Bleeds

Question 1

What is the first thing to do in upper GI bleed?

Answer 1

Secure the airway

If the bleed is brisk, the patient may vomit up blood and aspirate.

Get the airway secured while someone else is starting fluid resuscitation.

Question 2

If a patient is actively bleeding, what is your transfusion Hgb goal?

Answer 2

>9 g/dL in most cases of active bleed with hemodynamic instability

For some cases, like upper GI bleed, >7 remains the goal.

Also, if the patient has acute coronary syndrome, this is an independent indication for a transfusion goal of 9 g/dL.

Question 3

Gastric antral vascular ectasia (GAVE)

Answer 3

“Watermelon stomach”

Rare cause of UGIB. Associated with bone marrow transplant, scleroderma, and cirrhosis. The direct etiology remains unknown,

Question 4

Dieulafoy’s lesion

Answer 4

Large ectatic submucosal arteriole that erodes through the mucosal layer of the stomach.

Most appear in the proximal stomach (>95%), predominantly on the lesser curvature within 6 cm of the GEJ.

Question 5

UGIB Management Algorithm

Answer 5

Question 6

NG tube in UGIB

Answer 6

Following resuscitation and ABCs, if the patient is not intubated, an NGT may be put down to reduce risk of aspiration and provide clinical information (bilious? bloody stomach?)

Question 7

Administration of ___ prior to endoscopy can improve visibility, shorten endoscopy time, and reduce the need for second-look endoscopy

Answer 7

Administration of erythromycin prior to endoscopy can improve visibility, shorten endoscopy time, and reduce the need for second-look endoscopy

Due to its properties as a motilin agonist

Question 8

In order to adequately test for H. pylori, you need to. . .

Answer 8

. . . be off a PPI for at least one week

Question 9

Following ABCs and resuscitation + airway management, a patient with known UGIB should recieve. . .

Answer 9

. . . A high-dose PPI (and octreotide if the bleed is variceal or suspected variceal)

Question 10

Recommended strategy for upper GI vacieal bleed (in order)

Answer 10

1. Resuscitation and ABCs with airway protection
2. Octreotide
3. Endoscopic therapy (likely band ligation)
4. Beta blockade

Question 11

What are the interventional options for an upper GI variceal bleed?

Answer 11

1. Sclerotherapy or Band Ligation (most patients will get this – but rebleed risk is 30-50%. Band ligation is superior to sclerotherapy in outcomes.)
2. Sengstaken-Blakemore Tube
3. TIPS (Childs B or C)
4. Surgery (distal splenorenal shunt if Childs A or operative exploration as last resort if Childs B or C– if endoscopic treatment fails)

Question 12

Child-Pugh score

Answer 12

Question 13

An SB tube cannot be left in for more than ___

Answer 13

An SB tube cannot be left in for more than 48 hours

Due to risk of ischemia and esophageal necrosis

For this reason, it is a temporizing measure pending definitive therapy for an esophageal bleed

Question 14

What therapies might a surgeon perform during operative exploration for a patient with variceal UGIB refractory to endoscopic therapy?

Answer 14

• Bleeding vessel ligation
• Highly-selective vagotomy (prevent future ulcer formation)
• Surgical shunt (distal splenorenal, if Child-Pugh A)

Question 15

Choice of shunt in cirrhotic variceal bleed and Child-Pugh score

Answer 15

If you are Child-Pugh A, the splenorenal shunt has the best outcomes

If you are Child-Pugh B or C, the TIPS has the best outcomes