startTime":125.94,"endTime":128.06,"body":"and possibly therapeutic as well."},{"startTime":128.06,"endTime":130.08,"body":"[Dr. Wiener] Okay, well, you're"},{"startTime":128.06,"endTime":130.08,"body":"obviously on the right lines"},{"startTime":130.08,"endTime":132.28,"body":"because here's what the question's asking."},{"startTime":132.28,"endTime":135.4,"body":"The question says, in addition"},{"startTime":132.28,"endTime":135.4,"body":"to fluid resuscitation"},{"startTime":135.4,"endTime":138.11,"body":"including transfusion of"},{"startTime":135.4,"endTime":138.11,"body":"packed red blood cells,"},{"startTime":138.11,"endTime":140.27,"body":"all of the following are"},{"startTime":138.11,"endTime":140.27,"body":"appropriate therapies"},{"startTime":140.27,"endTime":142.51,"body":"at this time except?"},{"startTime":142.51,"endTime":145.4,"body":"A. endoscopic sclerotherapy;"},{"startTime":145.4,"endTime":148.84,"body":"B. endoscopic variceal ligation;"},{"startTime":148.84,"endTime":151.16,"body":"C. octreotide;"},{"startTime":151.16,"endTime":153.26,"body":"D. propranolol;"},{"startTime":153.26,"endTime":157.81,"body":"or E. transjugular intrahepatic"},{"startTime":153.26,"endTime":157.81,"body":"portosystemic shunt, or TIPS."},{"startTime":157.81,"endTime":159.085,"body":"[Dr. Handy] So these answers assume"},{"startTime":159.085,"endTime":161.41,"body":"that the bleeding is due"},{"startTime":159.085,"endTime":161.41,"body":"to esophageal varices"},{"startTime":161.41,"endTime":164.65,"body":"because all of these are"},{"startTime":161.41,"endTime":164.65,"body":"sort of related to varices."},{"startTime":164.65,"endTime":167.04,"body":"In that context, we need to"},{"startTime":164.65,"endTime":167.04,"body":"think about the therapies"},{"startTime":167.04,"endTime":169.39,"body":"for right now, the approach to patients"},{"startTime":169.39,"endTime":172.33,"body":"with a variceal bleed is"},{"startTime":169.39,"endTime":172.33,"body":"first to treat the acute bleed"},{"startTime":172.33,"endTime":173.95,"body":"which can be life-threatening,"},{"startTime":173.95,"endTime":176.29,"body":"and then it's to prevent further bleeding."},{"startTime":176.29,"endTime":178.79,"body":"The medical management of"},{"startTime":176.29,"endTime":178.79,"body":"acute variceal hemorrhage"},{"startTime":178.79,"endTime":181.39,"body":"includes the use of"},{"startTime":178.79,"endTime":181.39,"body":"vasoconstricting agents,"},{"startTime":181.39,"endTime":184.01,"body":"usually somatostatin or octreotide."},{"startTime":184.01,"endTime":186.93,"body":"Balloon tamponade with a"},{"startTime":184.01,"endTime":186.93,"body":"Sengstaken-Blakemore tube"},{"startTime":186.93,"endTime":189.18,"body":"or Minnesota tube can be used in patients"},{"startTime":189.18,"endTime":191.65,"body":"who cannot receive endoscopy"},{"startTime":189.18,"endTime":191.65,"body":"therapy immediately"},{"startTime":191.65,"endTime":195.405,"body":"or who need stabilization"},{"startTime":191.65,"endTime":195.405,"body":"prior to endoscopic therapy."},{"startTime":195.405,"endTime":198.11,"body":"Endoscopic intervention is"},{"startTime":195.405,"endTime":198.11,"body":"used as first-line treatment"},{"startTime":198.11,"endTime":199.91,"body":"to control bleeding acutely."},{"startTime":199.91,"endTime":202.97,"body":"Some endoscopists will use"},{"startTime":199.91,"endTime":202.97,"body":"variceal injection therapy"},{"startTime":202.97,"endTime":205.13,"body":"which is sclerotherapy as initial therapy"},{"startTime":205.13,"endTime":207.69,"body":"particularly when bleeding is vigorous."