Clinical Approach to the GI Patient: Upper GI Bleeding Flashcards
How is an acute upper GI bleed defined?
the source is proximal to the ligament of Treitz
what is the most common cause of an upper GI bleed?
PUD
what might the history be in a patient with an UGIB?
hematemesis (vomit bright red blood or coffee grounds); melena, and hematochezia (bright red blood per rectum) in massive UGIB
what are the severe symptoms of an acute upper GI bleed and what do they indicate?
indicate: anemia/ hypovolemia; orthostatic dizziness, confusion, angina, tachycardia, syncope, weakness, SOB
what are some co-morbid conditions that a patient with an acute upper GI bleed could have?
aortic stenosis, renal disease, smoking, liver disease, EtOH abuse, H. pylori, NSAIDs
how could a history of aortic stenosis and renal disease lead to an acute upper GI bleed?
the patient could have AVM, telangiectasias, and angiodysplasia
what medications could cause an acute upper GI bleed?
salicylates (aspirin), glucocorticoids, NSAIDs, and anticoagulants
what are the signs of hypovolemia?
resting tachycardia, orthostatic hypotension, supine hypotension
what might the abdominal exam be in a patient with an acute upper GI bleed?
severe abdominal pain, rebound tenderness and involuntary guarding, raises concern for perforation–> rule out perforation prior to endoscopy
what are the diagnostic tools used when dealing with an acute upper GI bleed?
x-ray/CT/MRI if suspect complication; EGD with biopsy (diagnostic and therapeutic)
what is the treatment/management of a patient with an acute upper GI bleed?
identify and stabilize unstable patients; 2 large bore IVs (18 gauge or larger); IV fluid bolus if signs of shock
what should you consider in patients with varices who are presenting with an acute upper GI bleed?
possibly octreotide–> it inhibits the secretion of gastric acid, reduces blood flow to the gastroduodenal mucosa, and causes splanchnic vasoconstriction; antibiotics if a variceal bleed
what are 8 things that could cause an upper GI bleed?
PUD, stress ulcers, esophageal varices, hemorrhagic gastritis, zollinger-ellison syndrome, mallory-weiss tear/ boerhaave syndrome, dieulafoy lesion, and GAVE syndrome
what is the etiology of stress ulcers (aka stress related mucosal disease)?
burns, CNS damage, and severe surgical or medical illness (stress)
how do you diagnose a stress ulcer?
EGD (diagnostic and therapeutic)
how do treat/manage a patient with a stress ulcer?
PPI; prevention of stress ulcers in critically ill patients (ICU)–> use of H2 blocker or PPI to reduce the incidence; the use of enteral nutrition reduces the risk of stress-related bleeding
where are curling ulcer’s typically found?
in the duodenum
what are esophageal varices and what causes them?
they are dilated submucosal veins in the esophagus; most commonly develop secondary to portal hypertension (cirrhosis)
what is the presentation of esophageal varices?
they are asymptomatic unless they are complicated by bleeding
when do esophageal varices bleed?
occurs after recent retching; 1/3 of patients with varices end up having an upper GI bleed
how do you diagnose esophageal varices?
EGD with biopsy (diagnostic and therapeutic)
when is a person at increased risk of bleeding from esophageal varices?
when the size of the varices is larger than 5 mm; the presence at endoscopy of red wale markings; the severity of liver diseases; active alcohol abuse
what is the treatment/management for esophageal varices?
acute resuscitation in ICU; IV fluids or blood products are essential; correct coagulopathy (underlying cirrhosis); emergent upper endoscopy with variceal banding
how can you prevent esophageal varices?
nonselective beta-adrenergic blocker (propranolol, nadolol)- reduce the risk of rebleeding: common side effects: fatigue and hypotension; long term treatment with band ligation reduces the incidence of rebleeding to about 30%
what is the cause of hemorrhagic erosive gastritis?
aspirin and NSAIDs, alcoholic (portal HTN gastropathy); severe stress/ critically ill
how might the physical exam look in a patient with hemorrhagic erosive gastritis?
because erosive gastritis is superficial, hemodynamically significant bleeding is rare; vital signs will be normal; liver disease stigmata acutely distressed
how do you diagnose a hemorrhagic erosive gastritis?
upper endoscopy with biopsy
what does the biopsy show in a patient with a hemorrhagic erosive gastritis?
there is usually no significant inflammation on histologic examination
how do you treat/manage a patient with a hemorrhagic erosive gastritis?
remove the offending agent: aspirin/ NSAID/ alcohol; if the patient has portal HTN gastropathy: beta-blocker (propanolol or nadolol)
what is the etiology of zollinger-ellison syndrome?
primary gastrinoma- non-beta islet cell- gastrin secreting tumor (usually in the proximal duodenum)
25% of primary gastrinomas are associated with what?
autosomal dominant familial syndrome MEN 1 (multiple endocrine neoplasia type 1)
what are the symptoms associated with MEN 1?
pancreatic gastrinoma, hyperparathyroidism (increased calcium), and pituitary neoplasm (gigantism)
what might the history/ presentation be in a patient with zollinger-ellison syndrome?
they have a PUD that isn’t responding to treatment, is severe, atypical, and recurrent
how do you diagnose zollinger-ellison syndrome?
EGD, serum (fasting) gastrin
what test is done first to diagnose zollinger-ellison syndrome? and is this confirmatory?
serum (fasting) gastrin: initial test done–> if it is >1000 pg/mL, then it can be confirmatory
when is an EGD suggestive of zollinger-ellison syndrome?
when you see large mucosal folds (hypertrophic gastric mucosa)
what is the confirmatory test if the serum (fasting) gastrin levels is less than 1000?
secretin stimulation test
why would you use endoscopic US, CT and MRI scans in a patient you thing may have zollinger-ellison syndrome?
to look for large hepatic metastases and primary lesions
in all patients with zollinger-ellison syndrome, what should you do?
draw levels of serum PTH-iPTH, prolactin, LH-FSH, and GH–> to exclude MEN 1
what is the treatment/management for zollinger-ellison syndrome?
PPI; surgical resection; in patients with MEN 1: treat hyperparathyroidism first
what is dieulafoy syndrome?
rare, potentially life threatening, an aberrant large-caliber submucosal artery; it runs a tortuous course within the submucosa and typically the lesion protrudes through a small mucosal defect
where is the most common site for a dieulafoy lesion?
the stomach (proximal stomach causes recurrent intermittent bleeding)
what might the history/presentation be like in a patient with dieulafoy lesion?
fatigue, hematemesis, occult GI bleed, pallor, elderly, male> female, often already hospitalized, no previous history
how do you diagnose a dieulafoy lesion?
awareness/ clinical suspicion; careful upper EGD
how do you treat a dieulafoy lesion?
transfusion if needed; endoscopic therapy; angiographic interventions for inaccessible lesions
what is gastric antral vascular ectasias (GAVE) syndrome?
rare, multiple superficial telangiectasias in the gastric antrum
when can GAVE syndrome be seen?/ what is it associated with?
in diffuse scleroderma and cirrhosis; more common in elderly
what might the history/physical exam look like in a patient with GAVE syndrome?
fatigue, non descript abdominal pain, occult GI bleed, pallor
how do you diagnose GAVE syndrome?
upper EGD
what can GAVAE syndrome be confused with on an EGD?
portal hypertension gastropathy
what is the difference between portal hypertension gastropathy and GAVE syndrome?
PHG has changes in the fundus more than the antrum
how do you treat someone with GAVE syndrome?
transfusion if needed; endoscopic band ligation, sclerotherapy, heater probe, and argon plasma coagulation
