1. HYHO: UGIB Flashcards
Presentation of a patient with UGI bleed
- Hematemesis = vomit blood
- Coffee ground emesis
- Melena (dark stools)
- Hematochezia (red/maroon blood in stool)
- Anemia
- Hypovolemic shock
How does a patient with hypovolemic shock present?
Why?
Cold, clammy, vasoconstriction due to low BV detected by baroreceptor reflex => increase HR, sympathetic stimulation and vasoconstriction of non-essential organs
What symptoms can a person with hypovolemic shock face?
1. Orthostatic hypotension
2. Tachycardia
What is the landmark that divides a UGIB from a LGIB?
Ligament of Trietz (the suspensory l. of the duodenum)
What are specific causes of UGIB?
- Peptic ulcer
- Esophageal ulcer
- Mallory-Weiss tear
- Variceal hemorrhage or portal HTN gastropathy
- Cancer
What specific symptoms indicate: peptic ulcer, esophageal ulcer and Mallory Weiss tear?
- Peptic ulcer: abdominal pain
- Esophageal ulcer: odonyophagia, dysphagia, GE reflux
- Mallory-Weiss tear: emesis, retching or coughing BEFORE hematemesis
What aspects of history are important to check in a patient with UGIB?
- History of GI or nose bleeds
- PUD
- Esophogeal or gastric variceal bleeding in pts with cirrhosis or chronic alcoholics.
What meds can form peptic ulcers => UGIB?
- Aspirin
- NSAIDS (ibuprofin, naproxen sodium)
What meds can promote bleeding?
- Antiplatelet drugs (clopidrogel)
- Anticoagulants (warfarin)
What patients can alter the presentation in one with a UGIB?
- Bismuth (pepto-bismol)
- Iron
PE for UGIB (4)
- Vital signs
- Confusion (=> lack of O2 to brain)
- Peripheral vasoconstriction (=> cool extremities and cyanosis)
- Signs of liver disease (jaundice, ascites, and caput medusa)
Labs for UGIB (4)
- CBC w/ diff
- Cogulation studies (PT with INR)
- Liver enzymes (AST/ALT)
- Albumin, BUN and creatinine
- Guiac stool testing
If HB is below _________/__________ low-risk patients/high-risk patients => transfuse
- Low-risk patient => below 7 g/dl
- High-risk patient => below 9g/dl
Steps involved in resuscitation of a patient with severe UGIB.
- *** Focus on circulating volume
- Airway and circulation
- Obtain urgent consulation and treat
What should be the INITIAL resuscitation focus in a patient with a UGIB?
- Correct circulating volume (hemodynamic stability)
If a patient with a UGIB is hemodynamically unstable, what do we do?
- Give 2 large bore IV access (16-18 gauge) in different limbs
- Central line ONLY IF: cannot access peripheral venous circulation or infusion would damage peripheral veins
- Replace blood
- If no blood => cystalloid fluids. If blood => NS
How should airway and circulation be controlled in UGIB? (3)
- Supplimental O2 and monitor on pulse ox
- Intubate to perform endoscopy
- Balloon tamponade for bleeding
If INR > 1.6, give _____
- Fresh frozen plasma
- Prothrombin complex concentrate
If actively bleeding, keep platelets ______
> 50,000
What should be done in a patient with UGIB to make sure if a transfusion is needed, we do not have to waste time and check blood types against donated blood?
Cross and match 2-4 units of blood-PRBC.
What procedure can be done to ID source of bleeding?
- EDG (esophagogastroduodenoscopy) = looks at the eso, stomach, and first part of duodenum.
How can we visualize and treat esophageal varices?
Endoscopy with band ligation
When endoscopy with band ligation is combined with _________ => lower risk of rebleeding and mortality
Endoscopy + Sclerotherapy (IV injection that irritates the vein => causes it to close)
Interventational radiology procedures for UGIB?
- Trans-arterial embolization
- TIPS procedure (tranjugular intrahepatic portosystemic shunt) => reduce portal systemic pressure by shunting blood AWAY from varices
When is surgery indicated for UGIB and what types are done?
- Perform surgery when cannot perform TIPS or endoscopy, or not available.
- Surgeries
- 1. Surgical resection and vessel ligation
- 2. Splenorenal shunt
Meds for PUD
PPI (Omeprazole or esomeprazole 40mg IV BID)
Meds for esophogastric variceal bleeding and/or cirrhosis.
- Prophylactic ABX: 1g Ceftriaxone or 400mg BID of fluoroquinolone.
- 50mcg IV bolus and then trip at 50mcg/hr of Octetride (Somatostatin) to shunt blood away from varices.
- DO NOT USE _________ for transfusion, except in RARE and DIRE situations.
- Treatment of choice for anemia, when if trauma: _____
- Whole blood
- PRBC + crystalloid fluid
OSE for GI system
- TART and TP for T1-L2 (T5 - 9 = > UGI)
- Parasympathetics for UGI (vagus nerve = OA and AA joints)
- Chapman points for stomach acidity: Left 5th ICS
- Chapman points for stomach peristalsis: Left 6th ICS
5 Factor Model for UGIB: Respiratory and Circulation (4)
- Volume resuscitation w crystalloids and see if transfusion is needed.
- Once stable => rib raising
- Improve excursion of diaphragm by fucking with phrenic nerve (C3-5)
- Indirect MFR to thoracolumbar diaphragm
5 Factor Model for UGIB: Metabolic - NRG (4)
- Endoscopy/surgery to fix bleeding
- Take PPI and DQ NSAIDS
- Nutritional needs
5 Factor Model for UGIB: Biomechanical and behavioral
- Biomechanical: Fix SD: OA/AA and thoracic spine (T5-9)
- Behavioral: stop excess alcohol and smoking.
5 Factor Model for UGIB: Neurologic
- Viscerosomatic findings
- Chapmans points
- Celiac ganglion
When should OMT be done for a UGIB?
- After pt is stabilized and ID treatment of bleeding
What 4 things should you remember for a UGIB?
- Recognize, resuscitate and intubate early
- Consult GI, radiology and surgery to dx and tx
- Give ABX to patient
Pt presents with hematemesis and melena. What is the first thing we do to determine course of action.
-
Determine if the pt is hemodynamically stable or unstable
- Stable: upper endoscopy within 24 hours
- Unstable: resuscitate, prep for emergency upper endoscopy and consult surgery and or interventional radiology if upper endoscopy cannot be performed.