},{"startTime":207.69,"endTime":209.79,"body":"Variceal band ligation is used to control"},{"startTime":209.79,"endTime":211.99,"body":"acute bleeding in over 90% of cases"},{"startTime":211.99,"endTime":214.03,"body":"and should be repeated until obliteration"},{"startTime":214.03,"endTime":216.37,"body":"of all varices is accomplished."},{"startTime":216.37,"endTime":218.268,"body":"When esophageal varices extend into"},{"startTime":218.268,"endTime":221.83,"body":"the proximal stomach, band"},{"startTime":218.268,"endTime":221.83,"body":"legation is less successful."},{"startTime":221.83,"endTime":223.95,"body":"In these situations"},{"startTime":221.83,"endTime":223.95,"body":"when bleeding continues"},{"startTime":223.95,"endTime":226.182,"body":"from gastric varices, consideration for"},{"startTime":226.182,"endTime":228.82,"body":"transjugular intrahepatic"},{"startTime":226.182,"endTime":228.82,"body":"portosystemic shunt,"},{"startTime":228.82,"endTime":230.98,"body":"which we call TIPS, should then be made."},{"startTime":230.98,"endTime":232.82,"body":"This offers an alternative to surgery"},{"startTime":232.82,"endTime":235.67,"body":"for acute decompression"},{"startTime":232.82,"endTime":235.67,"body":"of portal hypertension."},{"startTime":235.67,"endTime":237.5,"body":"[Dr. Wiener] So TIPS is"},{"startTime":235.67,"endTime":237.5,"body":"also used for patients"},{"startTime":237.5,"endTime":239.79,"body":"with refractory ascites or frequent bleeds"},{"startTime":239.79,"endTime":241.02,"body":"as you mentioned, right?"},{"startTime":241.02,"endTime":243.17,"body":"[Dr. Handy] Yeah in the"},{"startTime":241.02,"endTime":243.17,"body":"properly selected patients,"},{"startTime":243.17,"endTime":245.74,"body":"TIPS will reduce chronic"},{"startTime":243.17,"endTime":245.74,"body":"portal hypertension"},{"startTime":245.74,"endTime":247.31,"body":"but since you're diverting portal blood"},{"startTime":247.31,"endTime":248.78,"body":"to the systemic circulation,"},{"startTime":248.78,"endTime":252.12,"body":"you run a risk of worsening"},{"startTime":248.78,"endTime":252.12,"body":"hepatic encephalopathy."},{"startTime":252.12,"endTime":253.47,"body":"Encephalopathy can occur"},{"startTime":253.47,"endTime":256.07,"body":"in as many as 20% of patients after TIPS"},{"startTime":256.07,"endTime":258.85,"body":"and is particularly"},{"startTime":256.07,"endTime":258.85,"body":"problematic in elderly patients"},{"startTime":258.85,"endTime":261.76,"body":"and in patients with"},{"startTime":258.85,"endTime":261.76,"body":"pre-existing encephalopathy."},{"startTime":261.76,"endTime":263.21,"body":"TIPS should really only be reserved"},{"startTime":263.21,"endTime":266.27,"body":"for individuals who fail"},{"startTime":263.21,"endTime":266.27,"body":"endoscopic or medical management,"},{"startTime":266.27,"endTime":268.5,"body":"or who are poor surgical risks."},{"startTime":268.5,"endTime":271.91,"body":"And it can sometimes be used"},{"startTime":268.5,"endTime":271.91,"body":"as a bridge to transplantation."},{"startTime":271.91,"endTime":273.16,"body":"[Dr. Wiener] Okay, so you've mentioned"},{"startTime":273.16,"endTime":275.1,"body":"the two endoscopic treatments,"},{"startTime":275.1,"endTime":278.92,"body":"you've mentioned octreotide"},{"startTime":275.1,"endTime":278.92,"body":"as a portal vasoconstrictor"},{"startTime":278.92,"endTime":282.47,"body":"and you've mentioned TIPS"},{"startTime":278.92,"endTime":282.47,"body":"as a last ditch treatment."