Approach to upper GI bleeding 2

Question 1

causes of UGI bleeding

Answer 1

peptic ulcer (47%). erosions (29%). esophageal varices (10). mallory weiss tear. erosive esophagitis. neoplasms. esophageal ulcer. other - AV malformations, fistulas, etc.

Question 2

mallory weiss tear

Answer 2

tear in mucus membrane of lower esophagus or upper stomach where they join - most often caused by longterm vomiting or coughing

Question 3

Causes of duodenal or gastric ulcers

Answer 3

H pylori. Meds - NSAIDs, aspirin, clopidogrel, warfarin, anti-coags, corticosteroids, SSRIs. idiopathic. stress ulcer. zollinger ellison syndrome.

Question 4

endoscopic hemostasis: 4 techniques

Answer 4

injection therapy (1:10 000 diluted epi). thermal methods. endoscopic clips. sclerosants.

Question 5

ulcer treatment: low vs. high risk. what about for all?

Answer 5

low = oral PPI. high = endoscopic therapy then IV PPI infusion then oral PPI. for all: treat cause, test/treat for H pylori, discontinue aggravating meds if possible

Question 6

2 types of malignancies and symptoms

Answer 6

adenocarcinoma + lymphoma (also recall gastric higher chance of malignancy). chronic blood loss, anemia, pain, weight loss

Question 7

esophagitis: causes? treatment?

Answer 7

reflux, infection, pill induced, radiation. PPI + antifungal/viral.

Question 8

cameron’s ulcer

Answer 8

erosions/ulcers at margin of a hiatus hernia

Question 9

mallory weiss ter: what type? where? history of?

Answer 9

longitudinal mucosal tear at level of GE-junction. history of vomiting.

Question 10

esophageal varices: why?

Answer 10

liver cirrhosis = portal hypertension = expansion of esophageal veins = can bleed

Question 11

treatment for esophageal varices

Answer 11

do not over resuscitate. IV octerotide (lowers portal vein pressure) banding/sclerosant. blakemore tube. TIPS. liver transplant.

Question 12

what is octreotide?

Answer 12

somatostatin analogue: decreases portal pressure (and also splanchnic blood flow) so effective for variceal bleeding.

Question 13

TIPS

Answer 13

transhepatic internal portal shunt - connects portal and hepatic veins

Question 14

aortoenteric fistula

Answer 14

is a connection between the aorta and the intestines, stomach, or esophageus - can be significant blood loss into the intestines resulting in bloody stool and death.[1] It is usually secondary to an abdominal aortic aneurysm repair.

Question 15

UGI bleeding: what % will stop spontaneously? other therapy?

Answer 15

80%. medical, endoscopic, surgical, risk reduction.

Question 16

medical therapies for UGI bleeds

Answer 16

PPIs (IV then oral, usually life long). H2 antagonists - not really recommended. maybe in ICUs to prevent stress ulcers.

Question 17

PPI pre and post endoscopy?

Answer 17

pre = reduce endoscopic stigmata, reduce need for endoscopic therapy. post: high risk will use IV then oral, low risk will use oral PPI

Question 18

invasive radiology use?

Answer 18

after rebleeding despite 2 attempts at endcoscopic control, or with uncontrolled bleeding: can do radiographic embolisation

Question 19

H pylori therapy?

Answer 19

Clamet: clarithromycin 500 mg, amoxycillin 1g, metronidazole 500 mg + PPI –> all BID. second line would be PPI + bismuth + metro + tetracycline