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Clin Therapeutics II (Spring 2018) > Exam 1: GI emergencies (bleeds, APAP OD) > Flashcards

Exam 1: GI emergencies (bleeds, APAP OD) Flashcards

1
Q

How do people present with UGIB?

A

Hematemesis / Melina / hematochezia

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2
Q

Epidemiology of GI bleeds (HINT: incidence, which end more common, which sex more common)

A

100/100,000

UGIB 4x common

M>F

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3
Q

Upper GI Bleed is proximal to which ligament?

A

Ligament of Treitz in duodenum

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4
Q

MC cause of Upper GI Bleed?

A

Peptic ulcer

Another high RF is Mallory Weiss tear d/t vomiting

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5
Q

Meds which can cause Upper GI Bleed? (hint: 3)

A
  1. ASA
  2. NSAIDs
  3. Prednisone

Anticoagulants too

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6
Q

2 types of Upper GI Bleed?

A

Non-variceal

Variceal

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7
Q

Variceal Upper GI Bleed bleed due to pressure increase where?

A

Increased pressure in portal vein from liver disease

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8
Q

“Better after I eat” means Upper GI Bleed is most likely where?

A

Duodenum. Would be worse with stomach bleed.

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9
Q

What scoring system do you use for UGIB risk stratification. What does it predict. What factors contribute to score (HINT 3)

A

Rockall scoring. Validated predictor of mortality with UGIB

AGE: <60, 60-79, >80

SHOCK: (SBP>100, HR <100), (SBP>100, tachy), (hypotension SBP <100)

Comorbidity: no major, cardiac failure/CAD, renal/liver failure and malignancy

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10
Q

What increases risk of UGIB (HINT: comorbidities, age, H&H, presenting sx)

A
  • CV compromise
  • Age > 65
  • consisting cardio/resp dz
  • Hgb < 10 (HCT<30)
  • hematemesis and Melena
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11
Q

What in a patient’s hx would make you concerned for UGIB? (HINT: comorbidities, social activities, meds, prev surg)

A

-Prev bleeding—bleeds likely to rebelled
-EtOH/Liver dz
-Steroids—PUD/esophagitis
-Liver dz—Esophageal/gastric varicies
-anticoagulant/NSAIDs
-severe vomiting—Mallory Weiss Tear
Aortic surgery-aortoenteric fistula

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12
Q

What does emesis look like in Upper GI Bleed?

A

Coffee ground

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13
Q

Stool in Upper GI Bleed?

A

Large black tarry stool (aka melena)

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14
Q

Hematemesis, Melena, Hematochezia in which GI bleed?

A

Upper GI Bleed

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15
Q

BUN/Cr 36:1 without renal insufficiency highly suggests what?

A

Upper GI Bleed

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16
Q

What BUN/Cr is dehydration?

A

20:1

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17
Q

What BUN/Cr suggest upper GI bleed?

A

36:1

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18
Q

How to fluid resuscitate Upper GI Bleed?

A

2 large bore IVs

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19
Q

Keep elderly HCT above what in Upper GI Bleed?

A

> 30%

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20
Q

When to give FFP in Upper GI Bleed?

A

If >10 units blood required AND fibrinogen <1, or INR 1.5x normal

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21
Q

When to give PLT in Upper GI Bleed?

A

PLT <50k with active blood

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22
Q

How to treat Peptic Ulcer in Upper GI Bleed?

A

High dose IV PPI!

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23
Q

When to contact GI with an Upper GI Bleed?

A

ASAP!

