Gastro hemorrhage Flashcards
Typical sx
Pts w hematemesis/coffee ground emesis/melena considered to have
hematochezia
Hematemsis (bright red/maroon), coffe ground emesis, melena (black/tar stools), hematochezia (bright red/maroon stool)
bleeding prox to LoT
distal to LoT
Occult bleeding
acute brisk bleeds
Hb does not fall bc
w extravascular fluid enters to restore volume
wout overt sx (may see anemia/syncope/light headed)
change in vitals
proportional loss plasma, RBC
normocytic anemia
Class 1
Class 2
Class 3
Class 4
Blood loss % vol Pulse BP Resp
<750, <15, <100, Norm x2
750-1000, 15-30, 100-120, ortho, 20-30
1500-2000, 30-40, 120-140, dec, 30-40
> 2000, >40, >140, dec, >35
Orthostasis
Chronic bleed best judged by
Vitals usually
Upper GI bleeding
dec SBP/pulse >20 when standing
Anemia- micro from Fe loss
Normal
inc BUN/creat- absorped blood products, more profound bleeding/IV vol depletion
MCC upper GI hemorrhage
presentaton
as they penetrate MM
PUD- NSAID/H pylori assc
epigastric pain/tenderness
erodes GD arteries or L gastric artery- brisk hemorrhae
2nd MCC upper GI hem
results from
arterial bleeding
Gastritis- ulcers are diffuse/subepithelial
NSAID, alcohol, stress (trauma, burns, surgery, ventilation)
unlikely
3rd MCC upper GI hem
assc dz
RF
most terminate
very high
Gastroesophageal varices- portal HTN
CLD, viral hep, ALD/NALD
IV drugs, alcohol, met syndrome
spontaneously, others w intervention
mortality
MW tears
can extend to
presentatin
superficial tear at GE jxn
venous/arterial plexus
retching/vomiting (bright red/coffee)
Erosive duodenitis
gastric adenocarc
aortoenteric fistula
HHT
NSAIDs
neopastic, identical to PUD
result of surgery, herald bleeding, severe GI hem
AD, AVM w telangectassias, painless GI hem
Signs of upper GI hemorrhage 1st step
suspected variceal hemorrhage medication
prophylacis
give PPI- gastric acid damages mucosa & inhibits coag cascade
Octreotide- splanchin VC, dec bleeding
AB for SBP
Test for hematemesis/melena
hemodynamic instability/suspected variceal hem
high risk of rebleed needs
clean ulcers/ MW/gastritis
upper endo
endoscopy
endoscopic hemostatic therapy
no further mx
Ulcers and bleeding/visible vessels
procedure
continue
hospitalized, observed
endoscopic hemostasis, EPI, clips
PPI
Alternatives for unstable pt
Angiography
allows ofr
Rn imaging (radiolabled RBC to localize bleeding, direct therapy)
intervention if localized, massive bleeding (unstable, failed others)
transcatheter embolization
Lower GI hemorrhage characterized by
intestinal bleeds more
Left side vs right side
hematochezia- colon bleeding
obscure GI hem
Bright red/mroon
MCC hematochezia
hemorrhoids are
low gade bleeding
hemorrhoids- self lim
dilated submucosal blleds in anus- above (in) below (ext) dentate line
blood coaing stool/dripping into toilet bowl
Significant bleeding & hospitalization mcc
angiodysplasias
Infectious colitis
Ischemic colitis pt
precipitated by
bleedign area
presentation
Diverticulosis- bright red/maroon colored
dilated, tortuous submucosal vessles- bleed from veins/small volume
Camp, salm, shig
older adult, athero dz
hypoTN, shock, arrhy
anastomosis (splenic flexure, sigmoid/des colon)
ab pain, small bleed- necrosis/friability
UC presntation
CD presentation
Colon cancer
Meckel Diverticulum
hematochezia, tenesmus
fever, wl, watery diarrhea
uncommon, occult bleeding
hematochezia- incomp obliterated omphalmomesenteric duct- maroon colored stools
Lower GI bleeding presentation is usually w out
Procedure of choice
Going further
hemodynamic instab
colonoscopy
upper endoscopy
Alternative to endoscopy
RN imaging/angiography (same as Upper)
Obscure GI hem
source
causes
less common
symptoms of blood loss but neg UE/colonoscopy
SI (J/I)
tumors, erosions/ulcers (NSAIDS)
gastric erosion, angiodysplasia, ectasia
Evaluation of Obscure Gi hem
comps
another alternative
can do
cant do
wireless capsule endoscopy- view entire GI tract
intervention not possible
push enteroscopy- view duodenum/jejunum
biopsy/interv
not entire jejenum/ileum