EXAM #2: GI BLEEDING Flashcards
What delineates between upper and lower GI bleeding?
Trietz angle
What does occult bleeding indicate?
Slow bleeding/ low volume
What is melena and indication of?
UGI bleed
- Esophagus
- Stomach
- Duodenum
What is hematochezia?
Dark red blood or dark maroon colored blood
What does hematochezia indicate?
- Usually lower GI bleed
- Potentially v. fast UGI
What do you need to remember about stool color?
DO NOT USE STOOL COLOR TO R/O ORIGIN
What is the typical manifestation of chronic GI bleeding?
Anemia
What is the typical presentation of acute GI bleeding?
Signs and symptoms of volume loss
How much does the blood pressure need to drop when changing positions for positive orthostatic changes?
20 mm/Hg (systolic), also:
- 10 mm/Hg diastolic
- HR increase 10 bpm
What change will be heard with bowel sounds in a UGI?
Increased bowel sounds–blood is an irritant
Review the first case study in the ppt. How sick is the patient? Why?
V. sick
- Hx of HTN and hypotensive
- Beta blocker and tachycardia
- Orthostatic changes
Significant hypovolemia*
What is the DDx of a UGI?
1) PUD
2) Erosive esophagitis/ gastritis/ duodenitis i.e. NSAIDs or H. pylori
3) Gastroesophageal varices
What is GAVE?
Gastric antral vascular ectasia
- Dilated small vessels in the antrum of the stomach
What is the buzzword associated with GAVE?
Watermelon Stomach
What is a cause of UGI that is associated with very high mortality?
Aortoenteric fistula
- Abnormal connection between aorta and intestines
- Typically occurs secondary to AAA repair
What is a Dieulafoy lesion?
- Abnormal arterial GI vessel
- V. superficial
- Life-threatening bleeding results
What is the most common etiology of lower GI bleed, especially in the elderly?
Diverticulosis
List the three most common causes of Lower GI Bleed.
1) Diverticulosis
2) Angiectasias
3) Hemorrhoids
What two diseases increase the rate of Angiectasias?
1) AAA
2) Renal failure
What is Osler-Weber Rendu?
Genetic disorder that causes diffuse vascular dysplasia
- Increases the risk for bleeding
- Also known as Hereditary Hemorrhagic Telangectasia (HHT)
- Autosomal dominant inheritance
What two diseases can cause hyperpigmentation of the oral mucosa that can predispose one to GI bleeding?
1) Osler-Weber Rendu/ HHT
2) Peutz-Jeghers Syndrome
What must be performed during the PE if you suspect volume loss in a patient?
Orthostatic vital signs
What are the predictors of UGI?
1) Less than 50 y/o
2) Melenic stool
3) BUN/Creatinine ratio greater than 30
What are the indications for an NG tube in the face of GI Bleeding?
1) Hematemesis
2) Frank hematochezia
Note that 15-20% of patients with upper GI bleeding will have a negative NG aspirate–keep in differential even if negative.
How do you begin the resuscitation of a patient with significant hypovolemia?
1) IV access (bilateral large bore)
2) Crystalloids
3) Anticipate need for blood transfusion
When do you need to transfuse a patient with a GI bleed?
Hgb less than or equal to 7 g/dL
What is AIMS65? What is it used for?
Risk score that predicts mortality, length of stay, and cost
- Albumin less than 3
- INR greater than 1.5
- AMS
- Systolic less than 90 mm/Hg
- 65+ y/o
What is the Rockall Scoring System?
Predictor of mortality in UGIB
What is the utility of the Blatchford Score?
This score predicts the NEED for ENDOSCOPIC THERAPY
Once you have resuscitated a patient with a non-variceal UGIB, how can you start pharmoctherapy?
IV PPI
- Facilitates clot formation
- stop once diagnostic endoscopy has been performed
What procedure is always indicated for patients with a suspected UGIB?
Endoscopy (within 24 hours)
What is the purpose of endoscopoy?
1) Confirmation of diagnosis
2) Risk stratification
3) Speeds access to therapy
When is endoscopic therapy required? What determines this requirement?
Stigmata i.e. characteristics:
1) Active bleeding
2) Nonbleeding visible vessel
Treating these is done to prevent rebleeding*
What are the stigmata that don’t require endoscopic therapy?
1) Adherent clot
2) Flat pigmented spot
3) Clean base
How is hemostasis achieved with endoscopy?
1) Epi injection
2) Electrocoagulation
3) Clipping (mechanical)
Often combination therapy is employed.
In a patient with CAD that is on ASA, when should ASA be re-started following a UGIB?
As soon as the bleeding as been resolved
What is the mnemonic for remembering the clinical features of variceal bleeding?
1/3
- Occurs in 1/3 of patients with cirrhosis
- 1/3 are initially fatal
- 1/3 rebleed in 6 weeks
- 1/3 survive a year
What is the mnemonic to remember how to manage variceal bleeding?
VARICEALB
V= Vasoconstrictor A= Antibiotics R= Resuscitation IC= ICU level care E= Endoscopy AL= Alternative B= Beta blockers
What is the common vasoconstrictor used to treat Variceal bleeding?
Terlipressin
Why are ABX used in Variceal bleeding?
- Reduce infection
- Reduces rebleeding
When should endoscopy be performed in variceal bleeding?
ASAP after resuscitation
What is the “alternative” rescue technique used to treat variceal bleeding?
TIPS
Transjugular Intrahepatic Portosystemic Shunt
What type of beta-blocker should be used to treat Variceal bleeding?
Nonselective
What are the predictors of severe LGIB?
1) HR greater than 100
2) SBP less than 115
3) Syncope
4) Nontender abdominal exam
5) 2+ comorbid conditions
What are the three major risk factors for mortality in LGIB?
1) Age
2) Intestinal ischemia
3) Comorbid illness
What do you do a colonoscopy in LGIB?
Unlike UGIB, urgent colonscopy is NOT required
What is the alternative study to a colonscopy in a LGIB?
Angiography
Note that the advantage of this is that IR can coil this and provide definitive treatment.
When is surgery required for LGIB?
1) SEVERE bleeding
- Requires more than 6 units of blood
What procedure is indicated in obscure GI bleeding?
Capsule endoscopy
