44 GI Bleed Flashcards
Chapter 44. Gastrointestinal bleeding
Most common cause of UGIB? 2nd most common cause?
Most common: ulcer
2nd: varices
Most common cause of LGIB? 2nd most common cause?
Most common: Hemorrhoids
2nd: vascular ectasias
GI bleeding manifested as hematemesis, coffee-grounds material, melena or hematochezia
Overt GI bleeding
GI presenting with symptoms of blood loss or anemia such as light headednes, syncope, angina, iron deficiency anema or positive fecal occult blood tests
Occult GI bleeding
What is infusion used to enhance clot stability in PUD and decrease further bleeding
80 mg IV bolus then 8 mg/hr infusion
What is the target intragastric pH to enhance clot stability in GI bleed
Intragastric pH of more than 6
True or false. High intermittent PPI are non inferior to constant infusion PPI therapy
True.
How many days can aspirin be re started in cardiac patient who has GI bleeding
As soon as possible in span of 1-7 days
What is classic history of Mallory Weiss tears?
Vomiting or retching or coughing prior to hematemesis especially in an alcoholic patient
How soon should endoscopy be done in cirrhotics with UGIB
Urgent endoscopy within 12 hours
Vasoactive medications given to esophageal varices and for how long
Ocreotide Somatostatin Vapreotide Terlipressin For 2-5 days
When is TIPS consider in acute variceal bleeding in patients with advanced liver disease
First 1-2 days of hospitalization
Most important cause of gastric and duodenal erosion
NSAIDs
Endoscopically visualized breaks which are confined to the mucosa and do not cause major bleeding due to the absence of arteries and veins in the mucosa
Erosion
Percent small intestinal GIB account for up to what percent of cases?
5-10% of GIB cases
Most common cause of small intestinal GIB in adults more than 40 years
Vascular ectasia
Neoplasm
NSAID induced
Most common cause of significant small intestinal GIB in children
Meckels diverticulum
Which colon often present with diverticular bleeding
Right colon
True or false. Diverticular bleeding stop spontaneously in 10% of patients thus endoscopy should be done
False. Resolve spontaneously in 80-90% of patients
Syndrome presenting with bleeding vascular ectasias and aortic stenosis
Heyde’a syndrome
Best initial assessment of GIB
Heart rate and blood pressure
What does melena indicate on the status of GIB
Blood has been present in the GI tract for more than 14 hrs and as long as 3-5 days
What is the transfusion threshold in GIB
Hgb below 7 mg/dl
True or false. Hemoglobin and hematocrit may be normal in acute GIB due to proportionate reduction in plasma and red cell volume
True
How long it may take for the acute GIB blood loss be seen as decrease in hemoglobin count
As as 72 hour before Hgb/Hct drops
True or false. When hematochezia is the presenting symptom of UGIB it is associated with hemodynamic instability and dropping hemoglobin
True
How is intensive PPI done
IV bolus 80 mg then drip 8 mg/hr x 3 days OR
IV bolus 80 mg then IVTT 40-80 mg BID or 40 mg TID x 3 days
Then
Twice daily PPI for day 4-14
Then once daily PPI
Ulcer. Active bleeding or visible vessel Endoscopic therapy? Medical therapy? Diet? Hospital stay?
Active bleeding or visible vessel Endoscopic therapy: Yes Medical therapy: Intensive PPI Diet: clear liquids for 2 days after endoscopy Hospital stay: 3 days after endoscopy
Ulcer: adherent clot Endoscopic therapy? Medical therapy? Diet? Hospital stay?
Ulcer: adherent clot Endoscopic therapy: may do Medical therapy: Intensive PPI Diet: clear liquids for 2 days after endoscopy Hospital stay: 3 days after endoscopy
Ulcer: flat pigmented spot Endoscopic therapy? Medical therapy? Diet? Hospital stay?