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24
Q

How to dx Upper GI Bleed? What else can you also do with this diagnostic

A

Endoscopy

Can also tx with mechanical clips +/- epi, cautery, or fibrin/thrombin. +/- epi

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25
Emergent management of UGIB (tx in ER)
#1 stabilize the pt: airway, circulation, ID source Fluids: 2 large bore IV Type+screen. Keep hct over 30 in elderly FFP if>10 units of blood, fibrinogen <1 or INR 1.5X Normal Platelets if <50K and bleeding Early endoscope High dose IV PPI for UGIB
26
What if can’t find Upper GI Bleed with endoscopy?
Angiography Useful if bleeding persists and endoscopy fails to ID bleeding site Angiography with transcatherter arterial embolization for all UGIB with known source of arterial and negative endoscopy
27
Tx plan for Upper GI Bleed?
Resuscitation and early endoscopy->banding +/- sclerotherapy if still bleeding in 5-7 days repeat banding +/- sclerotherapy -> vasoconstrictor +/- tamponade if fail endoscopy x2 and med therapy->consider TIPPS
28
How many times to try endoscopy with banding in Upper GI Bleed? When?
Twice if still bleeding in 5-7 days
29
When to consider TIPSS in Upper GI Bleed?
Fail endoscopy x2 and med therapy -refractory bleeding/ascites, Bud-Chiari clots
30
What does PT need after TIPSS?
New liver
31
Goal pressure for Portal Vein in Upper GI Bleed?
<12mmHg. Can’t bleed below that pressure.
32
General categories of tax for varicies
``` Endoscopic: banding or sclerotx Medical: Octreotide Tamponade: Sengstaken-blakemore tube/balloon Surgery: Shunts TIPSS ```
33
Complications of TIPS surgery
* Restenosis, occlusion, thromboembolism * Hepatic encephalopathy d/t ammonia buildup * Hemorrhage, hemobilia, cholangitis * Stent migration * Heart failure, liver failure * infection
34
Prevention of variceal bleeds
Octreotide, Beta blockers: propranolol BID (hold if low bp) Banding ppx Long acting nitrates
35
H Pylori therapy? (hint: 3)
1. PO PPI 2. Clarithromycin, 3. Amoxicillin OR Metronidazole for 7-14 days
36
Treatment for varicies
``` Endoscopic banding/sclerotherspy Octreotide (SST analog) Tamponade with balloon Shunts TIPS ```
37
What 3 therapies are equivalent for variceal treatment
Somatostatin = sclerotherapy = tamponade
38
Which med to give for vasoconstriction in Upper GI Bleed? What med to go along with it?
Vasopressin. NTG for heart and spleen to loosen constriction.
39
If using pressure techniques for variceal bleeds, what is the longest the balloon should be inflated for?
Inflated less than 24 hours
40
What is used for primary/secondary treatment of variceal bleeds?
Beta-blockers (Propanolol 40-80mg BID) Primary: seen in cirrhosis —> ?ppx banding Secondary: once bleed settles—> Bblocker Long acting nitrates Goal: keep PV pressure < 12 Soft foods
41
Where is lower GI Bleed located?
Distal to Ligament of Treitz
42
Which is more common- Upper GI bleed or Lower GI bleed?
Upper GI bleed by 4x
43
Major cause of Lower GI Bleed?
Diverticulosis
44
Bright colored blood in stool means what?
Bleed is close to rectum. “Hematochezia”.
45
Other causes of LGIB
``` Angangioectasias Hemorrhoids Colitis: (IBD, infections, ischemic) Neoplasm Post-polypectomy Dieulafoy’s lesion ```
46
What defines severe LGIB HR and SBP which make Lower GI Bleed “severe”?
HR>100 SBP<115 Continued bleeding w/in 24 hrs, decline in HCT and recurrent bleeding
47
Abdomen feels like what in Lower GI Bleed?
LLQ discomfort, crampy
48
Predictors for severe LGIB (HINT 7)
* HR >100 * SBP <115 * Syncope * Nontender abdominal exam * Bleeding during first 4 hrs of evaluation * ASA use * > 2 active comorbid conditions * 0 Factors – 6% risk * 1-3 Factors 40% risk * > 3 is 80% risk
49
What percent of Lower GI Bleed resolve spontaneously?
80%
50
