Approach to Upper GI Bleeding Flashcards
Upper vs Lower GI bleeding
UGIB is bleeding proximal to the ligament of Treitz, which means bleeding from the duodenum, stomach, and esophagus
T/F Epistaxis is UGIB
false. nose bleeds, hemoptysis(coughing out blood, not vomiting) or bleeding beyond the ligament of treitz is not an UGIB
Manifestations of bleeding
hematemesis
coffee-ground emesis
melena
hematochezia
what does bloody emesis vs coffee ground emesis indicate?
bloody emesis indicates moderate to severe bleeding
coffee-ground emesis indicates limited or old bleeding.
Why is melena black and why is it an indicatory of UGIB
its black because of Hb being altered by intestinal bacteria as it leaks from the top of the GI tract and moves throguh the intestime.
90% of melena cases are due to bleeding originating proximal to the ligament of treitz. 10% are due to bleeding from the small bowel or right olon.
confounders that look like melena but arent
iron supplements
bismuth products
hematochezia is red or maroon stools that are typically due to LGIB or ____
massive UGIB
- blood has a cathartic effect on the bowel
- look for associated sins that a large volume GIB
Outline the flow scheme of causes of when someone presents with hematemeis or melena.
- exclude any bleeding disorders if they have melena first
- could be due to :
1. portal hypertension (15%) characterized by esdophago-gastric varices.
2. PUD (55%) due to H Pylori, NSAIDS, stress (bascular causes, mechanical causes, radiation, inflammatory disease), ZES.
3. Other, such as Mallory Weiss tear, tumors, or esophagitis/gastritis.
most common cause of UGIB
PUD. Ulcers are defects in the mucosa that goes down to muscularis mucosae. If erosion occurs to a blood vessel, blood will move into the lumen of the stomach.
Role of COX1 and 2 (cyclooxygenase)
- stimulate mucin secretion
- stimulate bicarbonate secretion
- sitmulate phospholipid secretion
- enhance blood flow and oxygen deliver
- increase epithelial restitution and proliferation
they all do this because they convert arachidonic acid to PGE2 PGI2 and TxA2 etc which are prostaglandins.
HPylori mainly causes ulcers in the ___.
What are the two broad reasons why Hpylori makes ulcers/causes PUD
makes ulcers in the duodenum
- increases gastric acid secretion
- induces gastric meaplasia of duodenum
ZES is characterized by tumors in the:
pancrease– tumors of islet cells (non beta).
- these tumors produce astrin which stimulates H+ release. Results in hyperacid secretion.
How do varices in portal hypertension happen?
in portal hypertension, the liver gets stiff and blood flow isn’t optimum. this can be due to a number of things like smoking, drinking, hepatitis, other live complications. When the liver is stigg, BF can’t occur. it starts to backflow into veins of the stomach and esophagus. Causes pooling and variceal appearance.
Mallory Weiss Tear occurs in the:
longitudinal mucosal laceration/dissection in the distal esophagus or proximal stomach due to retching and heaving.
managing the patient with UGIB
- resuscitation– and emergency management: ABCs first: stable vs unstable, what degree of hypovolemia?/ Circulation access, 2 large bore IVs 18 guage. Volume resuscitation, and basic labs: CBC, urea, creatine, INR/PPT
- clinical assessment and pharmacotherapy
- endoscopy
- rescue therapy
managing the patient with UGIB
- resuscitation– and emergency management: ABCs first: stable vs unstable, what degree of hypovolemia?/ Circulation access, 2 large bore IVs 18 guage. Volume resuscitation, and basic labs: CBC, urea, creatine, INR/PPT
- clinical assessment and History
- investigations: labs, endoscopy (CALL GI), pharmacotherapy
- rescue therapy
what is shock
inadequate end organ tissue perfusion.
four subtypes of shock
cardiogenic
septic
neurogenic
hypovolemic. not enough volume in blood due to bleed/ ugib. can be mild, moderate, severe.
symptoms of mild hypovolemia
postural signs only. feeling pale cool clammy, with decreased perfusion in the skin. this means theres a deficit of <15% blood volume
symptoms of moderate hypovolemia
deficit in 20-40% volume. Decreased perfusion in the kidneys, pancreas, and spleen.
10, 20, 30 rule: Diastolic up down by 10, systolic down by 20, and HR up by 30.
Oliguria: less urine outpu
symptoms of severe hypovolemia
deficit of >40% blood volume
- decreased perfusion to the brain and heart
decreased level of consciousness, cardiac arrest
what to do during clinical assessment
confirm GI bleed, and localize UGI and LGIB
determine differential diagnosis
what to do during clinical assessment
confirm GI bleed, and localize UGI and LGIB
determine differential diagnosis
causes of esophagitis
gerd, drug induced, infection related
causes of gastritis
H Pylori, NSAIDS, alcohol, radiation, bile reflux.
what’re some vascular problems that could be causing UGIB
- angiodysplasia
- dieulafoy’s lesion
- gastric antral vascular ectasia (GAVE)
- Blue rubber bleb nevs syntome.
