Casefiles 6: upper GIB, SBS Flashcards

1
Q

Once the patient’s clinical problem of upper GI bleed is recognized, the appropriate priorities in this patient’s management are ?

A

(1) address the anemia and intravascular volume, (2) diagnosis, and (3) treatment

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2
Q

A critical step in the initial management of patients with acute upper GI bleeding is to determine ?

A

whether the bleeding is nonvariceal in origin or due to portal hypertension and bleeding from gastric and/or esophageal varices

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3
Q

Patients with suspected variceal bleeding should receive ?

A

octreotide and broad-spectrum antibiotics, empirically

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4
Q

For the patient with presumed nonvariceal bleeding, initiate treatment with ?

A

high-dose PPI, consisting of 80 mg omeprazole IV bolus followed by 8 mg/h IV drip for 72 hours.
may benefit from early (within 24 hours) upper GI endoscopy and possibly endoscopic intervention

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5
Q

think variceal bleed if ?

A

diagnosis of cirrhosis, hx of vatical bleed, ascites, thrombocytopenia, high INR, high bilirubin

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6
Q

think nonvariceal bleed if ?

A

NSAID or anticoagulant use

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7
Q

Dieulafoy’s erosion

A

rare GIB, occurs when erosion causes bleeding from aberrant submucosal artery located in the stomach
frequently significant and requires prompt diagnosis by endoscopy and endoscopic or operative control of bleeding

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8
Q

Isolated gastric varices most commonly develop as the result of ?

A

splenic vein thrombosis, which then produce “left-sided” or sinistral portal hypertension. With thrombosis of the splenic vein, blood return from the spleen can only return from the spleen through the short gastric veins, thus causing increase in pressure and size of the short gastric veins. This condition is correctable by splenectomy

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9
Q

Hemorrhagic shock severity: Class I

A

Well-compensated shock with generally normal vital signs and up to 15% or 750 mL blood loss in an average sized adult

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10
Q

Hemorrhagic shock severity: Class II

A

Slight tachycardia, normal systolic BP with elevated diastolic BP, associated with up to 30% or 750 to 1500 mL blood loss in an average adult

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11
Q

Hemorrhagic shock severity: Class III

A

Tachycardia to 120 associated with hypotension. Patient is generally anxious appearing and diaphoretic. The patient can have up to 40% blood volume loss or up to 2000 mL in an average size adult.

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12
Q

Hemorrhagic shock severity: Class IV

A

Tachycardia to 140 associated with severe hypotension. Patient is generally unresponsive with decreased mentation. The associated blood loss is greater than 40% of circulating volume or over 2000 mL.

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13
Q

The in-hospital mortality from acute upper GI bleedings is approximately ?, where most deaths are attributable to ?

A

10% to 15%

exacerbation of existing medical illnesses secondary to blood loss and shock

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14
Q

Glasgow Blatchford score (GBS)

A

a commonly used scoring system that takes into account patient’s pulse rate, SBP, Hgb, BUN, and medical comorbidities.
ranges from 0 to 23, and the score has been found to correlate with the patient’s need for early endoscopic interventions

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15
Q

Rockall score

A

combines clinical parameters and endoscopic findings, and the calculated scores have been shown to help predict individual patient’s rebleeding and mortality risks.

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16
Q

recent major change in the transfusion strategy for patients with acute upper GI hemorrhage, which now utilizes a restrictive transfusion approach when hemoglobin levels fall below ?

A

7 g/dL
-results in fewer transfusions, less bleeding, fewer adverse events, and had improved survival in comparison to patients in the liberal transfusion group

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17
Q

if upper GIB, get this in the first 24 hrs, as it is valuable for diagnosis, treatment, and risk stratification and prognostication

A

Upper GI endoscopy

can even employ hemostatic techniques: epinephrine injections, thermal application techniques, and clip applications

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18
Q

non-variceal bleeding causes

A

PUD, Gastritis/duodenitis, esophagitis, Mallory-Weiss tear, AVM, others (Dieulafoy’s and cancer)

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19
Q

What has emerged as an alternative to surgery for patients in whom endoscopic treatments have failed to control bleeding?

A

TAE: Transarterial Embolization
utilizes angiography to access the bleeding vessels and then control the bleeding either with the infusion of vasoconstrictive medication (vasopressin) or with mechanical occlusion by embolization

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20
Q

The indication for surgical control of nonvariceal bleeding is ?

A

to achieve hemostasis when endoscopic therapies fail
involves the creation of a gastrotomy or duodenotomy to access the bleeding area directly, followed by placement of sutures to control the bleeding areas

21
Q

Discharge from the emergency department without in-patient endoscopy can be considered for patients with ?

A

SBP less than 110 mm Hg, pulse rate less than 100 beats/minute, hemoglobin greater than 13 g/dL (men) or 12 g/dL (woman), BUN less than 18.2 mg/dL, and the absence of melena, syncope, heart failure, and liver disease. Overall, requirement for intervention is less than 1%

22
Q

recent changes in resuscitation of hemorrhagic shock

A

do not necessarily restore normal vital signs and normal hgb values, as recent studies suggest that restoration of normal vital signs may contribute to increased bleeding
-crystalloid products should be administered sparingly during the initial resuscitation, if excessive can produce coagulopathy, hypothermia, and worsening bleeding

23
Q

pharmacologic therapy for variceal bleeding aims to to reduce portal pressure and decrease bleeding and involves ?