},{"startTime":282.47,"endTime":283.93,"body":"So I guess that means propranolol"},{"startTime":283.93,"endTime":285.76,"body":"is not indicated in this case, right?"},{"startTime":285.76,"endTime":286.974,"body":"The answer's D?"},{"startTime":286.974,"endTime":289.18,"body":"[Dr. Handy] Right, beta"},{"startTime":286.974,"endTime":289.18,"body":"blockers, like propranolol"},{"startTime":289.18,"endTime":291.57,"body":"or sometimes nadolol is also used,"},{"startTime":291.57,"endTime":293.27,"body":"those have been shown to decrease the risk"},{"startTime":293.27,"endTime":295.92,"body":"of recurrent variceal"},{"startTime":293.27,"endTime":295.92,"body":"bleeding and reduce mortality"},{"startTime":295.92,"endTime":298.35,"body":"from subsequent bleeds,"},{"startTime":295.92,"endTime":298.35,"body":"but they should not be used"},{"startTime":298.35,"endTime":300.75,"body":"in the setting of an"},{"startTime":298.35,"endTime":300.75,"body":"acutely bleeding patient."},{"startTime":300.75,"endTime":302.32,"body":"This patient here is hypotensive,"},{"startTime":302.32,"endTime":304.63,"body":"so giving a beta blocker"},{"startTime":302.32,"endTime":304.63,"body":"would not be helpful"},{"startTime":304.63,"endTime":306.4,"body":"and potentially make things worse."},{"startTime":306.4,"endTime":308.81,"body":"[Dr. Wiener] Okay, now this is"},{"startTime":306.4,"endTime":308.81,"body":"actually a two part question."},{"startTime":308.81,"endTime":310.68,"body":"It goes on to ask,"},{"startTime":310.68,"endTime":313.66,"body":"in the patient above, all of"},{"startTime":310.68,"endTime":313.66,"body":"the following could be used"},{"startTime":313.66,"endTime":316.02,"body":"as prophylaxis for"},{"startTime":313.66,"endTime":316.02,"body":"further variceal bleeding"},{"startTime":316.02,"endTime":318.79,"body":"except? And the answers are,"},{"startTime":318.79,"endTime":321.53,"body":"A. initiation of a"},{"startTime":318.79,"endTime":321.53,"body":"non-selective beta blocker,"},{"startTime":321.53,"endTime":324.19,"body":"such as propranolol, which"},{"startTime":321.53,"endTime":324.19,"body":"you've all ready mentioned;"},{"startTime":324.19,"endTime":328.72,"body":"B. initiation of daily"},{"startTime":324.19,"endTime":328.72,"body":"subcutaneous octreotide injections;"},{"startTime":328.72,"endTime":331.35,"body":"C. liver transplantation;"},{"startTime":331.35,"endTime":333.68,"body":"D. repeated variceal ligation;"},{"startTime":333.68,"endTime":335.19,"body":"if the initial bleed was controlled"},{"startTime":335.19,"endTime":337.61,"body":"with endoscopic variceal ligation;"},{"startTime":337.61,"endTime":339.91,"body":"or once again, TIPS."},{"startTime":339.91,"endTime":342.08,"body":"[Dr. Handy] Well, we've all ready"},{"startTime":339.91,"endTime":342.08,"body":"mentioned a number of these."},{"startTime":342.08,"endTime":344.94,"body":"So propranolol, repeated variceal ligation"},{"startTime":344.94,"endTime":346.82,"body":"and TIPS can all be used chronically"},{"startTime":346.82,"endTime":349.05,"body":"to prevent further variceal bleeds,"},{"startTime":349.05,"endTime":351.38,"body":"and liver transplantation"},{"startTime":349.05,"endTime":351.38,"body":"in selected patients"},{"startTime":351.38,"endTime":352.53,"body":"is essentially curative"},{"startTime":352.53,"endTime":355.69,"body":"because you're fixing the"},{"startTime":352.53,"endTime":355.69,"body":"underlying problem of cirrhosis."