Ulcer: flat pigmented spot Endoscopic therapy: no Medical therapy: once daily PPI Diet: clear liquids after endoscopy Hospital stay 1-2 days after endoscopy
Esophageal varices Endoscopic therapy? Medical therapy? Diet? Hospital stay
Esophageal varices
Endoscopic therapy: ligation
Medical therapy: Vasoactive drug
Diet clear liquids for 2 days after Endoscopic therapy
Hospital stay 3-5 days after Endoscopic therapy
Mallory Weiss Tears. Active bleeding Endoscopic therapy? Medical therapy? Diet? Hospital stay
Mallory Weiss Tears. Active bleeding Endoscopic therapy Yes Medical therapy: anti emetic if ongoing nausea Diet clear liquids for 1 day endoscopy Hospital stay 1-2 days after endoscopy
Mallory Weiss Tears. No active bleeding Endoscopic therapy? Medical therapy? Diet? Hospital stay
Mallory Weiss Tears. No active bleeding Endoscopic therapy No Medical therapy: anti emetic if ongoing nausea Diet regular diet after endoscopy Hospital stay discharge after endoscopy
Erosion. Endoscopic therapy? Medical therapy? Diet? Hospital stay
Erosion Endoscopic therapy. No Medical therapy. Once daily PPI Diet: regular diet after endoscopy Hospital stay: discharge after endoscopy
How is vasoactive drug ocreotide given?
Intravenous 50 ug bolus then 50 ug/h infusion for 2-5 days
What promotility agent may be given before endoscopy to improve visualization
Erythromycin 250 mg IV before endoscopy
When should upper endoscopy be done in most patients with UGIB
Within 24 hours
True or false. Cirrhotics patients with UGIB should be antibiotics and vasoactive drug prior to endoscopy
True. Antibiotics to decrease infection and vasoactive drug to control bleeding
True or false. In patients with hematochezia and hemodynamic instability and upper endoscopy may be done first to ry le out an UGIB before LGIB
True
What is procedure of choice for most patients admitted for LGIB
Colonoscopy after oral lavage
What procedure to do if LGIB is massive
CT angiography
If no bleeding found on colonoscopy what is the next procedure
99Tc labeled red cell scan
What is the initial test if patients with massive bleeding is suspected from the small intestines
CT angiography or 99Tc red blood cell scan prior to angiography
Others repeat EGD and colonoscopy as second look can detect 25% or bleeding
Other clues to UGIB
Hyperactive bowel sounds
Elevated BUN
What is included in the Glasgow Blatchford score
BUN Hgb SBP HR Other markers Melena Syncope Hepatice disease Cardiac failure
Algorithm for LGIB. No hemodynamic instability. Age more than 40 yrs old.
Colonoscopy
Algorithm for LGIB. No hemodynamic instability. Age less than 40 yrs old. Minimal bleeding
Flexible sigmoidoscopy
Algorithm for LGIB. No hemodynamic instability. Age less than 40 yrs old. Copious bleeding
Colonoscopy
Algorithm for LGIB. No hemodynamic instability. Colonoscopy identified bleeding site. Bleeding persists.
Angiography then surgery if bleeding persists
Algorithm for LGIB. No hemodynamic instability. Colonoscopy didn’t identify site.
Workup for small intestinal/ obscure bleeding site
Algorithm for LGIB. Hemodynamic instability.
Upper endoscopy
Algorithm for LGIB. Hemodynamic instability. Upper endoscopy done. No upper GI source. Able to bowel prep
Colonoscopy
Algorithm for LGIB. Hemodynamic instability. Upper endoscopy done. No upper GI source. Not able to bowel prep
Angiography or CT angiography first.
Algorithm for LGIB. Hemodynamic instability. Upper endoscopy done. Angiography done. Bleeding persists. Able to bowel prep.
Colonoscopy
Algorithm for LGIB. Hemodynamic instability. Upper endoscopy done. Angiography done. Bleeding persists. Instability persist.
Surgeru with intra operative endoscopy
Recommended for colorectal cancer screening at age 50 in average risk adults
Fecal occult blood testing
At what age is fecal occult blood testing recommended
Age 50 years old
Next step if second look procedure are negative
Video capsule endoscopy
What is the disadvantage of video capsule endoscopy
Does not allow full visualization of the small intestines
No tissue sampling
Cannot apply therapy
Used instead of video capsule endoscopy in patients with possible small bowel narrowing
CT enterography
Nest step if video capsule endoscopy turned out negative
Deep enteroscopy