What percent of Lower GI Bleed which resolve spontaneously rebleed?
30%
51
Dx for stable Lower GI Bleed? And how soon should pt have this.
Colonoscopy within 6-12 hrs or presentation (CAUTION IN UNSTABLE PT) Requires Rapid purge prep with 5-6L go lytely administered at rate of 1 L q 30-45 minutes Colonoscopy within 1 hr of clear stools
52
What test if active bleed with hematochezia in Lower GI Bleed?
NG lavage
53
NG lavage positive when in Lower GI Bleed?
Brown
54
Dx for unstable Lower GI Bleed?
Angiography +/- Tagged RBC scan
55
Dx for Lower GI Bleed if unstable, active, and no angiography available?
CT Angio
56
Tx for stable active Lower GI Bleed?
Urgent Colonoscopy
57
Tx for unstable active Lower GI Bleed?
Angiography +/- Tagged RBC scan. | Surgery if lifethreatening.
58
Why Angiography over Tagged RBC scan
Tagged RBC scan lacks tx capability Angiography great for bleeds that cant be stabilized or prep for colonoscopy. Thx capability: embolization with microcoils, polyvinyl alcohol and gelfoam
59
Complications of angiography
``` Bowel infarction Renal failure Hematoma Thrombosis Dissection ```
60
4 therapeutic actions of APAP What doesn’t APAP DO
Analgesia (same efficacy as salicylate) Inhibits brain prostaglandin syntherase Blocks pain impulses peripherally Antipyretic NOT anti inflammatory
61
Max dose of Acetaminophen?
4g
62
Potentionally lethal dose of Acetaminophen?
15g
63
Acetaminophen causes what to deplete?
Glutathione->increased NAPQI->hepatic necrosis
64
Half-life of Acetaminophen if liver healthy?
2h
65
Half-life of Acetaminophen if liver dysfunctional?
Up to 17h
66
Adult liver damage from APAP at which dose?
>150mg/kg or | >7.5g in 24h
67
Children liver damage from APAP at which dose?
>200mg/kg
68
How many phases of Acetaminophen Toxicity?
4
69
Overall complications of APAP toxicity
``` Jaundice d/t inc bill Renal failure HyperLactatemia Metabolic acidosis Hypophosphatemia, hypo or hyper glycemia *cardiac arrhythmia Pancreatitis, GIB, cerebral edema ```
70
Phase 1 of Acetaminophen Toxicity? Duration and what?
30min-4hr. Anorexia, nausea, vomiting, pallor, diaphoresis
71
Phase 2 of Acetaminophen Toxicity? Duration and what?
24-48h. RUQ pain d/t hepatic dmg, increased LFT, inc PTT, decreased renal function
72
Phase 3 of Acetaminophen Toxicity? Duration and what?
3-5 days. Hepatic necrosis, jaundice, renal failure, coag defect, hepatic encephalopathy
73
Phase 4 of Acetaminophen Toxicity? Duration and what?
4days - 2 weeks. Complete resolution or death.
74
When to do GI Decontamination in Acetaminophen Toxicity?
Within 1-2 hours ingestion.
75
How to do GI Decontamination in Acetaminophen Toxicity?
Ipecac + gastric lavage. Activated charcoal 50-100g. Cathartic to speed transit time.
76
When to take APAP level in Acetaminophen Toxicity?
4 hours post-ingestion
77
What is toxic value in Acetaminophen Toxicity?
150mg/dl at 4h from lab
78
What do you need to know in order to plot APAP level?
When APAP was taken
79
What tx for Acetaminophen Toxicity is a substitute for glutathianone?
NAC
80
Loading dose of NAC for Acetaminophen Toxicity?
140mg/kg x1
81
Maintenance dose of NAC for Acetaminophen Toxicity?
70 mg/kg q4h x17 doses Give 4hr after loading.
82
What if puke during NAC maintenance dose in Acetaminophen Toxicity?
Repeat dose and give Reglan
83
Is hemodialysis an effective tx for APAP Tox?
NO! not proven effective in reducing or prevent infections liver damage in OD
84
What LFTs are elevated with APAP tox? When will they be elevated ?
AST/ALT think hepatocellular injury Repeat q24h Elevation at 24-36
85
Which liver enzyme is specific for liver damage?
ALT
86
What PTT level is associated with poor <8% survival in APAP toxicity
PTT > 180s

Clin Therapeutics II (Spring 2018) (11 decks)

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