Approach to upper GI bleeding

Question 1

difference between gastric and duodenal ulcers

Answer 1

gastric = can be malignant. duodenal ulcers almost never are

Question 2

upper vs. lower GI bleed definition

Answer 2

upper = proximal to ligament of Treitz = esophagus, stomach, duodenum. lower = small bowel aka jejunum, ileum; or colon

Question 3

where is the ligament of Treitz

Answer 3

duodeno-jejunal flexure - connects duodenum to connective tissue

Question 4

GI bleeding can be (3)

Answer 4

overt (visible bleeding) occult (not visible, but iron deficient + positive occult blood test). obscure (overt or occult, means that no cause has been identified despite investigations)

Question 5

signs and symptoms of GI bleeding depend on (3)

Answer 5

location, volume + rate of blood loss

Question 6

some signs/symptoms of GI bleeding

Answer 6

fatigue. syncope. chest pain. dyspnea. abdo pain. hematemesis (blood in vomit). melena (black tarry stools = proximal source). hematochezia (red blood in stool = lower source)

Question 7

orthostatic vital signs: 20/10/20 rule?

Answer 7

significant vol. depletion if SCP decreases by 20, DBP increases by 10, HR increases by 20

Question 8

what to ask on history

Answer 8

HPI. weight loss, vomiting, other symptoms. age (>50 = increased mortality). past GI bleed history. comorbidities. medications. false positives.

Question 9

medications to ask about

Answer 9

aspirin. NSAIDs. clopidogrel. warfarin. new anticoags. corticosteroids

Question 10

false positives for GI bleed

Answer 10

iron. bismuth. beets. ENT source

Question 11

physical exam for GI bleed

Answer 11

vitals. skin (pallor, burising, petechiae). liver disease stigmata. abdomen: masses, tenderness. rectal: melena, blood, mass, occult blood. general: comorbidities

Question 12

resuscitation?

Answer 12

A - consider intubation. B - suppl. O2 + monitor O2 sat and blood gas. C: 2 large bore IVs - crystalloid or blood products for volume repletion.

Question 13

goal for circulation part of resuscitation?

Answer 13

Hb >70g/L. platelets >50. INR <1.5

Question 14

other important things to do in resuscitation

Answer 14

consider ICU. ECG. measure urine output. do frequent reassessments!

Question 15

investigations for upper GI bleed

Answer 15

CBC. liver enzymes. BUN. creatinine. INR. PTT. type/screen in case of transfusion. electrolytes. lactate (will go up).

Question 16

NG tube: what predicts what?

Answer 16

red aspirate predicts poor outcome + need for urgent endoscopy

Question 17

predictors for rebleeding/death (7)

Answer 17

age >65. shock. poor overall health status/comorbidity. low initial Hb. RBC on rectal/NG/hematemesis. inpatient. elevated creatinine or LFTs

Question 18

investigation for acute upper GI bleeding? purpose?

Answer 18

endoscopy to: diagnose bleeding source. risk stratify for rebleeding. treat lesion. then do second look endoscopy if first one obscured or if bleeding continues

Question 19

what investigations are not useful for upper GI bleed

Answer 19

abdo X ray, CT, barium series (unless you suspect tumor or perforation)

Question 20

Glasgow blanchard score: criteria?

Answer 20

urea >6.5. Hb >130 or 120. SBP <110. pulse >100. melena, shock, liver disease, tachycardia. no age criteria

Question 21

rockall risk score

Answer 21

score from 0 -11 depending on: age, shock, comorbidities, diagnosis, major stigmata or recent hemorrhage