Trauma or Iatrogenic causes for UGIB
MWT Forein body ingestion post-surgical bleeding cameron ulcers aortoenteric fistula*
portal hypertension causes for UGIB
esophageal or gastric varices
- ectopic varices
- portal hypertensive gastropathy
ulcerative erosion causes for UGIB
PUD due to H. Pylori or NSAIDS or ZES
esophagitis
gastritis
broad categories for causes of massive GI hemorrhage
ulcerative erosise portal hypertension vascular lsions trauma or iatrogenic other (tumors, hemobilia, hemosuccus pancreaticus) HP is described as bleeding from the ampulla of Vater via the pancreatic duct [1, 2]. It is one of the least frequent causes of upper gastrointestinal bleeding and is most often caused by chronic pancreatitis
Taking history: approaches to the DDX
Associated symptoms of PUD
uppder abdominal pain
pain associated with meals
dyspepsia
Taking history: approaches to the DDX
Associated symptoms of esophagitis/gastritis
reflux symptoms, retrosternal pain. dysphagia and odynophagia throat pain, dyspepsia
Taking history: approaches to the DDX
Associated symptoms of portal hypertension
stigmatta of chronic liver disease, jaundice, ascites, hepatic encephalopathy.
Taking history: approaches to the DDX
Associated symptoms of vascular lesions (angiodysplasia)
cutaneous angiodysplasia
hereditary hemoorhagic
telangiectasia
Taking history: approaches to the DDX
Associated symptoms of MWT
epigastric or pain
dysphagia odynophagia
Taking history: approaches to the DDX
Associated symptoms of malignancy
constitutional symptoms: weihgt loss, fevers/nigh sweat, anorexia, N and V, early satiety, epigastric pain, dysphagia.
Comorbid illnesses with UGIB
- pts susceptivle to adverse effects of anemia (coronary artery disease, pulmonary disease)
- patients predisposed to volume overload: heart failure, renal failure
- patients for whom bleeding is difficult to control: coagulopathy, thrombocytopenia, hepatic dysfunction.
SEE SLIDE 36 DRAW OUT TABLE
what to look for in CBC lab
-what is Hb? what was the baseline? is kidney function normal or was the bleed affect organs past the liver?
what to look for in coagulation studies
INR/PTT: are there any underlying bleeding disorders that need to be corrected?
what to look for in serum chemistry and renal function (creatinine)
what is the renal function? has there been disrupted end organ perfusion to kidneys? very bad bleed = damaged kidneys too because blood goes to kidneys after live.
what to look for with BUN (blood urea nitrogen)
produces as a by product of protein digestion. Increased in renal failure, increased out of proportion to creatinine in GI bleed if you’re digesting blood in GI
What to ask in type and screen
for blood transfusion. does this patient need a blood transfusion?
normal Hb levels
140-175 g/L in men, and 120-150 g?L in women. after giving saline, the concentration og Hb is down because blood is more diluted.
normal MCV
mean corpuscular volume (average size of the cells) ir normally 8-100fL
Who needs the blood transfusion during emergency management?
- Patients with Active bleeding and hemodynamic instability
- even if the Hb is normal? should we give blood first or crystalloid first (fluids for hypovolemia)
- Patients without active bleeding who are hemodynamically stable and Hb<90g/L for high risk or 70g/L low risk.
- avoid overtransfusion for patients with varices.
when should you transfuse platelets? when should you transfuse plasma?
platelets if signs of thrombocytopenia if platelet count is <50X10^9
plasma if INR>2.0
emergency pharmacotherapy management
PPIS (turns off proton pump and prevents H+ secretion, allows blood to clot)
initial bolus of 80mg IV pantoprazole
maintenance dose of 8mg/hr infusion IV or 40mg IV q12 hours
recall that acid comes from parietal cell which is stimulated by 1) gastrin
2) acetylcholine
3) histamine
why do we treat with PPIs in UGIB?
elevate the gastric pH
improve the clotting process
reduce clot degradation from gastric enzymes
+/- direct anti Hpylori effect
reduces recurrent GI bleeding
downstages high risk upper GI lesions
treatment for varcieal bleeding (portal hypertension)
use vasoactive medications
- initial bolus dose: octreotide 50mcg IV bolus
- maintenance dose: octreotide 50 mcg/hr infusion
all GI bleeds get PPI. If you think its related to liver, then also give octreotide.
aims/reasons and risks for gastroscopy (EGD- esophagogastro dudenoscopy)
aims: diagnotic (localize the bleeding) and therapetuic (you could use it to put hemoclips or foam or something)
under sedation. need consent/
risks: sedation, aspiration, bleeding, perforation.
if endoscopy fails: need intervnetional radiology for vessel embolization or surgery.