},{"startTime":355.69,"endTime":358.35,"body":"[Dr. Wiener] So the answer"},{"startTime":355.69,"endTime":358.35,"body":"is B, we use octreotide"},{"startTime":358.35,"endTime":360.15,"body":"acutely but not chronically?"},{"startTime":360.15,"endTime":361.94,"body":"[Dr. Handy] Right, as in this patient"},{"startTime":361.94,"endTime":363.55,"body":"during the acute variceal bleed,"},{"startTime":363.55,"endTime":364.7,"body":"a continuous infusion"},{"startTime":364.7,"endTime":367.82,"body":"of octreotide may promote"},{"startTime":364.7,"endTime":367.82,"body":"splanchnic vasoconstriction"},{"startTime":367.82,"endTime":370.47,"body":"and can be used to manage"},{"startTime":367.82,"endTime":370.47,"body":"acute variceal bleeding."},{"startTime":370.47,"endTime":373.26,"body":"However, a subcutaneous"},{"startTime":370.47,"endTime":373.26,"body":"octreotide is not used"},{"startTime":373.26,"endTime":374.89,"body":"as prophylactic treatment."},{"startTime":374.89,"endTime":377.25,"body":"[Dr. Wiener] Okay, so the"},{"startTime":374.89,"endTime":377.25,"body":"teaching points in this case"},{"startTime":377.25,"endTime":379.86,"body":"are that in patients with"},{"startTime":377.25,"endTime":379.86,"body":"known history of cirrhosis"},{"startTime":379.86,"endTime":381.95,"body":"who present with an acute upper GI bleed,"},{"startTime":381.95,"endTime":383.17,"body":"it should be treated initially"},{"startTime":383.17,"endTime":386.1,"body":"as if it is likely a"},{"startTime":383.17,"endTime":386.1,"body":"serial variceal bleed."},{"startTime":386.1,"endTime":389.3,"body":"Urgent endoscopy may be"},{"startTime":386.1,"endTime":389.3,"body":"diagnostic and therapeutic."},{"startTime":389.3,"endTime":390.74,"body":"In addition to supportive therapy,"},{"startTime":390.74,"endTime":393.04,"body":"there are a variety of acute"},{"startTime":390.74,"endTime":393.04,"body":"treatments which may be used"},{"startTime":393.04,"endTime":395.96,"body":"to control the acute bleeding"},{"startTime":393.04,"endTime":395.96,"body":"and after stabilization"},{"startTime":395.96,"endTime":397.41,"body":"additional treatments may prevent"},{"startTime":397.41,"endTime":399.95,"body":"subsequent episodes of bleeding."},{"startTime":399.95,"endTime":401.432,"body":"[Dr. Handy] To read"},{"startTime":399.95,"endTime":401.432,"body":"more, you can check out"},{"startTime":401.432,"endTime":403.97,"body":"Harrison's chapter on"},{"startTime":401.432,"endTime":403.97,"body":"gastrointestinal bleeding"},{"startTime":403.97,"endTime":406.827,"body":"and the chapter on cirrhosis"},{"startTime":403.97,"endTime":406.827,"body":"and its complications."},{"startTime":406.827,"endTime":409.41,"body":"[outro music]"},{"startTime":411.09,"endTime":413.95,"body":"[Mr. Shanahan] This is Jim"},{"startTime":411.09,"endTime":413.95,"body":"Shanahan, publisher at McGraw Hill."},{"startTime":413.95,"endTime":415.57,"body":"Harrison's Podclass is brought to you"},{"startTime":415.57,"endTime":417.56,"body":"by McGraw Hill's Access Medicine,"},{"startTime":417.56,"endTime":419.66,"body":"the online medical resource that delivers"},{"startTime":419.66,"endTime":422.88,"body":"the latest trusted content from"},{"startTime":419.66,"endTime":422.88,"body":"the best minds in medicine."},{"startTime":422.88,"endTime":425.433,"body":"Go to accessmedicine.com to learn more."}]}