A

octreotide (bolus + infusion), somatostatin (infusion), terlipressin (not available in the United States given in boluses), or vasopressin (infusion)

  • broad-spec abx ppx: IV 3rd gen cephs or oral FQs
  • helpful to begin with PPI in case it is non-variceal in origin
24
Q

If the patient continues to bleed and remains unstable prior to endoscopy becoming available, options include placement of ?
more permanent options ?

A

a Sengstaken–Blakemore tube or another type of balloon tamponade device to temporarily control the bleeding, in place for 24 hrs, high rebleeding rates
more permanent:
transjugular intrahepatic portal-systemic shunt (TIPS), endoscopic therapy, or self-expanding intraesophageal stent placement

25
Q

primary ppx of variceal hemorrhage (in a cirrhotic patient with known gastroesophageal varices that have not previously bled)

A

noncardioselective beta-blocker (propranolol 40 mg bid initially and titrate the to reach target HR of 50 to 55 bpm) has been shown to prevent variceal bleeding
Alternatively, prophylactic variceal banding

26
Q

a noncardio-selective beta-blocker that is often used for primary prophylaxis for variceal hemorrhage and reduces portal pressure more effectively than propranolol

A

Carvedilol

In addition to its beta-blockage activities, it is a vasodilator because of its alpha-1 receptor blocking properties

27
Q

red wale sign

A

This refers to an endoscopic finding consisting of linear, red streaks that are noted on an esophageal varix; this finding is suggestive of a recent or impending bleeding

28
Q

TIPS

A

Transjugular Intrahepatic Portosystemic Shunt
an endovascular approach that creates a portosystemic shunt within the liver parenchyma
drawbacks: can produce or worsen encephalopathy in some patients, possible restenosis and occlusion of the shunt

29
Q

the most common presenting symptom of variceal bleeding?

most important first step?

A

hematemesis
immediate airway stabilization
unstable patients should receive fluids, blood products, and vasoactive agents for blood pressure support

30
Q

benign liver lesions

A
Cyst
Hemangioma
Focal nodular hyperplasia
Adenoma
Biliary hamartoma
Abscess
31
Q

malignant liver lesions

A
Hepatocellular carcinoma
Cholangiocarcinoma (bile duct cancer)
Gallbladder cancer
Metastatic colorectal cancer
Metastatic neuroendocrine cancer (carcinoid)
Other metastatic cancers
32
Q

variceal bleeding episodes can be successfully controlled 80% to 90% of the time with ?

A

endoscopic treatments

Endoscopic band ligation (preferred treatment over endoscopic sclerotherapy)

33
Q

The ? score helps determine the prognosis of patients who present with acute variceal bleeding

A

Child-Turcotte-Pugh

http://casefiles.mhmedical.com.mwu.idm.oclc.org/ViewLarge.aspx?figid=140649060&gbosContainerID=92&gbosid=246083

34
Q

Variceal diameter greater than ? is associated with an increased risk of bleeding.

A

5 mm

35
Q

Initial ? is recommended at the time of cirrhosis diagnosis.
If no varices are seen during initial screening, repeat is recommended every ?
If grade-1 varices are seen, repeat at ? is recommended
Patients with grade-II or -III varicose or red wale sign are recommended to undergo ?

A

surveillance endoscopy
2 to 3 years
1 year
primary prevention with beta-blocker therapy or endoscopic banding.

36
Q

The SMA provides blood supply to ?

An SMA embolus typically lodges in the distal artery and is associated with ischemia of the ?

A

the small bowel a short distance distal to the ligament of Treitz to the right colon
right colon, ileum, and the distal portion of the jejunum

37
Q

Malabsorption and diarrhea after bowel resection, think ?

A

SBS: short bowel syndrome

38
Q

The most important therapeutic objective for SBS early on is to maintain ?

A

nutritional status and fluid/electrolyte balances

39
Q

the long-term prognosis of any patient with SBS is influenced by ?

A

the length, location, and function of the residual (remnant) bowel, age of the patient, and the supportive care that the patient receives

40
Q

ileal brake

A

physiologic feedback mechanism causing slowing of small bowel peristalsis and delays in gastric emptying, which allows for increased nutrient absorption
preservation of the ileum helps maintain nutritional status following small bowel resection
loss can result in rapid gastric emptying, decreased intestinal transit time that is similar to dumping syndrome

41
Q

Adverse effects of TPN

A

catheter and vascular-related complications, toxicities, biliary effects including cholestasis, hepatic effects including steatosis and fibrosis, renal effects such as hyperoxaluria and kidney stones, and osteoporosis.

42
Q

Most cases of SBS are caused by

A

Crohn’ disease and mesenteric infarction most commonly

surgical resections, traumatic injuries, or functional defects such as radiation enteritis and severe IBD

43
Q

the ? are the primary sites of absorption of fluids and most nutrients

A

ileum and jejunum

44
Q

normal adult small bowel length is usually ?

Most adults with ? of small bowel will experience symptoms of SBS

A

over 600 cm (~240 in or 20 ft)

less than 200 cm (or less than one-third)

45
Q

absorption in the duodenum/jejunum

A

Protein, carbohydrate, fat (requires bile acid production by liver), water-soluble vitamins, mineral (calcium, iron, folate)

46
Q

absorption in the ileum

A

B12, bile acids (enterohepatic circulation), magnesium

47
Q

absporption in the colon

A

Water, magnesium, sodium, fermentation of carbohydrates to short-chain fatty acids

48
Q

Two peptide analogs targeting intestinal absorptive functions currently approved for pharmacological support of SBS

A

glucagon-like-peptide (GLP) analog Teduglutide
-improves absorptive function of the remnant small bowel and promotes mucosal growth in the remnant small bowel.
Human growth hormone analog (somatropin)